X.

NURSING CARE PLAN

Assessment Diagnosis Planning Intervention Rationale Evaluation

Subjective: Ineffective breathing After the nursing  Determine  That would cause After the nursing
“Nahihirapan akong pattern related to intervention the presence of breathing intervention the
huminga” pulmonary infiltrates client will establish a factors/physical impairment client established a
as evidenced by normal respiratory condition As normal respiratory
Objective: respiratory rate of 28 pattern as evidenced noted in related pattern as evidenced
 With cpm by normal capillary factors by normal capillary
difficulty of refill, ABG, refill, ABG,
breathing respiratory rate and  Auscultate the  To evaluate respiratory rate and
 With rales in absence of DOB. chest presence/character absence of DOB.
posterior left of breath sounds
lobes and secretions
 Capillary
refill more  Assess for  That may restrict
than 3 concomitant respiratory effort
seconds pain/discomfort
 Epigasrtric
pain PRS 8/10  Elevate the head  To promote
 RR 28 of the bed and/or physiological ease
have the client sit of maximal
respiration

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X. NURSING CARE PLAN

up in a chair as
appropriate  For management
of underlying
 Administer
pulmonary
oxygen in lowest
condition
concentration
respiratory
distress or
cyanosis
 To promote
 Medicate with deeper respiration
analgesics as and cough
ordered  To maximize
 Stress importance respiratory effort
of good posture
and effective use
of accessory
muscle

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X. NURSING CARE PLAN

Assessment Diagnosis Planning Intervention Rationale Evaluation

Subjective: Acute pain related to  After the nursing  Assess for  To help  After the
“Sumasakit itong peritoneal irritation intervention, the referred pain, determine nursing
sikmura ko. Yung as evidenced by client will as appropriate possibility of intervention,
sakit umaabot facial grimacing, demonstrate underlying the client
hanggang likod ko” guarding behavior in behaviors of condition or demonstrated
the abdomen and reduced pain. organ behaviors of
Objective pain rate scale of dysfunction reduced pain
 Irritable 8/10 requiring
 Restless treatment
 Guarding
behavior evident  Accept  Pain is a
 Facial grimacing client’s subjective and
 Abdominal pain description of cannot be felt
after eating pain. by others

 Abdominal pain Acknowledge

that radiates to the pain

the back experience

 With abdominal and convey

girth of 68 cm acceptance of
client’s

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X. NURSING CARE PLAN

 With hypoactive response to

bowel sounds, 1- pain.
2 clicks
 With rigid, board  Maintain  To decrease
like abdomen patient on metabolic rate
upon palpation bed rest and reduce
 PRS of 8/10 secretion of
pancreatic
enzymes.

 Encourage  To promote
diversional non-
activities pharmacologic
pain relief

 Administer  To maintain
pain acceptable
medications as level of pain
ordered

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X. NURSING CARE PLAN

Assessment Diagnosis Planning Intervention Rationale Evaluation

Subjective: Fluid volume excess After the nursing  Measure  For changes After the nursing
“Namamanas ang related to fluid intervention, the abdominal that may intervention, the
mga paa ko.” leakage from the client will decrease girth indicate client decreased fluid
pancreas as evidence fluid volume excess. increase in volume excess.
Objective: by bipedal pitting fluid retention
 Pitting edema edema grade III. or edema.
Grade III on
both legs  Monitor vital  Significant
 With signs changes in
abdominal vital signs
girth of 68cm. may indicate
underlying
abnormality

 Observe skin
 For presence
and mucous
of decubitus
membranes
or ulceration

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X. NURSING CARE PLAN

 Record I & O  To provide

strictly means for
evaluating
improvement
or
deterioration
in the patient
status and to
check for
patient’s fluid
balance.

 Instruct the  To improve

patient to blood
elevate circulation
edematous
extremities

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X. NURSING CARE PLAN

Assessment Diagnosis Planning Intervention Rationale Evaluation

Objective Imbalanced nutrition After the nursing  Ascertain  To determine  After the nursing
 Dry lips less than body intervention the understanding information intervention the
 Pale mucous requirements related client will of nutritional needs of client client
membrane to inadequate dietary demonstrate an needs demonstrate an
 Nausea and supplement, impaired improvement in improvement in
vomiting when digestion and nutritional status.  Determine  Socioeconomics nutritional status.
eating absorption as lifestyle factor resources, amount
 Body weakness evidenced by weight that may of money
 Weight loss loss of 13 kg affect weight available for
Wt kg:45 kg purchasing food,
(10/18/17) and available
From: 58 kg upon storage space for
admission (10/10/17) food are all
factors that may
impact food
choice and intake

 Note age,  Helps determine

body fluid nutritional needs.
strength,

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X. NURSING CARE PLAN

activity level,
and current
condition or
treatment
needs

 Monitor  To determine
laboratory tests abnormalities in
the patients serum
lever especially
serum amylase
and lipase which
is a significant
indicator of acute
pancreatitis

 Consult with  For long term

dietician or nutritional needs
nutrition support
team as necessary

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X. NURSING CARE PLAN

Assessment Diagnosis Planning Intervention Rationale Evaluation

Subjective  Self-care deficit  After the nursing  Determine age an  That may affect After the nursing
 “Nahihirapan
related to interventions, the developmental ability of
akong bumangon interventions, the
at hindi rin ako impaired mobility client will be able issues individual to
makapunta sa client performed
as evidenced by to perform basic participate in own
banyo para umuhi
o dumumi dahil long term bed ADL’s such as care basic ADL’s with
dito sa sakit ng
stay getting to toilet to
tiyan ko” partial assistance.
commode and  Assist with  To encourage
Objective
being able to rise necessary client and bid on
 Unable to get to from bed with adaptations to success
toilet to commode
partial assistance accomplish
 Unable to rise
from the bed only. activities of daily
 With body living
malaise
 With
environmental  Review safety  To reduce risk of
barriers such as
nasogastric tube, concerns. Modify injury and
intravenous fluid activities or promote
and oxygen
attached environment successful
functioning.

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 Give family  Allows them free

information about time away from
respite or other the care situation
care option to renew
themselves

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