Republic of the Philippines

UNIVERSITY OF EASTERN PHILIPPINES

University Town, Northern Samar
Web: uep.edu.ph Email: ueppres06@gmail.com

COLLEGE OF NURSING AND ALLIED HEALTH SCIENCES

NURSING CARE PLAN

FILARIASIS

ASSESSMENT NURSING SCIENTIFIC OBJECTIVE/PLANNING NURSING SCIENTIFIC EVALUATION

DIAGNOSES RATIONALE INTERVENTION RATIONALE
SUBJECTIVE: Impaired Limitation in  Verbalize  Instruct the use of  For position  Responses to
Report of physical independent, understanding of siderails, overhead changes/transfer interventions/teaching
pain and mobility purposeful situation/risk factors trapeze, and roller and actions performed
discomfort related to physical and individual pads  Attainment/progress
on pain and movement of treatment regimen  Administer  To permit maximal toward desired
movement discomfort the body or and safety measures medication prior to effort/involvement outcome(s).
of one or  Demonstrate activity as needed in activities  Modification to plan
OBJECTIVE: more techniques/behavior for pain relief care
Limited range extremities that enable  Encourage  Enhances self-
of motion, resumption of participation in concept and sense
slowed activities self-care of independence
movement,  Maintain position of
gait change function and skin  Encourage  Promotes well-
integrity as adequate intake of being and
evidenced by fluids/nutritious maximizes energy
absence of foods production
contractures,
footdrop, decubitus,
and so forth
 Maintain or increase
strength and
function of affected
and/or
compensatory body
part
 Republic of the Philippines
UNIVERSITY OF EASTERN PHILIPPINES
University Town, Northern Samar
Web: uep.edu.ph Email: ueppres06@gmail.com

COLLEGE OF NURSING AND ALLIED HEALTH SCIENCES

NURSING CARE PLAN

PNEUMONIA

ASSESSMENT NURSING SCIENTIFIC OBJECTIVE/PLANNING NURSING SCIENTIFIC EVALUATION

DIAGNOSES RATIONALE INTERVENTION RATIONALE
SUBJECTIVE: Ineffective Inability to  Maintain airway  Position head midline  To open or  Client’s response to
Dyspnea airway clear patency. with flexion maintain intervention/teachings
clearance secretions or  Verbalized appropriate for patent airway and actions
OBJECTIVE: related to obstructions understanding of age/condition. in at-rest or performed.
Diminished or pneumonia from the cause’s therapeutic compromised  Attainment/progress
adventitious respiratory management individual. to wards the outcome.
breath sound, tract to regimen.  Suction  To clear airway  Modification to plan
cough, maintain a  Demonstrate naso/tracheal/oral when secretion of care.
changes in clear airway behaviors to prn is blocking the
respiratory improve or maintain airway.
rate and clear airway.
rhythm,  Identify potential  Auscultate breath  To ascertain
complications and sound and assess air status and note
how to initiate movements progress
appropriate  Monitor vital signs
preventive and  Assist with procedure  To
corrective actions. clear/maintain
open airway
 Republic of the Philippines
UNIVERSITY OF EASTERN PHILIPPINES
University Town, Northern Samar
Web: uep.edu.ph Email: ueppres06@gmail.com

COLLEGE OF NURSING AND ALLIED HEALTH SCIENCES

NURSING CARE PLAN

DIPHTHERIA

ASSESSMENT NURSING SCIENTIFIC OBJECTIVE/PLANNING NURSING SCIENTIFIC RATIONALE EVALUATION

DIAGNOSES RATIONALE INTERVENTION
SUBJECTIVE: Ineffective Decreased  Verbalized  Note current  affecting systemic • Response
Chest pain tissue oxygen understanding situation or circulation/perfusion. to
Dyspnea perfusion resulting in about the condition, presence of  To identify client at interventions,
Sense of failure to therapy regimen, conditions higher risk for teaching, and
“impending nourish the side effect of  Determine history venous stasis, vessel actions
doom” tissues at the medication. of conditions wall injury, and performed
OBJECTIVE: capillary  Demonstrate associated with hypercoagulability. • Attainment
Capillary refill level behavior changes to thrombus or  Helps in determining or progress
longer than 3 improve circulation emboli location and type of toward
sec, altered of  Assess skin color, perfusion problem. desired
respiratory temperature,  Helps differentiate outcome(s)
rate moisture, and type of problem • Modifi
whether changes  to determine cations to
are widespread or adequacy of systemic plan of care
localized. circulation.
 Compare skin  Administer fluids,
temperature and electrolytes,
color with other nutrients, and
limb when oxygen, as indicated
assessing  to promote optimal
extremity blood flow, organ
circulation. perfusion, and
 Measure capillary function.
refill
 Republic of the Philippines
UNIVERSITY OF EASTERN PHILIPPINES
University Town, Northern Samar
Web: uep.edu.ph Email: ueppres06@gmail.com

COLLEGE OF NURSING AND ALLIED HEALTH SCIENCES

NURSING CARE PLAN

CHICKEN POX

ASSESSMENT NURSING DIAGNOSIS SCIENTIFIC OBJECTIVES/ NURSING INTERVENTIONS SCIENTIFIC

RATIONALE PLANNING RATIONALE

Subjective Data: HYPERTHERMIA Core body • Maintain core  Assess neurological responses,  High fever accompanied
temperature above the temperature within normal noting the level of consciousness by changes in mentation
fever normal diurnal range range. and orientation, reaction to stimuli,
due to failure of reaction of pupils, and presence of  Central hypertension or
thermoregulation. • Be free of complications, posturing or seizures. postural hypotension can
Objective Data: such as irreversible brain occur.
Abnormal posturing; or neurological damage  Monitor blood pressure and
seizure and acute renal failure. invasive hemodynamic parameters  Hyperventilation may
initially be
Flushed skin; skin • Identify underlying cause if available
warm to touch; or contributing factors and present, but ventilatory effor
vasodilation importance of treatment, as  Monitor respirations. may eventually be
well as signs/symptoms impaired
Hypotension;  Administer replacement fluids and
requiring further
tachycardia; electrolytes by seizures or
evaluation or intervention.
tachypnea; apnea hypermetabolic state
 Maintain bedrest (shock and acidosis).
• Demonstrate behaviors to
Irritability; lethargy;
monitor and promote  Administer medications, as
stupor; coma  to support circulating
normal thermia. indicated, to treat underlying cause, volume and tissue
such as antibiotics (for infection),
• Be free of seizure
dantrolene (for malignant  to reduce metabolic
activity.
hyperthermia), or beta-adrenergic demands and oxygen
blockers (for thyroid storm). consumption perfusion.