NURSING CARE PLAN 1

NURSING
CUES GOAL NURSING INTERVENTIONS RATIONALE EVALUATION
DIAGNOSIS
SUBJECTIVE FLUID VOLUME Within 8 hours of INDEPENDENT Within 8 hours of
DEFICIT related to rendering holistic rendering holistic
> Sige man ko ug osmotic diuresis nursing care, the 1. Obtain history of illness 1. Assist estimation of total nursing care, the
uhawon. Ganahan secondary to patient will : volume depletion. patient achieved and
ko mo inom ug increased blood Symptoms may have been demonstrated
tubig kay dali ra glucose levels >Achieve/Demonstr present for varying amounts evidences of
magmala akong ate adequate of time. adequate hydration
2. Monitor BP changes
baba as verbalized hydration as and stable vital signs:
2. Hypovolemia is manifested
evidenced by stable ( with moist lips and
by hypotension along with
OBJECTIVE Inference: V/S and increased minimal moisture on
tachycardia and tachypnea;
Increased serum intake of fluid. skin; vital signs as
estimates of the severity the
> Received on bed glucose levels follows:
hypovolemia may be made
in supine position, T 37.4 C
3. Assess peripheral pulses, when BP drops more than
with an ongoing IVF F & E from cells P 85 bpm
capillary refill, skin turgor and 10mmHg
of PLR 1L @ 900 cc are pulled by R 21 cpm
mucous membranes.
level, regulated at greater osmotic 3. Indicators of level of DHN, BP 110/70
40 gtts/min, hooked power of glucose 4. Monitor I & O, calculate 24-hour and circulating volume mmHg
at right cephalic fluid balance, weight daily and adequacy
vein, with Foley bag Cellular monitor urine specific gravity.
catheter dehydration 4. Provides ongoing estimate of
attachment 5. Provide frequent TSB. volume replacement needs,
Kidneys excrete kidney.
Urinary output of excess glucose
400-600 cc per
shift Water is pulled 6. Discourage intake of alcoholic 5. TSB promotes skin moisture
because of high and caffeinated beverages. and prevents dryness. Also
>Diluted urine, osmotic power of promotes comfort of patient.
color is yellow 7. Provide frequent oral care and
glucose(osmotic
eye care. 6. Alcohol and caffeine exert a
diuresis)
>Thirsty most of diuretic effect increasing
the time, takes fluid loss.
Increased
frequent sips of urination(polyuri 7. Fluid losses from body,
water a) decreases the skin and
mucosal moisture thereby
>Dry lips with 8. Promote patient safety. rendering the area
cracks noted susceptible to injury.

>Dry skin with little

to no moisture
noted
9. Keep fluids within clients reach 8. Patients manifest symptoms
Poor skin turgor and encourage frequent intake of decreasing LOC with fluid
noted not less than 1500 ml/day. loss making patient
susceptible to accidents.
>Vital Signs as
follows: COLLABORATIVE
T - 38C
1. Do IV follow-ups, as ordered. 9. Encouraging patient to
P 110 bpm
rehydrate maintains fluid
R 36 cpm
balance and replaces fluid
BP 100/60
2. Monitor indwelling urinary loss from present condition.
mmHg
catheter and urinary output.
COLLABORATIVE

1. IV therapy promotes
rehydration and restores
fluid balance.
3. Administer medications as
indicated. 2. Monitoring the placement of
the catheter and bag
ensures prevention of
4. Monitor and regulate IVF as infection; the urine output
ordered. must be monitored for color,
consistency, specific gravity
and composition to
determine degree of renal
function.
5. Monitor lab studies, e.g.
3. Insulin injection promotes
Hct; utilization of glucose to cells.

4. This is to prevent over

infusion and under infusion
of patient; IVF therapy
BUN/Cr; replaces fluids and
electrolyte losses.

Serum osmolality;
Assesses level of hydration and is
often elevated because of
Sodium;
hemoconcentration that occurs
after osmotic diuresis.

Potassium;

Elevated values may reflect

cellular breakdown from
dehydration or signal the onset of
renal failure.

Elevated due to hyperglycemia and

dehydration.

May be decreased reflecting shift

of fluids from the intracellular
compartment (osmotic diuresis).

Initially, hyperkalemia occurs in

response to acidosis, but as this
potassium is lost in the urine, the
absolute potassium level in the
body is depleted. As insulin is
replaced and acidosis is corrected,
serum potassium deficit becomes
apparent.
 NURSING CARE PLAN
2
NURSING
CUES GOAL NURSING INTERVENTIONS RATIONALE EVALUATION
DIAGNOSIS
SUBJECTIVE ALTERED Within 8 hours of INDEPENDENT Within 8 hours of
NUTRITION less rendering holistic rendering holistic
>Di man ko than body nursing care, the 1. Determine pt ability to chew, 1. Patients with upper GI nursing care, the
ganahan mukaon, requirements patient will: swallow and taste food. problems may manifest patient manifested
sahay di sad ko related to a. Take in difficulty in chewing and increased in food
pakan-on, ga sigi ra decreased appropriate swallowing. intake; able to finish
2. Ascertain clients dietary
ug lugaw, as appetite, painful amounts of of her meals.
program and usual pattern; 2. Identifies deficits and
verbalized chewing and calories and
compare with recent intake. deviations from the
swallowing, nutrients as
OBJECTIVE insulin deficiency evidenced by therapeutic needs.
3. Provide liquids containing
and presence of increased in nutrients and electrolytes.
> Received on bed infection. food intake. 3. Oral route is preferred when
in supine position, 4. Discuss eating habits, including client is alert
with an ongoing IVF food preference and
of PLR 1L @ 900 cc Inference: intolerance. 4. To determine appeal to
level, regulated at clients likes and dislikes.
40 gtts/min, hooked Presence of oral .
at right cephalic thrush + disease 5. Observe for presence of
vein, with Foley Bag state hypoglycemia, e.g., changes in 5. Once carbohydrate
Catheter LOC, cool/clammy skin, rapid metabolism begins (blood
attachment Results to lesions pulse, hunger, irritability, glucose level reduced), and
which can cause anxiety, headache, as insulin is being given,
Lack of local pain on oral lightheadedness, shakiness hypoglycemia can occur.
interest in cavity
food noted 6. Observe presence of 6. This may indicate protein-
Chewing and subcutaneous fat/muscle energy malnutrition.
Complains of swallowing is wasting, loss of hair, fissuring
difficulty and affected of nails, delayed healing, gum
pain when bleeding, swollen abdomen.
chewing and Changes in 7. This is needed to evaluate
swallowing appetite(decrease 7. Auscultate bowel sounds, note the degree of deficit.
d) characteristics of stool.
8. Adequate rest and sleep
Facial
Decreased food 8. Encourage adequate rest and periods decreases caloric
grimacing
intake sleep periods. demand and prevents
when
fatigue.
swallowing
 noted Nutrition is
altered 9. Include SO in meal planning, as 9. Promotes sense of
Weakness indicated. involvement, provides
noted information for SO to
understand nutritional needs
of the patient.
10.Provide simple health teachings
to patient and SO regarding 10.Simple health teachings
Decreased
management of DM type 2. promote client and SO
movements
education and So
noted
involvement. Promotes
independence of client as
COLLABORATIVE well.

1. Monitor and regulate IVF and COLLABORATIVE

>Vital Signs as do follow-ups as ordered.
follows:
T - 38C 1. Monitoring IVF regularly
P 110 bpm prevents overinfusion and
R 36 cpm underinfusion of client. IV
BP 100/60 follow-ups are for fluid
mmHg replacement.
 NURSING CARE PLAN 3
NURSING
CUES GOAL NURSING INTERVENTIONS RATIONALE EVALUATION
DIAGNOSIS
SUBJECTIVE Fatigue related to Within 8 hours of INDEPENDENT Within 8 hours of
decreased rendering holistic rendering holistic
> Kapoi man ug metabolic energy nursing care, the 1. Discuss with patient the need 1. Education may provide nursing care, the
lihok-lihok, unya production from patient will: for activity. Plan schedule with motivation to increase patient displayed
naa pa jud ning decreased appetite, patient and identify activities activity level even though improvements in
catheter,as altered body A. Display that lead to fatigue. patient may feel too weak ability to participate
verbalized chemistry: improved initially. in desired activities.
insufficient insulin, ability to Evidence: The
OBJECTIVE and increased participate in 2. Alternate activity with periods 2. Prevents excess fatigue. patient showed
energy demands: desired of rest/uninterrupted sleep. appetite during
> Received on bed presence of activities. mealtimes and was
in supine position, infection. able to reposition
with an ongoing IVF 3. Monitor pulse, respiratory rate, 3. This indicates physiologic herself with minimal
of PLR 1L @ 900 cc Inference: and blood pressure before/after levels of tolerance. assistance.
level, regulated at activity.
40 gtts/min, hooked Decreased appetite 4. Patient will be able to
at right cephalic results from 4. Discuss ways of conserving accomplish more with a
vein with Foley bag presence of oral energy and encourage decreased expenditure of
catheter thrush; mastication adequate rest and sleep energy.
attachment and swallowing are periods.
altered.
>Weakness noted
5. Increases confidence level,
5. Increase patient participation in self-esteem as well as
>Limited Insufficient insulin
activities of daily living as tolerance level.
movements noted leads to decreased
uptake of glucose to tolerated.
6. Appetite to eat is necessary
>Lack of interest in cells thereby
6. Encourage patient to take in in order to provide extra
activities noted causing weakness.
adequate food and promote energy and prevent further
appetite. fatigue.
Presence of 7. Adequate fluid intake
>Vital Signs as infection triggers 7. Encourage fluid intake of not replenishes fluid loss.
follows: the inflammatory less than 1,500 ml/ day.
T - 38C process and the
P 110 bpm immune system to
R 36 cpm react against the 8. By assisting patient with
 BP 100/60 causative agents. 8. Promote safety of patient. ambulation, the patients
mmHg Therefore, there is safety is promoted
an increase in the preventing any accidents.
metabolic demands
of the body. 9. Health teachings increases
9. Provide health teaching with patients awareness and
patient regarding condition and promotes independence.
how to prevent fatigue.
10.The SO should be involved
10.Involve SO with patient care with patient care and health
and health teachings. teachings to promote health
education and enabling SO
to care for patient in home-
based care.