COLLEGE OF NURSING

SILLIMAN UNIVERSITY
Dumaguete City
NURSING CARE PLAN
CUES/ EVIDENCES NURSING
DIAGNOSIS
OBJECTIVES INTERVENTION RATIONALE EVALUATION
Subjective:
Veba!i"e#$ % gi
u&a' (a)*+ %
Veba!i"e#$ % )at*(g
(ag ,ige (a)* ug
eg!a$ (a)aba(tay
)* (ga (ag(i'a(g
)*+-
C!aime# t*
e./eie(ce *( a(#
*0 /*1u,e vagi(a!
b!ee#i(g ,i(ce
Oct*be+
C!aime# t* c*(,ume
2 /a#, *1 (a/)i( /e
#ay
Objective:
Vita! ,ig(,:
T345+5
*
C
63 27b/m
Ri,) 1* 8ui#
v*!ume #e9cit
e!ate# t*
/*!*(ge# vagi(a!
b!ee#i(g
:it&i( *u ;<#ay
cae$ t&e /atie(t
'i!! mai(tai(
a#e=uate 8ui#
v*!ume a,
evi#e(ce# by:
>+ Vita! Sig(,
;+ M*i,t muc*u,
memba(e,
4+ S)i( (*t #y
a(# &a, g**#
m*bi!ity a(#
tug*: ca( be
!i1te# ea,i!y
a(# ,(a/,
bac)
imme#iate!y
t* it, e,ti(g
/*,iti*(+
7+ Ca/i!!ay e9!!
!e,, t&a( 4
,ec*(#,
?+ A#e=uate
ui(ay
I(#e/e(#e(t:
>+ M*(it* Vita! Sig(,+
;+ A,,e,, ca/i!!ay
e9!! ,)i( tug*$
a(# muc*u,
1. Tac&yca#ia may
*ccu 'it&
&y/*v*!emia t*
mai(tai( a( e0ective
ca#iac *ut/ut+
U,ua!!y t&e /u!,e i,
'ea) a(# may be
iegu!a i1 e!ect*!yte
imba!a(ce a!,*
*ccu,+ Feve
i(cea,e,
metab*!i,m a(#
e.acebate 8ui# !*,,+
According to
Orlando, patient
behavior may be
verbal (spoken) or
nonverbal (actions,
vital signs) and an
inconsistency
between these two
types of behavior
may be the factor
that alerts the nurse
that the patient
At t&e e(# *1 *u ;<
#ay$ t&e /atie(t
mai(tai(e#
a#e=uate 8ui#
v*!ume
>+ Vita! Sig(,:
T3 45
*
C
63 5; b/m$

egu!a i(
&yt&m$
,t*(g
R3 ;@ c/m$
,i!e(t$
e0*t!e,,$
'it&*ut t&e
u,e *1
acce,,*y
mu,c!e,
A63 >7@B2@
mmCg
;+ M*i,t muc*u,
memba(e,
4+ S)i( i,
,!ig&t!y #y+
R3;4 c/m$
A63>7@BD@
mmCg
Lab*at*y
e,u!t,:
Cem*g!*bi(:
>@+> E
Cemat*cit: 4@+5
E
6** ca/i!!ay
e9!!
6** Tug*: S)i(
ca( be !i1te#
ea,i!y but it
,(a/, bac)
,!*'!y t* it,
e,ti(g /*,iti*(
Dy ,)i(
*ut/ut:
4@m!B&
memba(e,+
4+ A,,e,, c*!* a(#
am*u(t *1 ui(e+
Re/*t ui(e *ut/ut
!e,, t&a( 4@ mB&
1* ; c*(,ecutive
&*u,+
7+ M*(it* IBO ba!a(ce
C*!!ab*ative:
?+ A#mi(i,te
/ae(tea! 8ui#:
D?LR > L F ;*
gtt,Bmi(
needs help.
2. T* a,,e, t&e ,ig(, *1
a#e=uacy *1
&y#ati*( *
#eve!*/me(t *1
#e&y#ati*(+ n
Abdellah!s 21
nursing problems, it
is important to
recogni"e the
patient!s
physiological
responses of the
body to disease
conditions #
pathological,
physiological, and
compensatory.
$. C*(ce(tate# ui(e
#e(*te, 8ui# #e9cit+
/*!yuia ca( be
/e,e(t$ e=uii(g
m*e 8ui#
e/!aceme(t+
%. T* e(,ue accuate
/ictue *1 8ui#
,tatu,+ I(ta)e a(#
*ut/ut ,&*u!# be
a//*.imate!y e=ua!$
#e/e(#e(t *( #egee
*1 &y#ati*(+ n
Abdellah!s 21
nursing problems, it
Ca, /** ,)i(
tug*+
7+ Ca/i!!ay e9!!
i, !e,, t&a( 4
,ec*(#,
?+ Ui(ate# 4
time,G Ham
t* >/mI *1
ab*ut >g!a,,
i( am*u(t
5+ A#mi(i,te
Ta(e.emic Aci#
?@@ mg T+I+D+ a,
*#ee#+
H+ Revie' Lab*at*y
#ata Ge+g+ CbBCct$
e!ect*!yte,$
AUNBC$ UAI
is important for the
nurse to facilitate
&uid and electrolyte
balance.
'. Mai(te(a(ce *1
b*'e! e,t e=uie,
a!te(ative 8ui#
e/!aceme(t t*
c*ect !*,,e,
(. T* /eve(t a(# teat
e.ce,,ive b!ee#i(g
by i(&ibiti(g
/!a,mi(*ge(
activat* ,ub,ta(ce,
a(# by a(ti/!a,mi(
activityJ t&i, acti*(
/eve(t, t&e
bea)#*'( *1 c!*t,+
). E!evate# &em*g!*bi(
a(# e!evate# b!**#
uea (it*ge(
,ugge,t 8ui# #e9cit+
Ui(e ,/eci9c gavity
i, !i)e'i,e i(cea,e#+