NURSING CARE PLAN

ASSESMENT

NURSING

GOAL OF CARE

S: Ma init katawan

DIAGNOSIS
Hyperthermia related

After 10 hours of

ko As verbalized by

to the infectious

comprehensive nursing

process

intervention, the patient

client
O:

temperature will lower

-Skin warm to touch

down to normal levels:

with a temperature of

T: 36.5C 37.5C

38.0C
-Weakness observed
-Dry mucous
membranes
-Flushed Skin
-Pallor in palms
-WBC 3.18
-Hgb 10.9g/dL
-Hct 30.8%
-RBC 3.5g/
ASSESMENT

NURSING

GOAL OF CARE

INTERVENTION
INDEPENDENT
1. Provided tepid sponge
bath.
2. Assessed fluid loss &
facilitate oral intake.
3. Promoted bed rest.
4. Provided cool
circulating air using a
fan.
5. Assisted patient in
changing into dry
clothing.
6. Provided oral hygiene.
7. Monitored vital signs.
COLLABORATIVE
1. Maintained IV fluids as
ordered by physician.
2. Administered anti-pyretic as
ordered.
3. Administered antibiotic as
ordered.
INTERVENTION

EVALUATION
After 10 hours of
rendering nursing
intervention the patient
report a decrease of
body temperature from
38.0 to 36.9

EVALUATION

S: Nanghihina pa

DIAGNOSIS
Activity intolerance

katawan ko As

related to imbalance

verbalized by client

between oxygen
supply and demand

O:
-Decreased physical
activity
-Fatigue
-Generalized
weakness

After 10 hours of
Nursing interventions,
the patient will be able
to identify techniques
to enhance activity
tolerance such as:
1. Gradual increase in
activity level as
tolerated.
2. Rest in between
activities.

-Pallor in palms
-Hgb 10.9g/dL
-Hct 30.8%
-RBC 3.5g/

3. Client will
participate willingly in
necessary or desired
activities

INDEPENDENT
1. Assessed ability to
ambulate
2. Assessed capillary
refill.
3. Assessed skin turgor
4. Assisted client to
prioritized activities of
daily livings.
5. Planned activity
progression with client,
including activities that
client views as essential.
6. Evaluated reports of
fatigue, noting inability
to participate in
activities or ADLs
COLLABORATIVE
1. Monitored laboratory
studies especially
hemoglobin or
Hematocrit and RBC
count, arterial blood
gases.
2. Provided supplemental
oxygen as indicated

Goal partially met:

-Client still have pallor
in the palms,
-Patient demonstrated a
decrease in
physiological signs of
intolerance.
-Patient participated
willingly in necessary
desired activities.

ASSESMENT
S: May
mgapasaposaakinghita
As verbalized by
client
O:
-Bruises on both lower
extremities

NURSING

GOAL OF CARE

DIAGNOSIS
Ineffective protection

After 10 hours of

related to abnormal

nursing intervention

blood profile as

the client will be

evidenced by

protect from infection

reduced WBC and

and bleeding hazard

platelet count

that may contribute to

patients health

INTERVENTION

1.
2.

3.

condition.

-skin warm to touch

-Pallor in palms

1. To protect client

-Hgb 10.9g/dL

from bleeding and

-RBC 3.5g/dl

lessen the risk of injury

-WBC 3.18
-Platelet 30,000
2. To protect client
from infection

4.

INDEPENDENT
Monitored v/s.
Inspected skin/mucous
membrane for
petechiae, ecchymosis
areas, note bleeding
gums, blood in stools
and urine
Implemented measure
to prevent tissue
injury/bleeding. (Avoid
sharp object, minimize
invasive procedure,
gentle brushing of teeth
and gums with soft
toothbrush, avoid
needle stick, using
sustained pressure on
oozing puncture site)
Limited oral care to
mouthwash if indicated.
Avoid mouthwashes
with alcohol.

To protect client from infection.

EVALUATION
Goal Met
-The client protected
from Bleeding hazards
and the risk of injury
had been lessened.
-The client protected
from infection
-Demonstrated
improvement of V/S,
body temperature
lowered to 36.9C

1. Promoted good handwashing procedures by

staff and visitors.
Screen and limit visitors
who may have
infections. Place in
reverse isolation as
indicated.
2. Emphasized personal
hygiene.
3. Monitored temperature.
4. Stressed importance of
good oral hygiene.
Dependent:
1. Monitored CBC with
differential WBC and
granulocyte count, and platelets
as indicated.
2. Administered antibiotics as
indicated.
3. Administered Antipyretic as
needed

ASSESMENT

NURSING

GOAL OF CARE

DIAGNOSIS
Anxiety related to

After 10 hours of

fear of leukemia

Nursing interventions,

ayankongayon As

diagnosis as

the patient will be able

verbalized by client

evidenced by

to identify techniques

shakiness &

to managed anxiety.

restlessness

1. Display appropriate

S:
Natatakotakosakalag

O:
-Perspiration
-Shakiness
-Generalized
weakness
-Pallor in palms
-Restlessness

INTERVENTION

1.

2.
3.

range of feelings and

lessened fear.

4.

2. Appear relaxed and

report anxiety is
reduced.

5.

3. Demonstrate use of
effective coping
mechanisms and active
participation in
treatment regimen.

6.
7.

INDEPENDENT
Reviewed patients and
SOs previous experience
with cancer.
Encouraged patient to
share thoughts and feelings.
Provided open environment
in which patient feels safe
to discuss feelings or to
refrain from talking
Maintained frequent
contact with patient. Talk
with and touch patient as
appropriate
Assisted patient and SO in
recognizing and clarifying
fears to begin developing
coping strategies for
dealing with these fears.
Promoted calm, quiet
environment.
Provided reliable and
consistent information and

EVALUATION
Goal met:
-Client able to
expressed fear and
feelings and lessened
anxiety
-Client reported and
appeared to be more
relaxed
-Client participated
willingly in activities
and verbalized
management of
anxiety

support for SO

DM

ASSESMENT

NURSING

GOAL OF CARE

S-Nahihirapansiyasa

DIAGNOSIS
Ineffective Airway

After 10 hours of

pagginhawadahilsaple

Clearance related to

Nursing interventions,

manyaas verbalized

presence of mucus

the patient will be able

secretions

to

by the significant

INTERVENTION

1.

2.

others.
1. Patient will
O-

demonstrate maintain

3.
4.

airway patency.
Presence of mucus
secretions during

2. Patient will be able

coughing

to expectorate or clear

Difficulty breathing,

secretions readily.

abnormal breath
sounds like crackles.

3. Patient will
demonstrate behaviors

1.

2.

INDEPENDENT
Auscultated chest for
character of breath sounds
and presence of secretions.
Observed amount and
character of sputum or
aspirated secretions.
Assessed airway patency
Noted ability to expectorate
mucus/cough effectively;
document character,
amount of sputum,
presence of hemoptysis
DEPENDENT
Administered expectorants,
and/or analgesics as
indicated.
Monitored serial
ABGs/pulse oximetry;
chest x-ray.

EVALUATION
After 10 hrs. Patient
can able to breathe in
without the use of
accessory muscle,
and noted to have
clear airway as
evidence by absence
of crackles.

to improve or maintain

3.

clear airway.
ASSESMENT
SMataas ang blood
pressure niya as
verbalized by the SO.
O-

NURSING

GOAL OF CARE

DIAGNOSIS
Ineffective tissue

After 10 hours of

perfusion r/t to

rendering appropriate

1.

vascular resistance

nursing intervention the

2.

secondary to

patient will maintain

hypertension

optimal tissue
perfusion as evidence

INTERVENTION

3.

by strong peripheral
-pale skin noted

pulses, absence of

-cold clammy skin

pulses, cold clammy

-rapid pulses noted

skin and edema and

-edema

will not experience

-decreased level of

chest pain.

consciousness

Outcome criteria :

1. Verbalizes
understanding of the
diseased and its long

Humidified inspired air or

oxygen.

4.

5.
6.

INDEPENDENT
Monitored quality of pulses
and bp.
Assessed knowledge of
diseased and prescribed
management.
Provided information on
normal tissue perfusion and
possible causes for
impairement. Instruct the
patient to informed the
nurse immediately if
symptoms of the perfusion
persist, increased
Done passive range of
motion exercise to affected
extremities 2-4 hours.
Positioned properly
Avoided measures that
trigger the increased ICP
( e.g straining, strenuous

EVALUATION
Patients blood
pressure is still above
normal which is
160/110

term effects on target

organs and demonstrate
increased perfusion as
individually

7.
8.

appropriate.
2. Demonstrate
behavior of lifestyle
changes to improve
circulation.
3. Verbalized
understanding of
therapy regimen, side
effects of medication
and when to contact
health care providers.

1.
2.

coughing, positioning with

neck in flexion, head flat).
Involved family and
significant others.
Avoided sudden changes in
position
DEPENDENT
Administered oxygen as
ordered.
Administer an
antihypertensive drugs

ASSESMENT

NURSING

GOAL OF CARE

S-

DIAGNOSIS
Activity intolerance

After 10 hours of

Madalisiyangmapag

related to imbalance

Nursing interventions,

od As verbalized by

between oxygen

the patient will be able

supply and demand

to

secondary to anemia

1.Will show absence of

SO
O-

pallor in the skin and

Pale skin and

mucous membranes.

mucous membrane

2.Will demonstrates a

Generalized

decrease in

weakness

physiological signs of

Brittle nails

intolerance.

Capillary refill

3.Client will participate

delayed
Presence of

willingly in necessary

INTERVENTION

1.

2.
3.
4.

5.

1.

or desired activities.

leukonychia
2.

INDEPENDENT
Monitored blood pressure,
respirations during and
after activity.
Elevated head of bed as
tolerated.
Recommended quiet
atmosphere
Assisted client to
prioritized activities of
daily livings.
Planned activity
progression with client,
including activities that
client views as essential
DEPENDENT
Monitored laboratory
studies especially
hemoglobin or hematocrit
and RBC count, arterial
blood gases.
Provided supplemental
oxygen as indicated

EVALUATION
Goal partially met:
-Client still has pallor
in the palms, and
mucous membranes.
-Patient
demonstrated a
decrease in
physiological signs
of intolerance, such
as lowered blood
pressure, BP=120/80
mmHg
-Patient participates
willingly in
necessary desired
activities.

CARDIO

ASSESMENT

NURSING

GOAL OF CARE

INTERVENTION

EVALUATION

DIAGNOSIS
Ineffective breathing

After 10 hours of

INDEPENDENT

Goal met:

pattern related to

Nursing interventions,

huminga at saka

shortness of breath

the patient will be able

kinakapos ako sa

secondary to dyspnea

SNahihirapan akog

paghinga. As
verbalized by the
patient
O-Dyspnea
-Observed physical
discomfort
-use of accessory

1. Verbalize
awareness of
causative
factors
2. Demonstrate
appropriate
coping
behaviors like
proper
breathing

1. Assess respiratory rate and

depth by listening to lung
sounds.
2. Note muscles used for
breathing(sternocleidomastoid,

Patients able to
1. Verbalize
awareness of
causative
factors
2. Demonstrate

diaphragmatic) and

appropriate

retractions/flaring of

coping

nostrils
3. position client with proper
body alignment(semifowler_s position)
4. Ensure that oxygen delivery

muscle noted

system is applied to the

-oxygen in use via

patient, the appropriate

nasal cannula, 2-

amount of oxygen is

behaviors like
proper
breathing

3L/min

delivered
5. pace and schedule activities
providing adequate rest
periods
6. Encourage sustained deep
breaths by emphasizing
slow inhalation, holding
end inspiration)
7. Teach client appropriate
deep breathing and
coughing techniques
DEPENDENT
1. Administer oxygen at
lowest concentration
indicated
2. Refer the client to a
dietician and or support
groups.

ASSESMENT

NURSING

GOAL OF CARE

INTERVENTION

EVALUATION

After 10 hours of

INDEPENDENT

Goal partially met:

S-

DIAGNOSIS
Decreased cardiac

nahihirapan ako sa

output related to

Nursing interventions,

pag hinga, as

altered stroke

the patient will be able

Auscultate apical pulse;

Participate in

verbalized by the

volume: altered

to

note heart sounds; and

activities that reduce

client.

preload & afterload

Participate in activities

the workload of the

secondary to dilated

that

palpate peripheral pulses.

2. Check for calf tenderness;

O-

cardiomyopathy as

reduce

the

workload of the heart

-Decreased peripheral

evidenced by edema,

such

as

pulses

dyspnea and cold

medication

-Edema

clammy extremities.

weight reduction, and

-dyspnea

balanced

-cold clammy skin

plan.

-generalized
weakness

therapeutic
regimen,
activity/rest

1. Assess vital signs.

diminished pedal pulse;

swelling, local redness, or
pallor of extremity.
3. Monitor urine output,
noting decreasing output
and dark/concentrated
urine.
4. Encourage rest,
semirecumbent in bed or
chair. Assist with physical
care as indicated; elevate
legs, avoiding pressure
knee.

Patient able to

heart.
.

DEPENDENT
1. Monitor serial ECG, chest
x-ray changes, laboratory
studies (BUN, Creatinine)
2. Administer medications as
indicated: diuretics,
vasodilators, ACE
inhibitors, Digoxin,
inotropic agents,
adlosterone antagonist,
anticoagulant
3. Administer IV solutions,
restricting total amount as
indicated. Avoid saline
solutions.

ASSESMENT
S-

NURSING

GOAL OF CARE

INTERVENTION

EVALUATION

DIAGNOSIS
Fatigue related to

After 10 hours of

INDEPENDENT

Goal partially met:

Madalisiyangmapag
od As verbalized by

body weakness and

increase demand on

SO

Nursing interventions,
the patient will be able
to

physical exertion.

1.Will show absence of

O-

pallor in the skin

Pale skin and

2.Will demonstrates a

mucous membrane

decrease in

Generalized

physiological signs of

weakness

intolerance.

Capillary refill

3.Client will participate

delayed

willingly in necessary
or desired activities.

1. Monitored blood pressure,

respirations during and
after activity.
2. Elevated head of bed as
tolerated.
3. Recommended quiet
atmosphere
4. Assisted client to
prioritized activities of
daily livings.
5. Planned activity
progression with client,
including activities that
client views as essential
DEPENDENT
1. Monitored laboratory
studies especially
hemoglobin or hematocrit
and RBC count, arterial
blood gases.
2. Provided supplemental
oxygen as indicated

-Client still has pallor

in the palms, and
mucous membranes.
-Patient participates
willingly in
necessary desired
activities.