Nursing Care Plan I

Assessment Diagnosis Planning Intervention Rationale Evaluation

Subjective Chronic Short Term Goal: 1. Obtained clients 1. To rule out Partially Met:

Patient said pain At the end of 4 hours assessment of pain to worsening of Still with pain,

she always related to after nursing include location, underlying Pain scale:

felt pain in pathologic intervention patient characteristics, condition/developme 6-10

her bones. al disease will be able to: onset/duration, frequency, nt of complications.

Relieved from pain
Objective: process quality, intensity, and

Scale: precipitating/aggravating

7-8 factors.
Seemed
2. Provided comfort 2. To promote non
to
measures (e.g., cold packs, pharmacological
Facial
nurses presence), quiet pain management.
grimace
Vital environment.

Sign: 3. Encouraged the use of 3. To distract attention

- Temp:
relaxation techniques such and reduce tension.

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 36C as focused deep breathing
- PR: 80
exercise, imaging,
beats
CDs/tapes.
per
4. Encouraged adequate 4. May reduce muscle
minute
- RR: 24 periods of rest and sleep tension and anxiety,

breaths thereby producing

per relaxation effect

minute
- BP:
5. Administered analgesic, as 5. To prevent fatigue
90/70
indicated, to maximum which may
mmHg
dosage, as needed contribute to pain

(morphine tab) and to assist client

oxycontin 1 tab 10 mg one to explore methods

a day, pregabalin 75mg 1 for

tab one a day. alleviation/control

of pain.

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 Nursing Care Plan II

Assessment Diagnosis Goal of Care Intervention Rationale Evaluation

Subjective: Imbalanced Short term: 1. Identify client at risk 1. To determine Goal Not Met:

Patient EMD nutrition less After 3 days of for malnutrition informational - Patient still

said, she has than body nursing (client with chronic needs of client weak and no

no appetite. requirement interventions, the illness) appetite to

Objective: related to patient will be eat

Patient looks anorexia able to consume 6 2. Assessed nutritional 2. Identify

weak spoonsful of rice history, including a deficiencies,

Looks pale and viand instead preferred food. suspect the

mucous of 3. possibility of

membranes Long term goal: intervention.

Patients has - After 1 3. Assessed weight;

just eaten 2-3 month of calculate body fat (if 3. Observing

155
 spoons of nursing possible). weight loss /

food interventions, observe the

Diet: DAT, patient will effectiveness of

low salt low demonstrate the intervention

fat progressive 4. Observed and record

4. Observing
Weight: 40 weight gain the patient's food
caloric intake /
kgs and will have intake.
lack of quality
BMI = 18.5 a BMI of at
food
least 18.5
consumption.
24.9

(Normal) 5. Give food a little but

- Display 5. Little food can
often and or eat
normalizatio reduce
between meals.
n of vulnerabilities

laboratory and increase

values and be input also

156
free of sign prevent gastric

malnutrition distention.

6. Explored specific

eating habits 6. Identifies eating

(vegetables) habits.

7. Given and helped on

oral hygiene. 7. Increased

appetite and

8. Reviewed indicated oral input.

laboratory data 8. To identify

(albumin, BUN) deviations from

the normal and

to establish

baseline

9. Administered parameters

pharmaceutical 9. This will helps

157
 agents; vitamin and improve

mineral (iron) Nutritional

supplements supplementatio

(Buclizine with Iron n in patients w/

1 tab once a day) depressed

appetite.

Nursing Care Plan III

Assessment Diagnosis Goal of Care Intervention Rationale Evaluation

Subjective: Activity Goal: 1. Performed proper 1. Isotonic exercises Goal met:

The private intolerance exercise program to prevent

After 3 days of The patient respons
nurse said that related to (isotonic, active or contractures and
nursing to interventions
sometimes she generalized passive exercise) at least muscle atrophy,
interventions: and patient
can perform weakness 4 hours at a time on the maintain isometric
participate in
1. Clients
simple exercise hands, feet, and neck as muscle strength,
actions performed
can maintain
(walked around indicated. joint motion

158
corridor in the the normal maintains a and treatment

hospital and the function of passive exercise. regimen.

private nurse the

2. Self-care can
hold her hand musculoskel
move the joints
and body) but etal shown 2. Motivated patient to
and muscles of the
can only stay 10- by the whole participate in self-care.
body are active.
15 minutes. range of
3. Can facilitate
Weakness motion in
3. Positioned the client in early intervention
Objective: the joints of
accordance with body anyway.
She just laying the body
alignment.
on the bed, looks within 4. By positioning the

4. Monitored vital signs client in

weakness, pain, normal
according to client needs. accordance with
erosion on the limits,

bone muscle mass body alignment

and strength. can help prevent

contractures and

159
 maintain

structural integrity

of joints and

muscles.

Nursing Care Plan IV

160
 Assessment Diagnosis Goal of Care Intervention Rationale Evaluation
Subjective: Fatigue related - After 8 hours Identify the presence Important Partially met:

he patient can to physiological of nursing of physical and information can

- Patient still
walked a little condition intervention psychological be obtained from
weak
around the (anemia). the patient condition (anemia; knowing if fatigue

corridor, as her perform cancer treatment) is a result of an

verbalized. activities of underlying

daily living condition or

Objective: and participate disease process

- Weak in desired To assist in

- Pale (Hgb: activities at Obtain client/ SO evaluating the

3.79 x 10^ level of ability. descriptions of fatigue impact on the

6/UL) - Participate in (i.e., lacking energy or clients life.

recommended strength, tiredness,

Vital Sign: treatment weakness)

- Temp: 36C
- PR: 80 program Ask the client to rate

161
 beats per fatigue (using a 0 to 10 Fatigue may vary

minute or similar numerical in intensity and is

- RR: 24
scale) and its effects often
breaths per
Long term: on the ability to accompanied by
minute
- BP: 90/70 participate in desired irritability, lack of

mmHg - Within 6 days activities. concentration.

of nursing Review medication

-
interventions, regimen/ use Certain

the client will medication,

report including

improved prescription are

sense known to cause

of energy and/ or exacerbate

- Patient fatigue.

perform Monitor vital sign

activities of Basis before

162
 daily living performing

and participate exercise

in desired

activities at

level of ability

- Participate in

recommender

treatment

program

163