Nursing Management (Nursing Care Plan)

CUES NURSING DIAGNOSIS SCIENTIFIC PLANNING INTERVENTIONS RATIONALE EXPECTED OUTCOME

EXPLANATION
Risk for Injury related to Vasoconstriction Short Term: . Establish rapport To gain trust from the
S> Dizziness patient. . After 4-5 hours of safe,
Medyo malilyu ku After 4-5 hours of safe, quality, effective and
pin. quality, effective and Assess patient general efficient nursing
O> Increased blood pressure efficient nursing conditions. To have a baseline interventions, the patient
(+) Irritable interventions, the patient data after taking will be able to:
(+) Flushed Face will be able to: further assessments Safe from any
T 36.4 C Decreased oxygen to the Monitor Vital Signs especially Blood accidents or injury.
P 90 bpm tissues and CNS due to To be free from Pressure. Stabilized Vitals
R 20 cpm vasoconstriction any injury. signs especially
Bp 160/100 Secure the patient to a blood pressure.
mmhg Have normal and safe environment. Know some
Alteration on the stable blood causes of her
consciousness pressure. .To facilitate good condition.
Know some of Provide enough airway breathing Feel better
the contributing ventilation. pattern and for
Dizziness factors that inhaling oxygen.
cause dizziness.

Risk for injury Long term:

Care for herself To promote good
independently Provide necessary blood circulation.
when having health teachings such
dizziness. as foods rich in Iron.
. Provide information
some causes of her To inform the patient
dizziness. about her condition.
 CUES NURSING DIAGNOSIS SCIENTIFIC PLANNING INTERVENTIONS RATIONALE EXPECTED OUTCOME
EXPLANATION
S> Ano po ba Health seeking Increase blood Pressure Short Term: .
pwede kong behaviors related to After 4-5 hours of safe,
magawa para having an increased After 4-5 hours of safe, To assess specific To identify underlying quality, effective and
hindi tumataas blood pressure during quality, effective and concerns/habits/issues issues that could efficient nursing
yung presyon pregnancy. Patient worries about efficient nursing client desires to impact clients ability interventions, the patient
ko? previous condition that interventions, the patient change to control own health. will be able to:
may happen again during will be able to: Express desire to
pregnancy Active listen/discuss change specific
Verbalize specific concerns with client. habit or lifestyle
concerns, habits To help with patterns to
and issues about Use screening/testing development of plan achieve/maintain
her condition. as indicated, and of action. optimal health.
Seeks for an interventions To have more review results with Participate in
and medical attention knowledge and client/ SOs. planning for
infromation by To provide change..
discussing with information and
us about the Discuss with client her encourage client to
things she particular risk-taking make healthy choice
learned. behaviour(lack of for future.
Health seeking behavior healthy foods)
Long Term: To provide support for
Apply all the desired changes.
health teachings Use of therapeutic
and prevent risk communication skills.
factors that may To assist in
alter her higher management of
health level. Encourage use of stress.
The patient will relaxation skills,
be free from visualization and
reoccurrence of guided imagery. To lessen the risk
the undesired factors and further
condition. Instruct in individually complications of the
appropriate wellness client.
behaviours such as
regular medical
examinations, healthy
diet, exercise program,
early interventions and
treatment of risk
factors.
 CUES NURSING DX SCIENTIFIC PLANNING INTERVENTION RATIONALE OUTCOME
EXPLANATION
O> Fluid Volume excess Protein comes out in the Short Term: Establish Rapport To gain trust from the After 4-5 hours of safe,
(+) restlessness related to excessive urine patient. quality, effective and
(+) Bipedal edema fluid After 4-5 hours of safe, efficient nursing
VS of quality, effective and interventions, the
T 36.4 C Decreased albumin levels efficient nursing Restrict sodium and To reduce water patient will be able to:
P 90 bpm interventions, the patient fluid intake, as retention. Have stabilized
R 20 cpm will be able to: indicated. fluid volume as
Bp 160/100 Decreased oncotic Verbalize evidenced by
mmhg pressure understanding of balanced I/O,
individual normal vital signs
dietary/fluid Record I/O accurately; To watch out for fluid and free from any
Increased hydrostatic restrictions. calculate 24-hour fluid and electrolyte signs of edema.
pressure Have stable fluid balance. imbalances. Verbalize
volume as understanding of
evidenced by individual
Increased capillary balanced I/O, dietary/fluid
permeability normal vital signs Raise both feet. To reduce fluid restrictions.
and free from retention by
any signs of promoting fluid and Demonstrate
Fluid shifting outside of edema. venous return behaviours to
the capillaries To have a monitor fluid status
Long Term: Monitor for weight comparative baseline and reduce
Patient will be gaint and evaluates the recurrence of fluid
Accumulation of fluid to free from effectiveness of excess.
the tissues reoccurrence of interventions..
having any signs
of edema.
Edema