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VII. Nursing Care Plans

Assessment Diagnosis Planning Intervention Rationale Evaluation

Subjective: nahihirapan

Safe care deficit:hygiene related to

After hours ofnursing

! identify degree ofindividual impairment

!to identify thee"tent of the

After hours ofnursing

Assessment Diagnosis Planning Intervention Rationale Evaluation

Subjective:nars panu #olilinisin ng maayosang ari #o$

Ris# for infectionrelated toinsufficient#no%ledge toavoid e"posure topathogens

After hours ofnursingintervention& thepatient verbali'eunderstanding ofris# factors

!teach ris# factors foroccurrence of infection(e") s#in integrity&environmental e"posure*!Proper hand %ashing!cleanse incision sitesdaily

!to have proper#no%ledge aboutris# factors ininfection!to avoid crosscontamination!to prevent buildup of pathogens

After hours ofnursingintervention& thepatient hasverbali'edunderstanding ofris# factors

Assessment Diagnosis Planning Intervention Rationale Evaluation

Subjective:$Sumasa#it sa#it unginoperahan sa#in$as verbali'ed bythe patient+bjective:!,rimace facialreaction!pain scale of -

Pain related tosurgical incision

After hours ofnursingintervention& thepatient %ill sho%decrease or reliefof pain)

!monitor vital signs&including pain scale

!provide ade.uate restperiods and assist in acomfortable position!encourage deepbreathing e"ercises!administer analgesics asordered

!establishbaseline in orderto determineneededinterventions!promotesrecovery! relieves muscleand emotionaltension! to relieve pain

After hours ofnursingintervention& thepatient has sho%nrelief of pain)

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a#ong linisanang ari #o

pain& discomfort intervention& thepatient %ill be ableto perform safecare activities

%ithin level of o%n

ability

!allo% patient to performactivities to the fullest ofhis ability and assist asneeded

!provide positivereinforcement for tas#ssuccessfully and/orindependentlyaccomplished

patient0sstrength!to ma#e thepatientindependent of

their o%n s#illsand assist ifneeded)!forencouragementof the patient toparticipate in theactivities

intervention& thepatient is able toperform safe careactivities

Assessment D

iagnosis Planning Intervention Rationale Evaluation

Subjective:

madalas a#o

matuyuan ng

lalamunan

ngayon at tuyo

lagi ang bibig

#o$

+bjective:

!Decrease

urine output!1hirst

(drin#ing

eagerly*

!Dry lips and

s#in

!Poor s#in

turgor

2luid volume

Deficit related

to dehydration

as manifested

by diarrhea

After hours

of 3ursing

Interventions&

the patient

%ill sho%

improved

hydration

status

!monitor I/+

!instruct to

increase oral

fluid inta#e

!advice to

avoid caffeine&

tea& grape and

fruit juice

(diuretics*

!advice to ta#efluids that

replaces

needed

electrolytes

(e") ,atorade*

!accurately

measuring

inta#e and

output is vital

for the client

%ith fluid

volume

overload

!to add more

electrolyte tothe body

1he goal %as met