202460955-Nursing-care-plan.docx

8/10/2019 202460955-Nursing-care-plan.docx

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Date Plan: 12-03-2013,10:00am

Name: Jungco, Esterlina Attending Physician: Dr. Dalapo

Age: 63 yrs old Admitting Diagnosis: Ovarian Adeno CA s/s TAHBSO. CHEMO

Chief Complaint: For Chemotherapy

Assessment Cues Need Nursing Diagnosis Planning Intervention Rationale Evaluation

SUBJECTIVE

Naa gihapon koy

colostomy bag as

verbalized by the

client

OBJECTIVE

Weak appearance

Presence ofcolostomy bag

(+) discomfort

Minimal

Verbalization

V/S taken as

follows

CR:75bpm

RR:20cpmTemp: 36

B/P: 100/80mmhg

SUSTENAL

CARE

NEEDS

By.

Faye Glenn

Abdellahs

Theory

Disturbed body

image related to

presence of

stoma and

colostomy bag

(Nurses Pocket

guide 12th

edition)

BackgroundStudy:

Confusion or

dissatisfaction in

mental picture of

ones physical

self-related to the

presence of

stoma and

colostomy bag.

(Nurses Pocket

guide 12

th

edition,pg.125)

After 8 hours

span of nursing

care, client will

be able to

verbalize

understanding

of body

changes.

INDEPENDENT

-Monitor Vital Signs

-Position client in her

comfort side.

-Encourage verbalization

of feelings

-Encourage client and

relatives to

communicate with each

other

-Encourage the clients

relative/family members

to treat client normallyand not as an invalid

-Encourage client to

verbalize understanding

of presence of stoma

-Provide Health

Teachings

*Instruct client of

ostomy care

-To identify physical

responses associated

with both medical and

emotional conditions.

-To promote wellness.

-To assist client and to

deal with/accept issues ofself-concept related to

body image

-To enhance handling of

potential situations.

-To help client

acceptance and not

revulsion when theclients appearance is

affected.

-to provide positive

reinforcement and

encourage client to

continue efforts and

strive for improvement

-To promote wellness

-To prevent infection

-To prevent client from

Goal partially met. Client was

able to verbalize understanding

of body changes.


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*Encourage clients

family member to help

uplift clients feeling.

*Encourage client to

engage to incorporate

therapeutic regimen into

activities of daily living

such as specific exercises

and some houseworkactivities

DEPENDENT

-Administer medication

per doctors order.

Ranitidine 50mg IVTT

every 8 hours (6-2-11)

feeling invalid.

-To accommodate

individual needs and

support indepence

- Indirectly reduces

pepsin secretion.

-Blocks daytime and

nocturnal basal gastric

acid secretion stimulated

by histamine and reducesgastric acid release in

response to foods,

caffeine, pentagastrin,

and insulin.

(Wilson,Shannon,Shields.

Pearson Nurses Drug

Guide 2012)


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Date Plan: 12-04-2013,10:00am

Name: Shimomae, Jeno Attending Physician: Dr. Natanagara

Age: 19 years old Admitting Diagnosis: Severe Viral Infection R/O Dengue Fever

Chief Complaint: Fever, General Body Malaise

Assessment Cues Need Nursing Diagnosis Planning Intervention Rationale Evaluation

SUBJECTIVE

Galuya ko as

verbalized by the

client.

OBJECTIVE

(+) discomfort

Skin warm to touch

Weak appearance

Febrile, T-37.7c

V/S taken as

follows

Temp: 37.7c

CR:80bpm

RR:21cpm

BP: 90/80mmhg

SUSTENAL

CARE

NEEDS

By.

Faye Glenn

Abdellahs

Theory

Altered

thermoregulation

related to

diseases process

as evidenced by

Temp. 37.7c

(Nurses Pocket

guide 12th

edition)

Background

Study:Temperature

fluctuation between

hypothermia and

hyperthermia can

be related to

changes in

metabolic rate or

activity.

(Nurses Pocketguide 12

thedition

pg.836)

After 8 hours

span of nursing

care, client will

be able to

increase level

of ease and

temperature

would be

lowered to

T-37c

INDEPENDENT

-Monitor Vital signs


acknowledge and to

express feelings.

-Position client on his

comfort side.


develop an exercise or

activity.

-Keep environment free

from distraction which

may be confusing or

stressful to the client.

-Provide Tepid sponge

bath

-Provide Health teaching

* Instruct clients

companion to

communicate with the

client as much as

possible.

* Encourage client toeat and provide

information regarding

-To identify physical

responses associated

with both medical and

emotional conditions.

- To assist client to

identify feelings and

begin to deal with

problems.

-To facilitate comfort.

-To create therapeutic

milieu and assist client to

develop.

-To promote wellness.

-Help reduce body

temperature level.

-to help client to develop

and entertained.

-Enhances intake andgeneral well-being.

-to maintain wellness.

Goal met. Client was able to

increase level of ease and body

temperature is decreased as

evidence by Temp-37c


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nutritionally well-

balanced diet.

*Encourage client to

drink a lot of water

DEPENDENT

-Due Medications given

as by Aps order

Ceftriaxone

(Zefaxone)

1gm IVTT every

8 hours.

-to keep client hydrated.

-Inhibits third and finalstage of bacterial cell wall

synthesis, thus killing the

bacterium.

- Effective against serious

gram-negative organisms.

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202460955-Nursing-care-plan.docx