VI.

NURSING CARE PLAN

ASSESSMENT DATA NURSING DIAGNOSIS GOALS AND NURSING INTERVENTIONS AND EVALUATION
(Problem and Etiology) OBJECTIVES RATIONALE
(Subjective & Objective
Cues)

Subjective: Deficient Fluid Volume: Short term goals: Independent: Short-term.

hypertonic related to Goals met.
“sige man siya ug suka…” as frequent vomiting After 4 hours of 1) Maintain accurate intake and After 4 hours of
verbalized by the watcher. thorough nursing output, calculate 24-hour fluid thorough
intervention, the client balance and weigh daily. nursing
“galisod ko ug ihi” as will be able to: R – It serves as a baseline for doing intervention,
verbalized by the patient such interventions. the client was
a) reduce vomiting 2) Promote a well-ventilated able to reduce
by promoting an environment conducive for eating. vomiting by
environment R – To avoid the occurrence of
Objective: promoting an
conducive for vomiting. environment
• dysuria doing ADL’s 3) Provide frequent oral and skin conducive for
• serum Na+ level of b) improve skin care. doing ADL’s
115.5 meq/L turgor of the R – To prevent injury from dryness. and improved
(hyponatremic) patient from poor 4) Change position frequently skin turgor of
• decreased skin turgor to fair. R – To promote proper circulation the patient
of blood, thus, preventing from from poor to
Long term goals:
fluid deficit. fair.
After 1 day of thorough
Dependent: Long term.
nursing intervention,
the client will be able Goals met.
1) Administer medication
to: After 1 day of
(metoclopramide 1 ampule IVTT),
thorough
as ordered
a) Maintain body nursing
R – To decrease the occurrence of
fluid levels. intervention,
vomiting.
b) Completely the client was
2) Administer fluids and electrolytes
eliminate the able to
(PNSS 1L with 40 meq KCl), as
occurrence of maintain body
ordered.
vomiting. fluid levels,
R – To gradually correct the
c) Increase serum completely
deficient in fluid (hypertonic)
Na+ level from eliminated the

Page 38
 VI. NURSING CARE PLAN
115.5 meq/L to occurrence of
128.7meq/L. vomiting and
increased
serum Na+
level from
115.5 meq/L to
128.7meq/L.

ASSESSMENT DATA NURSING DIAGNOSIS GOALS AND NURSING INTERVENTIONS AND EVALUATION
(Problem and Etiology) OBJECTIVES RATIONALE
(Subjective & Objective
Cues)

Subjective: Imbalanced Nutrition: Short term goals: Independent: Short term

less than body goals:
“wala man siya’y gana mukaon requirements related to At the end of 2 hours 1) Use flavoring agents
tapos kung mukaon kay of nursing intervention R - To determine enhance food Goal partially
frequent vomiting and
musuka man dayon” as the patient will be able satisfaction and stimulate appetite met, At the end
poor appetite.
verbalized by the watcher to: 2) Encourage client to choose foods. of 2 hours of
Have family members bring foods nursing
a) Verbalize food that seen appealing (which are not intervention
preference which contraindicated)
Objectives: the patient will
is not
R – To stimulate appetite. be able to
contraindicated
• weakness to hr underlying 3) Promote pleasant, relaxing verbalize food
• weight loss of 4kg over disease to environment, including preference
a week (from 47 kg to promote good socialization when possible. which are not
43 kg) appetite. R - To enhance foo intake contraindicated
b) Improve appetite 4) Prevent/minimize unpleasant odors
• consuming ¼ share to hr
from poor to fair R – to reduce the occurrence of underlying
by eating ½
nausea and vomiting. disease to
share from ¼
share. promote good

Page 38
 VI. NURSING CARE PLAN
c) Reduce the Dependent: appetite and
occurrence of reduced the
vomiting. 1) Administer medication occurrence of
(metoclopramide 1 ampule IVTT),
Long term goals: vomiting but
as ordered
R – To decrease the occurrence of failed to
After 1 month of vomiting. improve
thorough nursing appetite from
intervention, the client Collaborative: poor to fair by
will be able to:
1) Refer to dietician fro modification eating ½ share
a) Regain the of diet (General Liquids) from ¼ share
weight loss of R – to gradually stimulate appetite
4kg to weigh for fast recovery. Long term
47kg from 43 kg. goals:

Goals not met

for patient was
not further
assessed.

ASSESSMENT DATA NURSING DIAGNOSIS GOALS AND NURSING INTERVENTIONS AND EVALUATION
(Problem and Etiology) OBJECTIVES RATIONALE
(Subjective & Objective
Cues)

Risk Factors: Risk for injury related to After 1 hour of Independent: Goals met.
uncontrolled body thorough nursing 1. Provide Health Teaching about After 1 hour of
• Knowledge deficit of movement secondary to providing safety during seizure
interventions, the thorough
the family members seizure attack. attacks.
on what to do when patient will be able to: nursing
R = to educate the patient and the
seizure occurs. significant others as well. interventions,
• Generalized a) Verbalize the the patient was
involuntary need for help in able to
2. Demonstrate the different ways in
movements during addressing the preventing th client from injury like verbalize the
seizure attack problem. putting the side rails up. need for help in
b) Understand the R = to promote safety unto the

Page 38
 VI. NURSING CARE PLAN
• Old age; weak and ways in clients. addressing the
restless managing the problem,
risk for injury 3. Instruct clients significant others to understood the
never leave the client alone
c) Demonstrate ways in
especially during seizure attack.
different ways in R = to prevent further damage and managing the
order to avoid injury. risk for injury
the occurrence of and
injury together demonstrated
with the Dependent: different ways
significant in order to
1. Administer medication, (diazepam
others. 1 ampule IVTT), as ordered avoid the
R = to treat active seizure, thus, occurrence of
promoting safety of the client for injury together
further possible injuries. with the
significant
others.

Page 38