Nursing Care Plans

XI.
NURSING CARE PLAN
#1 Nursing Problem: Difficulty of Breathing

CUES
NURSING
RATIONAL
PLANNIN
s>
DIAGNOSIS
Ineffective
E
G
Edema in the After
Nahihirapan
breathing
form
akong
pattern
huminga,
as pressure
verbalized
by diaphragm
the patient.
o> RR-30 bpm
>nasal flaring
>use
of edema.
of increased respiration.
in the lungs.
r/t ascites,
appropriate
on besides
nursing
>Placed the client in semi >to
intervention
fowlers position with arms pressure
compressing
and may
can
the supported with pillows.
on easily
diaphragm.
without
complaints
breathe with >Maintained calm attitude >to limit the level of

also minimal
cause shallow difficulty.
while dealing with client of anxiety.

and to significant others.
breathing and
muscles
impaired gas
>Encouraged adequate rest >to limit fatigue
>anasarca
exchange
periods between activities.
>ascites
resulting
>(+) crackles
respiratory
>Instructed patient to avoid >they can cause
compromise
overeating/gas-forming
abdominal
foods.
distention.
auscultation
now
relives breathe
accessory
upon
EVALUAT
The patient
thus affects its patient will
secondary to functions,
ascites
RATIONALE
ION
2 >Assessed for crackles and >identifies fluids Goal met.
of hours
reduced lung the liver and s,

capacity
INTERVENTIONS
in
difficulty.
# 2 Nursing Problem: Fluid Retention
CUES
ND
RATIONALE
PLANNING
INTERVENTIONS
RATIONALE
EVALUATI
ON
s>Nahihira
pan
Fluid
Fluid
akong volume
huminga
excess
volume After
excess
occurs
>Maintained
(FVE) appropriate
when
the nsg.
dahil sa laki r/t
body retains both Interventions,
ng tyan ko, excess
water and sodium the
as
fluid
in
verbalized
intake
proportions
by
the second
patient.
ary
o>edema,
edema.
I&O. Note decreased cardiac insufficiency, and met.
The
urinary output, (+) fluid fluid shift may caused patient
has
balance, (intake greater decreased urinary output stabilized
will than
similar demonstrate
accurate >decrease renal perfusion, Goal partially
output &
edema
fluid as
evidence
to stabilize fluid Be alert for acute or retention equals a weight by
balance
normal ECF. FVE volume
to is always secondary evidence
>Weighed as indicated. >one

as sudden
wt.
gain. gain
liter
formation. fluid volume
of
of
22lbs. I&O,
by >Followed sodium & >help to decrease ascites within
to an increase in balanced I&O, fluid
restrictions. and
edema normal
anasarca
total body water, v/s
>RR-30
because both water normal limits, IVF as indicated with as extracellular shifts,
still
bpm;restless
and
edema,
ness;
concentration
easy
fatigability
remains essentially edema.

normal
within >given oral fluids & >fluid restrictions, as well limits,
sodium and free from caution

signs
and
the
excess volume of
v/s
of >Administered
diuretics as ordered.
>promotes excretions of
fluids.
but
(+)
anasarca and
wt. gain.
fluid is isotonic.
# 3 Nursing Problem: Changes in body image
CUES
NURSING
RATIONALE
PLANNING
INTERVENTIONS
RATIONALE
EVALUATION
DIAGNOSIS
>determines
s> Ang laki Disturbed
laki
na
ng image
katawan
ko
abdominal
as enlargement
verbalized by secondary
the patient.
edema
ascites.
o> not looking

@ her body,
noted
>unintentional
hiding of body
body When edema is After

r/t present,
the appropriate
response
to
client is at risk nursing
changes.
>Promoted
for
accepting
to development
Interventions,
the
&
body
non-
patient judgmental attitude.
disturbance.
understanding
& acceptance
in
body
changes & of
self
in
shift.
ventilation of feelings.
>Listened to clients
comments
and
to
the
the
>Visited
frequently
acknowledge
body
image disturbance.
>respects
the
clients sensitivity
body
image
client
&
the
Goal met. The

patient accepted
and understands
changes in his
self
&
situation.
>helps the client

feel
valued.
>depending
individual
skills
situation.
situation
of
changes.
>encouraged
response
extent
to
and of body image will verbalize
within
>changes in
>Assessed the clients
the
and
on
coping
past
experiences.
>provides
opportunity
for
in
social
individual as someone
involvement
who is worthwhile.
listening
to
concerns
and
questions.
# 4 Nursing Problem: Body weakness
CUES
NURSING
RATIONALE PLANNING
INTERVENTIONS
RATIONALE
EVALUATION
DIAGNOSIS
>conserve energy &
s>
Konting Activity
After
>alternated rest & sleep
galaw o lakad intolerance r/t
appropriate
activity.
ko
nsg.
lang ascites,
napapagod na muscle
and
Interventions,
ako, ang dali wasting
the
patient
kong
will
feel
manghina, as
rested
with
verbalized by
fewer
the patient.
complaints of
fatigue
o>easy
fatigability,
>Assisted
with
activity
intolerance
&
>Noted client report on result

pain,
of
&
or
fatigue, contribute
to
difficulty intolerance
of
accomplishing tasks.
activity pattern.
>helps to minimize
in >Provided
positive
can
tolerate activity
better and can
perform
>symptoms may be
increase
tolerance
>increase
endurance.
(ADL)
Goal met. The

client
liver.
activities of daily living
weakness,
&
reduces demands on
more
ADLs
&
experience less
dyspnea
tachycardia.
&
frustrations
noted
activity.
atmosphere.
rechanneled energy.
>body
weakness,
noted
>PR-120 bpm
RR-30 bpm
>Promoted
&
comfort
measures & provided

for the relief of pain.
>to enhance ability

to participate in the
activity.

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XI.

NURSING CARE PLAN

#1 Nursing Problem: Difficulty of Breathing

>Placed the client in semi >to

fowlers position with arms pressure

the supported with pillows.

breathe with >Maintained calm attitude >to limit the level of

cause shallow difficulty.

while dealing with client of anxiety.

>Encouraged adequate rest >to limit fatigue

periods between activities.

>Instructed patient to avoid >they can cause

thus affects its patient will

reduced lung the liver and s,

# 2 Nursing Problem: Fluid Retention

dahil sa laki r/t

body retains both Interventions,

ng tyan ko, excess

water and sodium the

I&O. Note decreased cardiac insufficiency, and met.

urinary output, (+) fluid fluid shift may caused patient

balance, (intake greater decreased urinary output stabilized

accurate >decrease renal perfusion, Goal partially

to stabilize fluid Be alert for acute or retention equals a weight by

normal ECF. FVE volume

to is always secondary evidence

>Weighed as indicated. >one

formation. fluid volume

by >Followed sodium & >help to decrease ascites within

to an increase in balanced I&O, fluid

total body water, v/s

remains essentially edema.

within >given oral fluids & >fluid restrictions, as well limits,

sodium and free from caution

o> not looking

body When edema is After

client is at risk nursing

patient judgmental attitude.

Goal met. The

>helps the client

and of body image will verbalize

>Assessed the clients

# 4 Nursing Problem: Body weakness

>alternated rest & sleep

galaw o lakad intolerance r/t

ako, ang dali wasting

>Noted client report on result

Goal met. The

activities of daily living

measures & provided

>to enhance ability

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