XI.

NURSING CARE PLAN

NURSING NURSING ANALYSIS GOAL AND NURSING RATIONALE EVALUATION
PROBLEM DIAGNOSIS OBJECTIVES INTERVENTIONS
CUES
Interaction Altered Immediate Cause: GOAL:
tissue When the cancer After 2 days
Chief perfusion cells continue to nursing
complaint was related to grow and intervention,
vaginal hypovolemia metastasize in the client will
bleeding as different parts of be able to
manifested the body system show signs of
profuse by extremity especially in blood improved
bleeding weakness vessels, it can tissue
consuming 3 impede blood perfusion and
infant diapers circulation and increased
could cause circulating
occurrence of vaginal bleeding. blood volume
pain in her This could also as manifested
lower hamper sexual by warm skin,
abdomen pain activity between normal
(5/10) partners. Other peripheral
signs and pulses, vital
she is not able symptoms include signs within
to walk by bladder irritation client’s normal
herself since and distention, range, and
she was anemia, and increased
admitted in abdominal pain capillary refill
Rizal Medical Black, et.al.
Center (2005).Medical OBJECTIVES:
“Nanghihina Surgical Nursing. Collaborative Collaborative
kasi ang 7th Edition.Elsevier Facilitative
buong PTE LTD.p 927 After 6 hours Refer to the To achieve maximal The client was
katawan ko of nursing attending gains in function and able to regain the
eh”, as Intermediate intervention, physician and the psychosocial well- loss of blood
verbalized by Cause: the client will hematology being.
the client. Cervical cancer be able to laboratory Doenges, et. al, (2008).
begins in cells on regain the loss Nurse’s Pocket Guide.
“Hindi pa ako the surface of the of blood 11th Edition. F.A. Davis
nakakatayo cervix. Over time, Company. p. 608
simula nang the cervical cancer
maadmit ako. can invade more Have the client To prevent untoward
Nangangalay deeply into the undergo blood blood reaction.
na rin mga cervix and nearby typing and cross Kozier, et al.
paa ko”, tissues. The cancer matching (2008).Fundamentals
according to cells can spread by of Nursing.8th
her breaking away from Edition.Pearson.pp140
the original 2 – 1420.
She was (primary) tumor.
advised by They enter blood Have the client To increase circulating
her physician vessels or lymph undergo a series blood volume and
not to do any vessels, which of blood improve tissue
strenuous branch into all the transfusion perfusion.
activities tissues of the body. Doenges, et. al, (2008).
The cancer cells Nurse’s Pocket Guide.
Weight loss may attach to other 11th Edition. F.A. Davis
tissues and grow to Company. p. 710.
Loss of form new tumors
appetite that may damage Get the baseline Provides comparison
those tissues. The vital signs before with current findings
Observation spread of cancer is transfusion Doenges, et. al, (2008).
called metastasis. Nurse’s Pocket Guide.
The client is Black, et.al. Carry out post BT 11th Edition. F.A. Davis
currently on (2005).Medical order Company. p. 708
blood Surgical Nursing.
transfusion 7th Edition.Elsevier Check the vital
and IV PTE LTD.p 927 signs after BT;
infusion compare it with
Root Cause: the baseline vital
We noticed HPV (Human signs.
that the client papilloma Virus)
is in a difficult passed from
situation to Facilitative
person to person
move at the After 15 Have a doctor To prevent any problem The client was
time of through sexual minutes of countercheck the in relation to transfusion able to show no
interview contact can cause nursing compatible blood Kozier, et al. signs of
cervical dysplasia intervention, with the nurse (2008).Fundamentals transfusion
The client or the abnormal the client will of Nursing.8th reaction
looks weak alteration in cell be able to Observe any Edition.Pearson.pp140
structure. . New show no signs untoward signs 2 – 1420.
Pale Skin cells form when the of transfusion and symptoms
reaction
body does not
The client’s
need them, and old Independent Independent
skin is slightly
or damaged cells Supplemental
dry.
do not die as they After 10 Explain the Encourage client’s The client was
Pale nail beds should. The buildup minutes of purpose and the cooperation and able to enumerate
of extra cells often discussion, the benefits of the decrease anxiety of the 3 out of 4
Cold in forms a mass of client will be treatment to the client. purposes of the
extremities tissue called a able to client Kozier, et al. treatment
enumerate 3 (2008).Fundamentals
growth or tumor.
Delayed out of 4 of Nursing.8th
Growths on the
capillary refill purposes of Edition.Pearson.pp140
cervix can be the treatment 2 – 1420.
> 3 secs
benign or
The client has malignant. Benign Developmental
pale growths are not After 1 day Encourage mild Enhances venous The client was
conjunctiva. cancer. They are minutes of exercise such as return able to gradually
not as harmful as nursing walking in the Doenges, et. al, (2008). increase her level
Lips are pale. malignant growths intervention, corridor and Nurse’s Pocket Guide. of physical activity
the client will active range-of- 11th Edition. F.A. Davis
(cancer).
The inner lips be able to motion Company. p. 711.
and buccal Black, et.al. gradually
mucosa is (2005).Medical increase her Stress out the To prevent injury.
slightly dry Surgical Nursing. level of importance of Doenges, et. al, (2008).
and pale 7th Edition.Elsevier physical having someone Nurse’s Pocket Guide.
PTE LTD.p 927 activity. to assist her in 11th Edition. F.A. Davis
Measurement walking Company. p. 609.

V/S: Caution client to To maximize tissue

BP: 200/100 avoid activities perfusion
mmHg that increase Doenges, et. al, (2008).
PR: 98 bpm; cardiac workload Nurse’s Pocket Guide.
weak 11th Edition. F.A. Davis
RR: 21 cpm Company. p. 710.
T: 36.3 ˚C The client was
After 10 Explain the Encourage client’s able to show no
 minutes of procedure to the cooperation and signs of anxiety
Creatinine: discussion, the client decrease anxiety of the towards the
169.17nmol/L client will be client. procedure
able to show Kozier, et al.
no signs of (2008).Fundamentals
anxiety of Nursing.8th
towards the Edition.Pearson.pp140
procedure 2 – 1420.

Developmental The client was

After 15 Provide Loss of normal body able to verbalize a
minutes of opportunity for functions and can lead positive outlook in
discussion, the client to express to feelings of life
client will be feelings. powerlessness, anger,
able to and grief. Open
verbalize a Encourage SOs expression of these
positive to express feelings can help client
outlook in life support for the begin coping.
client. Black, et.al.
(2005).Medical Surgical
Nursing. 7th
Edition.Elsevier PTE
LTD.p 1861.