Nursing Care Plan I
Assessment Diagnosis Planning Intervention Rationale Evaluation
Subjective Chronic Short Term Goal: 1. Obtained clients 1. To rule out Partially Met:
Patient said pain At the end of 4 hours assessment of pain to worsening of Still with pain,
she always related to after nursing include location, underlying Pain scale:
felt pain in pathologic intervention patient characteristics, condition/developme 6-10
her bones. al disease will be able to: onset/duration, frequency, nt of complications.
Relieved from pain
Objective: process quality, intensity, and
Scale: precipitating/aggravating
7-8 factors.
Seemed
2. Provided comfort 2. To promote non
to
measures (e.g., cold packs, pharmacological
Facial
nurses presence), quiet pain management.
grimace
Vital environment.
Sign: 3. Encouraged the use of 3. To distract attention
- Temp:
relaxation techniques such and reduce tension.
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36C as focused deep breathing
- PR: 80
exercise, imaging,
beats
CDs/tapes.
per
4. Encouraged adequate 4. May reduce muscle
minute
- RR: 24 periods of rest and sleep tension and anxiety,
breaths thereby producing
per relaxation effect
minute
- BP:
5. Administered analgesic, as 5. To prevent fatigue
90/70
indicated, to maximum which may
mmHg
dosage, as needed contribute to pain
(morphine tab) and to assist client
oxycontin 1 tab 10 mg one to explore methods
a day, pregabalin 75mg 1 for
tab one a day. alleviation/control
of pain.
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Nursing Care Plan II
Assessment Diagnosis Goal of Care Intervention Rationale Evaluation
Subjective: Imbalanced Short term: 1. Identify client at risk 1. To determine Goal Not Met:
Patient EMD nutrition less After 3 days of for malnutrition informational - Patient still
said, she has than body nursing (client with chronic needs of client weak and no
no appetite. requirement interventions, the illness) appetite to
Objective: related to patient will be eat
Patient looks anorexia able to consume 6 2. Assessed nutritional 2. Identify
weak spoonsful of rice history, including a deficiencies,
Looks pale and viand instead preferred food. suspect the
mucous of 3. possibility of
membranes Long term goal: intervention.
Patients has - After 1 3. Assessed weight;
just eaten 2-3 month of calculate body fat (if 3. Observing
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spoons of nursing possible). weight loss /
food interventions, observe the
Diet: DAT, patient will effectiveness of
low salt low demonstrate the intervention
fat progressive 4. Observed and record
4. Observing
Weight: 40 weight gain the patient's food
caloric intake /
kgs and will have intake.
lack of quality
BMI = 18.5 a BMI of at
food
least 18.5
consumption.
24.9
(Normal) 5. Give food a little but
- Display 5. Little food can
often and or eat
normalizatio reduce
between meals.
n of vulnerabilities
laboratory and increase
values and be input also
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free of sign prevent gastric
malnutrition distention.
6. Explored specific
eating habits 6. Identifies eating
(vegetables) habits.
7. Given and helped on
oral hygiene. 7. Increased
appetite and
8. Reviewed indicated oral input.
laboratory data 8. To identify
(albumin, BUN) deviations from
the normal and
to establish
baseline
9. Administered parameters
pharmaceutical 9. This will helps
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agents; vitamin and improve
mineral (iron) Nutritional
supplements supplementatio
(Buclizine with Iron n in patients w/
1 tab once a day) depressed
appetite.
Nursing Care Plan III
Assessment Diagnosis Goal of Care Intervention Rationale Evaluation
Subjective: Activity Goal: 1. Performed proper 1. Isotonic exercises Goal met:
The private intolerance exercise program to prevent
After 3 days of The patient respons
nurse said that related to (isotonic, active or contractures and
nursing to interventions
sometimes she generalized passive exercise) at least muscle atrophy,
interventions: and patient
can perform weakness 4 hours at a time on the maintain isometric
participate in
1. Clients
simple exercise hands, feet, and neck as muscle strength,
actions performed
can maintain
(walked around indicated. joint motion
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corridor in the the normal maintains a and treatment
hospital and the function of passive exercise. regimen.
private nurse the
2. Self-care can
hold her hand musculoskel
move the joints
and body) but etal shown 2. Motivated patient to
and muscles of the
can only stay 10- by the whole participate in self-care.
body are active.
15 minutes. range of
3. Can facilitate
Weakness motion in
3. Positioned the client in early intervention
Objective: the joints of
accordance with body anyway.
She just laying the body
alignment.
on the bed, looks within 4. By positioning the
4. Monitored vital signs client in
weakness, pain, normal
according to client needs. accordance with
erosion on the limits,
bone muscle mass body alignment
and strength. can help prevent
contractures and
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maintain
structural integrity
of joints and
muscles.
Nursing Care Plan IV
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Assessment Diagnosis Goal of Care Intervention Rationale Evaluation
Subjective: Fatigue related - After 8 hours Identify the presence Important Partially met:
he patient can to physiological of nursing of physical and information can
- Patient still
walked a little condition intervention psychological be obtained from
weak
around the (anemia). the patient condition (anemia; knowing if fatigue
corridor, as her perform cancer treatment) is a result of an
verbalized. activities of underlying
daily living condition or
Objective: and participate disease process
- Weak in desired To assist in
- Pale (Hgb: activities at Obtain client/ SO evaluating the
3.79 x 10^ level of ability. descriptions of fatigue impact on the
6/UL) - Participate in (i.e., lacking energy or clients life.
recommended strength, tiredness,
Vital Sign: treatment weakness)
- Temp: 36C
- PR: 80 program Ask the client to rate
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beats per fatigue (using a 0 to 10 Fatigue may vary
minute or similar numerical in intensity and is
- RR: 24
scale) and its effects often
breaths per
Long term: on the ability to accompanied by
minute
- BP: 90/70 participate in desired irritability, lack of
mmHg - Within 6 days activities. concentration.
of nursing Review medication
-
interventions, regimen/ use Certain
the client will medication,
report including
improved prescription are
sense known to cause
of energy and/ or exacerbate
- Patient fatigue.
perform Monitor vital sign
activities of Basis before
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daily living performing
and participate exercise
in desired
activities at
level of ability
- Participate in
recommender
treatment
program
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