XIII.

NURSING CARE PLAN

Cues

Nursing
Diagnosis
S>Hirap
Cues siya Nursing
Ineffective
huminga as
breathing
Diagnosis
verbalized
by
the
S> Masakit Acutepattern
pain
significant other.
related to
ang aking
related to
anemia

tiyan as
inflammation
verbalized
O> Received of tissue in
patient with the Gi tract
by the
Oxygen support.
patient
- With nasal
flaring, pallor and
O> weak.
Received
-Increased work of
breathing
patient
with
used
of
facial
accessory
grimace and
muscles when
sharp
pain in
breathing
epigastric
- Tachypnea &
dyspnea
region
it noted.
- for 2lasted

3 hours, not
Respiratory rate:
radiating.
28 Brpm
andHgb:
pain95 g/l
scale of
6/10.
Relieved
when
analgesic is
given.

36 | P a g e

Scientific
Objectives
Nursing Intervention
Rationale
Rationale
Scientific
Coagulopathy
Objectives
Short Term:
Nursing
Intervention
An oxygen
Rationale
This offers for

After
3-4
hours
of
Rationale
saturation of 90% or
sufficient
Bleeding
nursing
intervention
Assess forgreater
location,
a subjective
should be Pain is oxygenation.
Bleeding
atatGIGI Short
term:
tract
patient will
sustained.
onset,
duration,
experience
and must be
tract
After 3-4

demonstrate
The
frequency and severity of described
byproper
the client in
of
Blood loss (RBC hours
understanding
about

Guarantee
that
quantity
of oxygen
pain.
order to plan effective
Blood
clotted
nursing
carries
hgb)
teachings imparted.
oxygen delivery treatment
is constantly

formation
intervention
system
is
so
Review factor that
Helpfuladministered
in establishing
Anemia

client will
administered
to
the
that
the
patient
aggravate or alleviate
diagnosis and treatment

Long Term:
patient.
does not
GI irritation and manifest
pain
needs
Lack of oxygen in After 1-2 days of
desaturate.
inflammation
decrease
in
the blood
nursing intervention
Administered
To change blood

pain.
Patient will
Encourage
pain RBC as To reduce pain and
Packed
loss and to treat

experience
no
signs
GI disturbanes
reduction techniques
promote anemia.
relief/comfort
ordered.
Difficulty
of
of
respiratory

breathing
compromise or
Provide
restwith To relieve
A sitting
stress
position
and for
Long
Term:
Acute pain
adequate
Place patient
complications.
permits for
After
2 days
appropriate body clients comfort
Patients breathing
maximum lung
alignment for
ofpattern
nursing
will be
and
maximum breathing
Comfortexcursion
and a quiet
maintained as Create a quiet, no
interventions
chest
expansion,
pattern.
atmosphere promote a if
manifested
the
patient by disruptive environment
not
relaxed feeling
eupnea, normal and comfortable
will
be free
contraindicated.
Persuade
temperature
when
respiratory rate and
from
pain
pattern, and no other
possible maintained deep
This simple
and
breaths by:
signs of hypoxia.
method enhances
1) Utilizing
client will be able to
demonstrate
Administer analgesics
To decrease
pain
deep inspiration
demonstration: Deep
breathe effectively.
relaxation
to maintain acceptable
breathing Exercise
skills.
level of 2)
painRequiring
as per the
This facilitates for
doctorspatient
order to yawn.
pain relief and the
capability to deep
Instruct
client
to

Deep
breathing
breathe.
Utilize pain
perform deep
breathing as exercises may reduce
management
exercises (DBE)
pain sensation/
used in
needed
Respiratory
excursion is not
compromised.
Give details on
effects of wearing
restrictive clothing.

Expected
Outcome
AfterExpected
1-2 days
episodes
of
Outcome
nursing
intervention
After
3-4 hours
client can
series of nursing
breathe
interventions
the
effectively ,
patient
will be
Patient will
experience
no
free
from pain
signs
of
and demonstrate
respiratory
relaxation skills.
compromise or
complication,
Patientss
breathing
pattern will be
maintained as
manifested by
eupnea, patient
will have normal
respiratory rate.

XIII. NURSING CARE PLAN

pain management
Monitor effectiveness of
pain medications

Cues

O> Patient is warm

to touch with
Flushing face, teary
eyes, dry skin and
dry mouth.
Temperature:
38.2oC

37 | P a g e

Nursing
Diagnosis
Hyperthermia
related to
Inflammation

Scientific
Rationale
Inflammation
/Infection

The body
compensates with
the stimuli

The body
increases
temperature due
to inflammation

Fever occurs

Objectives
Short term
After 2-3 minutes
of nursing
intervention the
patient and
significant others
will verbalize
understanding
regarding health
teachings
Long term
After 2- 3 hours
of nursing
interventions
patients
temperature will
decrease and
maintain within
normal range.

To promote timely
intervention/ revision of
plan of care

Nursing Intervention

Upkeep patient's
environment

Rationale

Monitor vital signs,

especially
temperature

To provide a relaxing
environment for the
patient
To evaluate
effects/degree of
hyperthermia

Apply TSB every 15

minutes

To decrease the
temperature

Administer
antipyretic medication
as ordered

To decrease
temperature quickly

Provide health
teachings to the
significant other such
as:
-Proper TSB
-Increase fluid intake

To be independent in
taking care and
maintaining the clients
temperature and
hydration status.

XIII. NURSING CARE PLAN

- avoid touching of
mass`

Cues

38 | P a g e

Nursing
Diagnosis

Scientific
Rationale

Objectives

Nursing Intervention

Rationale

Expected
Outcome

XIII. NURSING CARE PLAN

Impaired skin
Blood
After 1-2 days
O>Presenc integrity
Clotted
of nursing
e of Mass at related to
formation
intervention,the
right lower
inflammatory

client will be
quadrant
response
Sacral mass able to display
Localized
secondary to
occurred
improvement in
erythema
infection

wound
healing
Cues
Nursing
Scientific
Objectives
Purulent
Impaired
as
evidenced
Diagnosis
Rationale
discharge
skin
integrity by: After 3-4
O> Received Activity
Coagulopathy
Intact
skin
patient with
Intolerance r/t

hours
of or
weakness,
weakness
GI Bleeding minimized
nursing
presence
of
Restlessness

intervention
,
Blood Loss pus.the patients
Absence
of to
Physical

will be able
or
inactivity,
Decrease redness
perform
Fatigue
musculoskeletalerythema.
simple
function
activities of
Absence
of

daily living.
Restriction of purulent
activities discharge.
Patient &
significant
others will
demonstrate
proper hand
washing to
prevent further
infection.

39 | P a g e

Establishescomparativeba At the end of

seline providing
the 1-2 days
opportunity for timely
of nursing
intervention.
intervention,
Maintaining clean,dry skin the client was
able to
provides a barrier
to
Nursing good
Rationale
Expected
Outcome
Demonstrated
infection.Patting skin dry display
Intervention
skin
hygiene, e.g.,
instead of rubbing
wash
Establish
improvement
After 3-4 hours
series
thoroughly and To gain client
reduces
risk
of
dermal
trust
nursepatient
pat dry carefully.
of nursing in wound
trauma to fragile skin.
interaction
as
interventions,healing
the
Instructed family to
evidenced by:
Patient
prevent
Skin friction caused
by will participate
maintain
Develop
and dry To
clean,
Minimized
clothes,
stiff or rough clothes
willingly in necessary
adjust preferably
simple
Overexertion
cotton
fabric
leads to irritation
presence of
activity
like(any Tor of
desired activities.
shirt)
fragile skin and increases wounds.
brushing his
risk for infection
teeth
Minimized
Emphasized
Improved nutrition and
importance of
erythema.
Assist client
To protect
hydration
will
improve
adequate nutrition
Minimized
with activity
patient
from
skin condition.
and fluid intake.
purulent
injury
Long and rough nails
.
Promotefamily to
discharge.
Instructed
increase risk of skin
comfort

To
prevent
overclip and file nails
damage
measures on
exhaustion
regularly.
the activity
To determine the
Ascertain ability
current status
to stand and
and needs
move about
degree of
assistance
For patient
recuperation
Encourage
and recovery
complete bed
Assessed skin.
Noted color,
turgor,and sensation.
Described wounds
and observed
changes.

rest