Nursing Care Plans
Nursing Care Plans
CCF Nursing Care Plan
Nursing Problem: Impaired Gas Exchange
Nursing Diagnosis: Impaired gas exchange related to increased preload, mechanical failure, or immobility as manifested by increased respiratory rate, shortness of breath, and dyspnoea on exertion.
Objective/Goal: The patient will maintain normal gas exchange within 45 minutes of intervention.
Nursing Interventions:
Monitor the rate, rhythm, depth, and effort of respirations.
Auscultate breath sounds, noting areas of decreased/absent ventilation and presence of adventitious sounds.
Monitor for dyspnoea and events that influence ADLs.
Administer supplemental oxygen as prescribed.
Change oxygen delivery levels from mask to nasal prongs during meals.
Position to alleviate dyspnoea (e.g., semi-fowler’s position).
Monitor oxygen saturation levels.
Evaluation: The patient has maintained normal gas exchange within 45 minutes, evidenced by ease of breathing and reduced respiratory rate.
Nursing Problem: Disturbed Sleep Pattern
Nursing Diagnosis: Disturbed sleep pattern related to nocturnal dyspnoea, inability to assume favored sleep position as manifested by the inability to sleep throughout the night.
Objective/Goal: The patient will be able to have uninterrupted sleep throughout the night.
Nursing Interventions:
Determine patient’s sleep/activity pattern.
Encourage the establishment of a bedtime routine.
Adjust environment to promote sleep.
Regulate environmental stimuli to maintain normal day-night cycles.
Adjust medication schedule to support sleep.
Monitor patient’s sleep pattern and hours of sleep.
Evaluation: The patient is able to sleep throughout the night.
Nursing Problem: Activity Intolerance
Nursing Diagnosis: Activity intolerance related to fatigue secondary to cardiac and pulmonary congestion as manifested by dyspnoea, shortness of breath, weakness, and increased heart rate on exertion.
Objective/Goal: The patient will tolerate activity and perform ADLs throughout the hospital stay.
Nursing Interventions:
Encourage alternate rest and activity periods.
Provide emotional and physical rest.
Monitor cardiorespiratory response to activity.
Teach self-care techniques.
Assist in choosing appropriate activities.
Collaborate with therapists to plan and monitor activity.
Evaluation: The patient has tolerated activity and reported carrying out ADLs throughout the hospital stay.
Nursing Problem: Anxiety
Nursing Diagnosis: Anxiety related to dyspnoea or perceived threat of death as manifested by restlessness, irritability, and expressions of life threat.
Objective/Goal: The patient will verbalize a reduction in anxiety within two hours of intervention.
Nursing Interventions:
Assess the patient’s level of anxiety.
Establish a working relationship with the patient.
Use a calm, reassuring approach.
Explain all procedures to promote a sense of security.
Encourage the patient and family to talk about fears.
Provide reassurance and answer questions honestly.
Instruct on relaxation techniques.
Arrange for psychological counseling if possible.
Evaluation: The patient has verbalized a reduction in anxiety within two hours of intervention.
Pneumonia Nursing Care Plan
Nursing Problem: Ineffective Breathing Pattern
Nursing Diagnosis: Ineffective breathing pattern related to impaired expiration evidenced by cyanosis and increased respiratory rate.
Objective/Goal: The patient will have an improved breathing pattern within 30 minutes of admission.
Nursing Interventions:
Nurse in a fowler’s position.
Administer humidified oxygen via nasal catheter.
Administer Salbutamol inhaler and Aminophylline injectable.
Monitor respiratory rate half hourly.
Evaluation: The patient has improved breathing pattern evidenced by a respiratory rate of 18 breaths per minute.
Nursing Problem: Ineffective Airway Clearance
Nursing Diagnosis: Ineffective airway clearance related to increased production of secretions and bronchospasms evidenced by productive cough and wheezing.
Objective/Goal: The patient will have a clear airway within 30 minutes.
Nursing Interventions:
Suction secretions PRN.
Encourage the patient to cough up sputum.
Provide oral fluids and humidify the room.
Perform oral care 2 hourly.
Evaluation: The patient has a clear airway evidenced by the absence of productive cough and wheezing.
Nursing Problem: Impaired Gaseous Exchange
Nursing Diagnosis: Impaired gaseous exchange related to bronchial spasms and bronchial oedema evidenced by dyspnoea.
Objective/Goal: The patient's gaseous exchange will improve within 30 minutes.
Nursing Interventions:
Assess lung sounds hourly.
Monitor skin and mucous membrane for cyanosis.
Administer humidified oxygen.
Monitor oxygen saturation levels.
Evaluation: The patient has adequate gas exchange evidenced by oxygen saturation within the normal range.
Nursing Problem: Anxiety
Nursing Diagnosis: Anxiety due to fear of dying evidenced by restlessness and verbalization.
Objective/Goal: The patient's anxiety will be allayed throughout hospitalization.
Nursing Interventions:
Explain the condition and procedures in simple terms.
Provide a support person at the bedside.
Nurse away from critically ill patients.
Encourage the patient to verbalize fears.
Evaluation: Anxiety allayed throughout hospitalization evidenced by the patient being calm.
Malaria Nursing Care Plan
Nursing Problem: Fever
Nursing Diagnosis: Fever related to parasitemia evidenced by a high temperature of 37.5 degrees Celsius and above.
Objective/Goal: To reduce fever within 30 minutes to one hour of admission.
Nursing Interventions:
Remove excess clothing to cool the body.
Administer antipyretic drugs like Panadol to reduce temperature.
Administer anti-malarial drugs like Coartem as prescribed to clear the infection.
Do tepid sponging to cool the body and reduce the temperature.
Monitor temperature 4 hourly to assess if it is reducing.
Open nearby windows to allow more air to cool the body during the sweating stage.
Switch on the fan or air conditioner to cool the body.
Evaluation: Temperature reduced by one degree within 30 minutes to one hour evidenced by a temperature of 36.5.
Nursing Problem: Altered Nutrition
Nursing Diagnosis: Altered nutrition less than body requirement related to anorexia, nausea, vomiting, and diarrhea evidenced by weight loss.
Objective/Goal: To improve nutritional status within 1 week of hospitalization.
Nursing Interventions:
Do frequent mouth washes to moisten the mucous membrane and stimulate appetite.
Remove all unpleasant smells and unsightly items that could trigger nausea and anorexia within the environment.
Give prescribed anti-emetics such as Plasil to prevent and treat vomiting.
Provide 3 hourly feeds rich in vitamins, carbohydrates, and animal protein to provide for energy requirements and build worn-out tissues.
Feed the patient if unable to self-feed to meet daily nutritional requirements; insert a nasogastric tube if unconscious.
Involve relatives in planning meals to consist of what the patient likes.
Explain the value of nutrition in the healing process to encourage eating.
Weigh the patient on alternate days to determine weight gain or loss.
Evaluation: Patient's nutritional status improved within 1 week of hospitalization evidenced by weight gain.
Nursing Problem: Fluid Volume Deficit
Nursing Diagnosis: Fluid volume deficit related to diaphoresis, vomiting, and diarrhea evidenced by dry lips, excessive thirst, and sunken eyes.
Objective/Goal: To correct fluid volume deficit within 2 hours of hospitalization.
Nursing Interventions:
Provide oral fluids to replace lost fluids and quench thirst.
Administer prescribed intravenous fluids like Ringer's lactate depending on the extent of fluid loss.
Monitor and record intake and output on the fluid balance chart to ensure proper fluid replacement.
Evaluation: Fluid volume deficit corrected within 2 hours evidenced by moist lips, normal eyes, and normal thirst.
Nursing Problem: Anxiety
Nursing Diagnosis: Anxiety related to the disease process and fear of death evidenced by asking too many questions and restlessness.
Objective/Goal: To allay anxiety within 2 hours of hospitalization.
Nursing Interventions:
Allow the patient to verbalize fears and concerns to plan coping mechanisms.
Explain the condition, management, and possible outcomes to make the patient understand and accept the situation.
Arrange for spiritual counselors to discuss issues of faith and pray with the patient.
Provide acceptable diversion therapy such as watching television and listening to music.
Involve the patient and caretaker in the plan of care, explaining procedures and reasons.
Encourage visits from friends and relatives for encouragement.
Evaluation: Anxiety allayed within 2 hours of hospitalization evidenced by calmness and rest.
Cholera Nursing Care Plan
Nursing Problem: Fluid Volume Deficit
Nursing Diagnosis: Fluid volume deficit related to severe diarrhea and vomiting, evidenced by sunken eyes, dry mouth, poor skin turgor, and diminished urine output.
Objective/Goal: To replace the patient’s lost body fluid within the first 6 hours and restore normal urine output.
Nursing Interventions:
Administer intravenous fluids as prescribed.
Provide oral fluids as tolerated.
Keep accurate records of fluid intake and output.
Reassess the patient’s hydration status every 4-6 hours.
Administer prescribed antibiotics to reduce diarrhea and fluid loss.
Evaluation: The patient’s lost body fluids are replaced, evidenced by improved skin turgor and normal urine output.
Nursing Problem: Risk for Impaired Skin Integrity
Nursing Diagnosis: Risk for impaired skin integrity related to severe dehydration.
Objective/Goal: To preserve skin integrity throughout hospitalization.
Nursing Interventions:
Change the patient’s linen frequently to prevent moisture accumulation.
Encourage frequent turning and repositioning.
Use barrier creams as needed.
Perform gentle skin cleaning and drying.
Evaluation: The patient’s skin integrity is preserved.
Nursing Problem: Anxiety
Nursing Diagnosis: Anxiety related to knowledge deficit on the disease process, evidenced by asking too many questions and panic behavior.
Objective/Goal: To relieve the patient’s anxiety throughout hospitalization.
Nursing Interventions:
Reassure the patient that everything possible is being done to correct the situation.
Explain all procedures and the reasons for them.
Provide acceptable diversion therapy.
Involve the patient and the caretaker in the plan of care.
Evaluation: Anxiety is allayed, evidenced by the patient being calm and resting.
Diabetes Mellitus Nursing Care Plan
Nursing Problem: Fluid Volume Deficit
Nursing Diagnosis: Fluid volume deficit related to polyuria secondary to hyperglycemia, as manifested by excessive thirst, dry skin, and poor skin turgor.
Objective/Goal: The patient will maintain normal fluid balance.
Nursing Interventions:
Assess and monitor for fluid volume deficiency.
Administer fluid replacement as prescribed, up to 2 to 3 liters per day to replace lost fluids and prevent hypovolemia.
Monitor intake and output using a fluid balance chart to prevent fluid overload.
Assess skin turgor and mucous membrane for hydration.
Assess for signs of hypovolemic shock and electrolyte deficiency, e.g., sunken eyes, cold and clammy skin.
Weigh the patient daily to assess if the patient is gaining or losing weight.
Monitor blood glucose levels.
Evaluation: The patient demonstrates adequate hydration, evidenced by stable vital signs, appropriate urine output, good skin turgor, and electrolyte levels within the normal range.
Nursing Problem: Altered Nutrition
Nursing Diagnosis: Altered nutrition less than body requirements, related to insulin deficiency, decreased oral intake, and hyper-metabolic state, as manifested by weight loss, weakness, and increased ketones.
Objective/Goal: The patient will have improved nutrition and achieve weight gain.
Nursing Interventions:
Weigh the patient daily or as indicated to assess the adequacy of nutritional intake.
Ascertain the patient's dietary program and usual patterns to identify deficits and deviations from therapeutic needs.
Together with a nutritionist, help the patient adjust to the required dietary regulations.
Teach the patient about foods that increase blood glucose levels, e.g., carbohydrates.
Identify food preferences, including ethnic and cultural foods, to be incorporated into the meal plan to enhance cooperation after discharge.
Evaluation: The patient will achieve weight gain and select the appropriate amount of calories and nutrients.
Nursing Problem: Fatigue
Nursing Diagnosis: Fatigue related to decreased metabolic energy production, altered body chemistry, and increased energy demands, as manifested by overwhelming activity intolerance, decreased performance, and inability to concentrate.
Objective/Goal: The patient will tolerate activity and experience an increase in energy.
Nursing Interventions:
Discuss with the patient the need for activity and identify activities with the patient that lead to fatigue.
Alternate activity with periods of rest to prevent excessive fatigue.
Monitor pulse, respiratory rate, and blood pressure before and after activity to indicate physiological levels of tolerance.
Encourage the patient’s participation in activities of daily living as tolerated to increase confidence and self-esteem.
Evaluation: The patient verbalizes an increase in energy level and displays improved ability to participate in desired activities.
Nursing Problem: Knowledge Deficit
Nursing Diagnosis: Knowledge deficit of self-administration of insulin, care of equipment, and home monitoring of blood glucose, related to lack of previous exposure to information and skill, as manifested by questions/request for information and verbalization of the problem.
Objective/Goal: The patient will verbalize the disease process, and the need for blood glucose monitoring, and accurately demonstrate self-administration of insulin.
Nursing Interventions:
Work with the patient in setting mutual goals for learning to promote enthusiasm and cooperation.
Demonstrate finger stick testing, insulin administration, and urine testing, and have the patient do return demonstrations.
Stress the importance of adhering to the recommended diet to prevent hyperglycemia and hypoglycemia.
Review self-administration of insulin and care of equipment.
Have the patient demonstrate the procedure to verify understanding and correctness of the procedure.
Evaluation: The patient verbalizes and demonstrates accurate knowledge of proper insulin administration and the prescribed dietary regimen.
Nursing Problem: Risk for Infection
Nursing Diagnosis: Risk for infection related to decreased sensation and circulation to lower extremities.
Objective/Goal: The patient will remain free from infection.
Nursing Interventions:
Assess feet and legs for skin temperature, sensation, soft tissue injuries, corns, calluses, dryness, hammer toe or bunion deformation, hair distribution, pulses, and deep tendon reflexes.
Maintain skin integrity by protecting feet from breakdown.
Use heel protectors, special mattresses, and foot cradles for patients on bed rest.
Avoid applying drying agents to the skin, e.g., alcohol.
Apply skin moisturizers to maintain suppleness and prevent cracking and fissures.
Instruct the patient in foot care guidelines.
Advise the patient who smokes to stop smoking or reduce it if possible, to reduce vasoconstriction and enhance peripheral blood flow.
Evaluation: No skin breakdown and patient remains free from infection.
Neonatal Jaundice Nursing Care Plan
Nursing Problem: Risk for Impaired Parent-Infant Attachment
Nursing Diagnosis: Risk for impaired parent-infant attachment related to treatment with phototherapy.
Objective/Goal: To promote bonding between the mother and the infant during the period of phototherapy.
Nursing Interventions:
Initiate skin-to-skin contact between the mother and the infant during treatment with phototherapy to enhance parent-infant interaction.
Encourage parent participation in the care, such as diaper changing and feeding, to promote the parent's knowledge of the infant's physical characteristics and behavior.
Encourage breastfeeding by the mother to enhance parental feelings of contribution to the infant's care.
Take off the baby's eye shield 3-4 hours and during breastfeeding, so that the baby can see the mother.
Evaluation: During phototherapy, the mother is able to interact effectively with the infant.
Nursing Problem: High Risk for Altered Body Temperature
Nursing Diagnosis: High risk for altered body temperature related to treatment with phototherapy.
Objective/Goal: To maintain body temperature within the normal range of 36.2-37.2°C.
Nursing Interventions:
Maintain a warm environment for the baby because high and low temperatures predispose the infant to complications like kernicterus.
Remove the infant from the light source every 3-4 hours to prevent hyperthermia.
Turn the infant every 2 hours to provide maximum skin exposure for photodecomposition.
Evaluation: During hospitalization, the infant’s body temperature is maintained within the normal range of 36.2-37.2°C.
Nursing Problem: High Risk for Fluid Volume Deficit
Nursing Diagnosis: High risk for fluid volume deficit related to insensible loss of water during phototherapy.
Objective/Goal: To replace and maintain lost fluids.
Nursing Interventions:
Encourage the mother to breastfeed the baby every 2 hours (or 10-20% extra fluids) to replace the lost fluids.
Provide sips of dextrose 5% in between feedings to prevent dehydration.
Remove the infant from the phototherapy lamp every 3-4 hours to prevent excessive insensible water loss.
Observe the number of times the baby passes urine and maintain a feeding chart to prevent dehydration.
Evaluation: After treatment with phototherapy, the infant has no signs of dehydration.
Nursing Problem: Impaired Skin Integrity
Nursing Diagnosis: Impaired skin integrity related to bilirubin accumulation under the skin evidenced by itching and yellow discoloration.
Objective/Goal: To restore and maintain the normal skin integrity during the period of hospitalization.
Nursing Interventions:
Undress and expose the infant to light rays to help reduce the bilirubin levels.
Keep the diaper area clean and dry because the area is prone to breakdown as a result of frequent stooling.
Perform daily top and tail (bathing) with warm water to soothe the skin.
Observe for skin changes to check for early signs of complications (e.g., rash).
Evaluation: During hospitalization, the infant has no skin rash and no signs of skin infection, with intact skin.
Nursing Problem: Risk of Infection
Nursing Diagnosis: Risk of infection related to hospitalization.
Objective/Goal: To prevent infections during the period of hospitalization.
Nursing Interventions:
Strict isolation of the child with visitor restrictions, because the child’s immune system is not fully developed.
Clean the incubators regularly to prevent the spread of microorganisms.
Ensure that the mother washes her hands, breasts, and utensils during feeding of the infant to prevent the mother from spreading microorganisms.
Health staff should put on protective wear (e.g., masks, caps) while attending to the infant to prevent the transfer of organisms to the vulnerable infant.
Evaluation: During the period of hospitalization, the infant presents with no signs of infection, with body temperature within the normal range (36.2-37.2°C).
Glomerulonephritis Nursing Care Plan
Nursing Problem: Altered Urinary Elimination
Nursing Diagnosis: Altered urinary elimination related to kidney inflammatory process as evidenced by dysuria, frequency, and urgency.
Objective/Goal: To restore normal urinary elimination within 24 to 48 hours.
Nursing Interventions:
Assess the patient for dysuria, urgency, and frequency to determine the type of altered urinary elimination.
Administer prescribed antibiotic such as Ciprofloxacin 500 mg bid to eliminate causative bacteria and reverse the pathological process.
Offer the patient cranberry juice to acidify the urine and limit the multiplication of causative bacteria.
Advise the patient to withhold intake of urinary tract irritating substances such as caffeine, alcohol, tomatoes, and chocolates.
Offer the patient 3 to 4 liters of fluid in a day to flush out bacteria and toxins from the urinary system.
Encourage the patient to void every 2 to 3 hours to promote bladder emptying and prevent stasis of urine.
Evaluation: The patient will report improvement of dysuria, frequency, and urgency after 24 to 48 hours.
Nursing Problem: Acute Pain
Nursing Diagnosis: Acute pain related to kidney inflammation and muscle spasm as evidenced by patient verbalization and groaning.
Objective/Goal: To relieve pain within 30 minutes to 1 hour.
Nursing Interventions:
Let the patient assume the most comfortable position to ensure maximum rest.
Assess the pain intensity using a pain scale to determine the severity of pain and select the appropriate analgesic for the level of pain.
Administer a prescribed opioid analgesic such as pethidine 50 to 100 mg tid for severe pain (levels of 8 to 10 on the pain scale) to disrupt the transmission of painful impulses to the central nervous system.
Administer prescribed mild analgesic such as paracetamol 1 g tid for moderate pain (levels of 4 to 7) to reduce the production of chemical mediators of inflammation.
If the pain is mild (levels of 1 to 3), offer diversional therapy such as guided imagery, soft soothing music, television, or reading material to divert the patient’s attention away from focusing on pain.
Evaluation: The patient will stop groaning, report less pain, and appear calm and relaxed after 30 minutes to 1 hour.
Nursing Problem: Fever
Nursing Diagnosis: Fever due to kidney inflammation as evidenced by a raised temperature of more than 37.5°C.
Objective/Goal: To relieve fever within 30 minutes to 1 hour.
Nursing Interventions:
Measure axillary body temperature to determine fever and need for intervention.
Administer prescribed antipyretic such as paracetamol 1 g tid to reduce the production of chemical mediators of inflammation.
Remove extra linen and clothing to promote heat loss.
Open nearby windows to promote air circulation and heat loss.
If it can be tolerated, offer the patient a cool drink to promote heat loss.
Evaluation: The patient’s temperature will reduce by 0.5 to 1°C after 30 minutes to 1 hour.
Nursing Problem: Risk for Fluid Volume Imbalance
Nursing Diagnosis: Risk for fluid volume imbalance related to nausea and vomiting.
Objective/Goal: To prevent fluid volume deficit within 24 to 48 hours.
Nursing Interventions:
Administer prescribed antiemetic such as promethazine 25 mg bid to relieve nausea and vomiting.
If severe vomiting, offer intravenous fluids such as Ringer’s lactate 1 liter in 8 hours to replace lost fluids and electrolytes.
If tolerated, offer 3 liters of oral fluids in 24 hours to maintain the patient’s hydration status.
Monitor input and output to detect any fluid overload or dehydration.
Evaluation: The patient will have normal intake and output, moist lips, and normal skin turgor within 24 to 48 hours.
Nursing Problem: Anxiety
Nursing Diagnosis: Anxiety related to pain, altered urinary elimination, and fear of death as evidenced by apprehension and insomnia.
Objective/Goal: To relieve anxiety within 12 to 24 hours.
Nursing Interventions:
Observe the patient for signs of anxiety such as apprehension and insomnia to determine need for nursing intervention.
Allow the patient to verbalize their fears and worries to enable you to detect the cause of their anxiety and plan care.
Involve significant others such as a spouse in the management of the client to prevent the client’s feelings of alienation.
Provide privacy when providing nursing care to promote the patient’s personal dignity.
Evaluation: The patient’s anxiety will be relieved after 12 to 24 hours.
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