Nursing Care Plan

Date Plan: 12-03-2013,10:00am
Attending Physician: Dr. Dalapo

Admitting Diagnosis: Ovarian Adeno CA s/s TAHBSO. CHEMO
Name: Jungco, Esterlina

Age: 63 yrs old
Chief Complaint: For Chemotherapy
Assessment Cues
Need
Nursing Diagnosis
Planning
Intervention
Rationale
Evaluation
INDEPENDENT
SUBJECTIVE
Naa gihapon koy
colostomy bag as
verbalized by the
client
SUSTENAL
CARE
NEEDS
Disturbed body
image related to
presence of
stoma and
colostomy bag
OBJECTIVE
Weak appearance
Presence of
colostomy bag
(+) discomfort
Minimal
Verbalization
V/S taken as
follows
CR:75bpm
RR:20cpm
Temp: 36
B/P: 100/80mmhg
By.
Faye Glenn
Abdellahs
Theory
(Nurses Pocket
th
guide 12 edition)
Background
Study:
Confusion or
dissatisfaction in
mental picture of
ones physical
self-related to the
presence of
stoma and
colostomy bag.
(Nurses Pocket
th
guide 12 edition,
pg.125)
After 8 hours
span of nursing
care, client will
be able to
verbalize
understanding
of body
changes.
-Monitor Vital Signs
-To identify physical

responses associated
with both medical and
emotional conditions.
-Position client in her

comfort side.
-To promote wellness.
-Encourage verbalization
of feelings
-To assist client and to

deal with/accept issues of
self-concept related to
body image
-Encourage client and

relatives to
communicate with each
other
-To enhance handling of

potential situations.
-Encourage the clients

relative/family members
to treat client normally
and not as an invalid
-To help client

acceptance and not
revulsion when the
clients appearance is
affected.
-Encourage client to
verbalize understanding
of presence of stoma
-to provide positive

reinforcement and
encourage client to
continue efforts and
strive for improvement
-Provide Health
Teachings
*Instruct client of
ostomy care
-To promote wellness

-To prevent infection
-To prevent client from
Goal partially met. Client was

able to verbalize understanding
of body changes.
*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 housework
activities
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 reduces
gastric acid release in
response to foods,
caffeine, pentagastrin,
and insulin.
(Wilson,Shannon,Shields.
Pearson Nurses Drug
Guide 2012)
Date Plan: 12-04-2013,10:00am

Attending Physician: Dr. Natanagara
Admitting Diagnosis: Severe Viral Infection R/O Dengue Fever
Name: Shimomae, Jeno

Age: 19 years old
Chief Complaint: Fever, General Body Malaise
Assessment Cues
Need
Nursing Diagnosis
Planning
Intervention
Rationale
Evaluation
INDEPENDENT
SUBJECTIVE
Galuya ko as
verbalized by the
client.
SUSTENAL
CARE
NEEDS
OBJECTIVE
(+) discomfort
Skin warm to touch
By.
Faye Glenn
Abdellahs
Theory
Altered
thermoregulation
related to
diseases process
as evidenced by
Temp. 37.7c
(Nurses Pocket
th
guide 12 edition)
Weak appearance
Background
Study:
Febrile, T-37.7c
Temperature
fluctuation between
hypothermia and
hyperthermia can
be related to
changes in
metabolic rate or
activity.
V/S taken as
follows
Temp: 37.7c
CR:80bpm
RR:21cpm
BP: 90/80mmhg
(Nurses Pocket
th
guide 12 edition
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
-Monitor Vital signs
-To identify physical

responses associated
with both medical and
emotional conditions.
acknowledge and to
express feelings.
- To assist client to
identify feelings and
begin to deal with
problems.
-Position client on his

comfort side.
-To facilitate comfort.
develop an exercise or
activity.
-To create therapeutic

milieu and assist client to
develop.
-Keep environment free

from distraction which
may be confusing or
stressful to the client.
-To promote wellness.
-Provide Tepid sponge

bath
-Help reduce body

temperature level.
-Provide Health teaching

* Instruct clients
companion to
communicate with the
client as much as
possible.
* Encourage client to
eat and provide
information regarding
-to help client to develop

and entertained.
-Enhances intake and

general 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
nutritionally wellbalanced diet.

*Encourage client to
drink a lot of water
-to keep client hydrated.
DEPENDENT
-Due Medications given
as by Aps order
Ceftriaxone
(Zefaxone)
1gm IVTT every
8 hours.
-Inhibits third and final

stage of bacterial cell wall
synthesis, thus killing the
bacterium.
- Effective against serious
gram-negative organisms.

Nursing Care Plan

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

Attending Physician: Dr. Dalapo

Name: Jungco, Esterlina

-Monitor Vital Signs

-To identify physical

-Position client in her

-To promote wellness.

-To assist client and to

-Encourage client and

-To enhance handling of

-Encourage the clients

-To help client

-to provide positive

-To promote wellness

Goal partially met. Client was

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

Name: Shimomae, Jeno

-Monitor Vital signs

-To identify physical

-Position client on his

-To facilitate comfort.

-To create therapeutic

-Keep environment free

-To promote wellness.

-Provide Tepid sponge

-Help reduce body

-Provide Health teaching

-to help client to develop

-Enhances intake and

Goal met. Client was able to

nutritionally wellbalanced diet.

-to keep client hydrated.

-Inhibits third and final

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