XI.

NURSING CARE PLAN

#1 Nursing Problem: Difficulty of Breathing

CUES

NURSING

RATIONAL

PLANNIN

s>

DIAGNOSIS
Ineffective

E
G
Edema in the After

Nahihirapan

breathing

form

akong

pattern

huminga,

as pressure

verbalized

by diaphragm

the patient.
o> RR-30 bpm
>nasal flaring
>use

of edema.

of increased respiration.

in the lungs.

r/t ascites,

appropriate

on besides

nursing

>Placed the client in semi >to

intervention

fowlers position with arms pressure

compressing

and may

can

the supported with pillows.

on easily

diaphragm.

without
complaints

breathe with >Maintained calm attitude >to limit the level of

also minimal

cause shallow difficulty.

while dealing with client of anxiety.

and to significant others.

breathing and

muscles

impaired gas

>Encouraged adequate rest >to limit fatigue

>anasarca

exchange

periods between activities.

>ascites

resulting

>(+) crackles

respiratory

>Instructed patient to avoid >they can cause

compromise

overeating/gas-forming

abdominal

foods.

distention.

auscultation

now

relives breathe

accessory

upon

EVALUAT

The patient

thus affects its patient will

secondary to functions,
ascites

RATIONALE

ION
2 >Assessed for crackles and >identifies fluids Goal met.

of hours

reduced lung the liver and s,

capacity

INTERVENTIONS

in

difficulty.

# 2 Nursing Problem: Fluid Retention

CUES

ND

RATIONALE

PLANNING

INTERVENTIONS

RATIONALE

EVALUATI
ON

s>Nahihira
pan

Fluid

Fluid

akong volume

huminga

excess

volume After

excess
occurs

>Maintained

(FVE) appropriate
when

the nsg.

dahil sa laki r/t

body retains both Interventions,

ng tyan ko, excess

water and sodium the

as

fluid

in

verbalized

intake

proportions

by

the second

patient.

ary

o>edema,

edema.

I&O. Note decreased cardiac insufficiency, and met.

The

urinary output, (+) fluid fluid shift may caused patient

has

balance, (intake greater decreased urinary output stabilized

will than

similar demonstrate

accurate >decrease renal perfusion, Goal partially

output &

edema

fluid as

evidence

to stabilize fluid Be alert for acute or retention equals a weight by

balance

normal ECF. FVE volume

to is always secondary evidence

>Weighed as indicated. >one

as sudden

wt.

gain. gain

liter

formation. fluid volume

of

of

22lbs. I&O,

by >Followed sodium & >help to decrease ascites within

to an increase in balanced I&O, fluid

restrictions. and

edema normal

anasarca

total body water, v/s

>RR-30

because both water normal limits, IVF as indicated with as extracellular shifts,

still

bpm;restless

and

edema,

ness;

concentration

easy

fatigability

remains essentially edema.

normal

within >given oral fluids & >fluid restrictions, as well limits,

sodium and free from caution

signs

and

the

excess volume of

v/s

of >Administered
diuretics as ordered.

>promotes excretions of
fluids.

but
(+)

anasarca and
wt. gain.

fluid is isotonic.
# 3 Nursing Problem: Changes in body image

CUES

NURSING

RATIONALE

PLANNING

INTERVENTIONS

RATIONALE

EVALUATION

DIAGNOSIS
>determines
s> Ang laki Disturbed
laki

na

ng image

katawan
ko

abdominal
as enlargement

verbalized by secondary
the patient.

edema
ascites.

o> not looking

@ her body,
noted
>unintentional
hiding of body

body When edema is After

r/t present,

the appropriate

response

to

client is at risk nursing

changes.

>Promoted

for

accepting

to development

Interventions,
the

&

body
non-

patient judgmental attitude.

disturbance.

understanding
& acceptance
in

body

changes & of
self

in

shift.

ventilation of feelings.
>Listened to clients
comments

and
to

the

the

>Visited
frequently
acknowledge

body

image disturbance.
>respects

the

clients sensitivity
body

image

client
&
the

Goal met. The

patient accepted
and understands
changes in his
self

&

situation.

>helps the client

feel

valued.

>depending
individual
skills

situation.

situation

of

changes.

>encouraged

response

extent

to

and of body image will verbalize

within
>changes in

>Assessed the clients

the

and

on
coping
past

experiences.
>provides
opportunity

for

in

social

individual as someone

involvement

who is worthwhile.

listening

to

concerns

and

questions.

# 4 Nursing Problem: Body weakness

CUES

NURSING

RATIONALE PLANNING

INTERVENTIONS

RATIONALE

EVALUATION

DIAGNOSIS
>conserve energy &
s>

Konting Activity

After

>alternated rest & sleep

galaw o lakad intolerance r/t

appropriate

activity.

ko

nsg.

lang ascites,

napapagod na muscle

and

Interventions,

ako, ang dali wasting

the

patient

kong

will

feel

manghina, as

rested

with

verbalized by

fewer

the patient.

complaints of
fatigue

o>easy
fatigability,

>Assisted

with

activity

intolerance

&

>Noted client report on result

pain,

of

&

or

fatigue, contribute

to

difficulty intolerance

of

accomplishing tasks.

activity pattern.
>helps to minimize

in >Provided

positive

can

tolerate activity
better and can
perform

>symptoms may be

increase
tolerance

>increase
endurance.

(ADL)

Goal met. The

client

liver.

activities of daily living

weakness,
&

reduces demands on

more

ADLs

&

experience less
dyspnea
tachycardia.

&

frustrations
noted

activity.

atmosphere.

rechanneled energy.

>body
weakness,
noted
>PR-120 bpm
RR-30 bpm

>Promoted

&

comfort

measures & provided

for the relief of pain.

>to enhance ability

to participate in the
activity.