Diabetes Mellitus

NCP
Assessment Diagnosis Planning Intervention Rationale Evaluation
Subjective:“Hind Risk for After 8 hours Observe for signs of Patient may be admitted After 8 hours of
i gumagaling ang infection of nursing infection and with infection and nursing
sugat ko” as related to high interventions, inflammation inflammation which may interventions, the
verbalized by the glucose levels, the patient will •Provide continued worsen the condition patient was able to
patient. decreased identify skincare. Keep the skin of client. identify
leukocyte interventions dry, and the linens also Circulation maybe interventions to
Objective: function to prevent or dry and wrinkle free. impaired, placing patient at prevent or reduce
•Flushed reduce risk • Encourage adequate increased risk for skin the risk of infection
appearance of infection dietary and fluid intake irritation.
•Wound drainage of 3000ml per day. •Reduces transmission
• Vital signs taken •Promote good hand of microbes
as follows: washing by nurse and • High glucose in the blood
T: 37.4 patient. creates excellent medium
P: 86 •Promote health teaching for bacterial growth.
R: 17BP: 120/9 on taking medications and •Provides knowledge and
ways how to decrease the understanding for patient
risk of infection

Assessment Diagnosis Planning Intervention Rationale Evaluation

Subjective: Impaired skin After 1 wk of nursing Assessed skin. Noted color, Establishes comparative At the end of the 1week
Concern ako at integrity r/t large interventions, the patient will turgor, and sensation. baseline providing nursing intervention,
nababahala sa vessel destruction be able to display Described wounds and opportunity for time the client was able to
sugat ko as evidenced by improvement in wound observed changes display improvement in
intervention.
alteration in healing as evidenced by: wound healing as
Demonstrated good skin
altered level pressure hygiene, e.g., wash evidenced by:
of consciousness distribution, Intact skin and Minimized thoroughly and pat dry
ulceration presence of wound. carefully. Intact skin
generalized Maintaining clean, dry skin
weakness Absence of itchiness, redness. Instructed family to maintain Minimized presence of

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 clean, dry clothes preferably provides a barrier to wounds,
numbness of the After 8 hours of nursing cotton fabric infection. Patting skin dry
lower extremities intervention the patient will be instead of rubbing reduces Absence of redness or
Emphasize importance
able to: risk of dermal trauma to itchiness
of adequate nutrition and
disruption of skin fluid intake. fragile skin.
layers at the left Participate in prevention After 8 hours of nursing
leg measures and Demonstrate to family intervention the patient
treatment program members how to make a will be able to:
edema on both guava decoction to apply in Skin friction caused by stiff
upper and lower Demonstrate proper wound the wound as alternative or rough clothes leads to Participate
extremities care c/o watcher disinfectant. irritation of fragile skin and in prevention measures
increases risk for infection. and treatment program
Instruct the family to clip
muscle weakness and file the nails regularly. Improved nutrition and
Demonstrate
hydration will proper wound care c/o
improved skin watcher
Apply lotion on leg condition.

Assists them in optimal

healing with less
expensive resources.

Assessment Diagno Planni Intervention Rationale Evaluation

sis ng
Subjective:“Pakiramdam kolagi Fluid After 8 Monitor orthostatic blood pressure Hypovolemia may be After 8 hours of Nursing
akong nanghihina sakana volume hours of changes. manifested by hypotension interventions, the patient
uuhaw” deficient nursing and tachycardia. was able to demonstrate
(I feel weak and I’m always related to interventi Monitor respiratory pattern like adequate hydration
thirsty) osmotic ons, the Kussmaul’s Respirations and acetone Lungs remove carbonic acid evidenced by stable vital
As verbalized by the patient. diuresis patient breath. through respirations, signs, palpable peripheral
from will producing a compensatory pulses, good skin
Objective:· Dry skin and hypergly demonstr Monitor temperature, skin color and respiratory alkalosis turgor and capillary refill
mucous membrane.· Poor skin cemia ate moisture. for ketoacidosis.
turgor.· Sudden weight loss.· adequate Goal is
V/S taken as follows: hydration Assess peripheral pulses, capillary refill, Fever, chills, and diaphoresis Provision of fluid balance.
T:37.1 skin turgor, and mucous membrane. are common with infectious Demonstrate adequate

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P:85 process; fever with flushed, hydration as evidenced by
R:20 Monitor input and output. Note urine dry skin may reflected stable vital signs palpable
BP: 110/80 specific gravity hydration peripheral pulses, good
skin turgor and capillary
refill, individually
appropriate urinary
output.

Myocardial Infarction

Nursing
Assessment Nursing Diagnosis Planning Rationale Evaluation
Interventions
 initially assess, assist in determining cause and After rendering of nursing
Ineffective The patient will document, and effect of the chest discomfort and intervention, the patient
Subjective: cardiac tissue alleviate and report to the provide a baseline data for had appears comfortable
perfusion related appears physician the characteristics findings of ischemic and is free from pain.
“hindi normal to reduced following: the pain and symptoms. Blood pressure is 110/80.
comfortable and
yung vital signs coronary blood patient’s Temperature of 37.1˚C.
is free of pain
niya” as flow. description of But the RR 40 and PR
and other sign chest discomfort,
verbalized by the 101 bpm are still
and symptoms: the effect of it on compensating to maintain
relative of the
respiratory rate, cardiovascular cardiac output. The goal
patient.
cardiac rate, and perfusion change is partially met.
Objective: blood pressure in blood pressure
return to and heart sounds,
prediscomfort changes in LOC,
Auscultated
level. decrease in urine
heart have extra
output and to the
sound
skin temperature, An ECG
nad other during symptoms may be useful in
shortness of
symptoms such the diagnosis of an extension of
breath
as nausea, MI.
increase
cool & pale sweating, or
skin
complaints of
unusual fatigue. Oxygen therapy increases the

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obtain a 12 – oxygen supply to the myocardium
lead ECG if actual oxygen saturation is less
recording the than normal.
symptomatic
event, as medication therapy is the first
prescribed by line of defense in preserving
physician, to myocardial tissue. The side effects
determine of the medications can be
extension of hazardous and the patient’s status
infarction. must be assessed.

 physicals rest reduces

administer myocardial oxygen consumption.
oxygen at the Stress response, this results, this
level of result, increase myocardial oxygen
prescribed. consumption.x`x`x`x`

administer
medication
therapy as
prescribed, and
evaluate the
patient’s response
continuously.

ensure

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 physical rest;
use the bedside
commode with
assistance;
backrest
elevated to
promote
comfort; diet as
tolerated; arms
supported during
upper extremity
activity; use of
stool softener to
straining stool.
Provide a restful
environment.

Nursing
Assessment Planning Nursing Interventions Rationale Evaluation
Diagnosis
Objective: Decreased Cardiac After of 8 hours of >take vital signs >for bseline data. After of 8 hours of nursing
Output related to nursing intervention the patient
>cold clammy alteraion of stroke intervention the >Auscultate heart >Decreased cardiac output should be display
volume patient will be sounds: results in diminished hemodynamic stability. The
skin
display weak/thready pulses. goal is partially met.
hemodynamic Irregularities suggest
> prolonged stability. dysrhythmias, which may require
capillary refill further evaluation/monitoring.

>crackles S3 is usually associated with HF,

sounds on chest but it may also be noted with the
Note development of S3, mitral insufficiency
S4; (regurgitation) and left
ventricular overload that can
accompany severe infarction. S4
may be associated with

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 myocardial ischemia, ventricular
stiffening, and pulmonary or
systemic hypertension.

Indicates disturbances of normal

blood flow within the heart, e.g.,
incompetent valve, septal defect,
Presence of or vibration of papillary
murmurs/rubs. muscle/chordae tendineae
(complication of MI). Presence
of rub with an infarction is also
associated with inflammation,
e.g., pericardial effusion and
pericarditis.

Crackles reflecting pulmonary

congestion may develop because
of depressed myocardial
function.

>Auscultate breath >Heart rate and rhythm respond

sounds. to medication, activity, and
developing complications.
Dysrhythmias (especially
>Monitor heart rate and premature ventricular
rhythm contractions or progressive heart
blocks) can compromise cardiac
function or increase ischemic
damage. Acute or chronic atrial
flutter/fibrillation may be seen
with coronary artery or valvular
involvement and may or may not
be pathological.

>Increases amount of oxygen

available for myocardial uptake,
reducing ischemia and resultant
cellular irritation/dysrhythmias.

Cardiac index, preload/afterload,

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 contractility, and cardiac work
can be measured noninvasively
>Administer with thoracic electrical
supplemental oxygen, as bioimpedance (TEB) technique.
indicated. Useful in evaluating response to
therapeutic interventions and
identifying need for more
aggressive/emergency care.

Measure cardiac output Provides information regarding

and other functional progression/resolution of
parameters as infarction, status of ventricular
appropriate. function, electrolyte balance, and
effects of drug therapies.

May reflect pulmonary edema

related to ventricular
dysfunction.
Enzymes monitor
resolution/extension of
infarction. Presence of hypoxia
indicates need for supplemental
review serial ECGs. oxygen. Electrolyte imbalance,
e.g., hypokalemia/hyperkalemia,
adversely affects cardiac
rhythm/contractility.

Review chest x-ray.

Monitor laboratory data,

e.g., cardiac enzymes,
ABGs, electrolytes.

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 Assessment Nursing Diagnosis Planning Nursing Interventions Rationale Evaluation

Objectives: impaired skin After rendering of assess, document the skin for guiding data. After of 8 hours of nursing
integrity related to nursing patient. intervention the patient had
physical prolonged bed intervention the to avoid possible monitor fluid status and
immobilization pressure. patient will not be ask the physician if the that can trigger to his reduce occurrence of fluid
able to get a bed patient will allowed to turn disease. excess. the goal is met.
prolonged bed sore. the patient on side-to side
pressure . and the time interval.

do the skin care to avoid possible

complication on skin.

Naso Pharyngeal Cancer Nursing Care Plans

Ineffective Airway Clearance

Scientific Nursing
Assessment Nursing Diagnosis Objectives Rationale Evaluation
Explanation Interventions

Subjective cues: Ineffective airway Ineffective airway After 3 hours of NI,  Establish rapport  To get the trust of
"Magkasakit ya clearance r/t tissue clearance is the pt will be able to the pt.
knyan mangisnawa necrosis located in inability to clear verbalize  Position head to  To open or
nang, lalu na pag nasal area AEB secretions or understanding of facilitate airway maintain open
sasabi ya" as dyspnea, obstruction from the cause and airway in at-rest
verbalized by the restlessness, use of respiratory tract to therapeutic or com promised
SO accessory muscle, maintain a clear management individual
cough, and nasal airway in which regimen and  Elevate head of  To take advantage
Objective cues: flaring. partial or complete demonstrate bed of gravity

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 Dyspnea blockage of the behaviors to decreasing
 Restlessness breathing tubes to improve or maintain pressure on the
 Use of accessory the lungs. clear airway. diaphragm and
muscle Obstruction of the enhancing
 Cough airway can be due drainage
 Nasal flaring to different causes  Encourage deep-  To maximize
 Prolonged including foreign breathing and effort in
expiratory phase bodies, allergic coughing exercise expectorating
reactions, secretions
infections,  Increase fluid  Hydration can
anatomical intake help liquefy
abnormalities and viscous secretions
trauma. The onset and improve
of respiratory secretion
distress may be clearance
sudden with cough.  Support  To improve lung
There is often reduction/cessatio function
agitation in the n of smoking
early stage of
airway obstruction.

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Impaired Physical Mobility
Scientific Nursing
Assessment Nursing Diagnosis Objectives Rationale Evaluation
Explanation Interventions

Subjective cues: Impaired physical Impaired physical After 3 hours of  establish rapport  to gain
“Magkasakit kung mobility related to mobility is nursing cooperation
gagalo”, as decreased muscle limitation in intervention, the pt.  monitor and  for baseline data
verbalized by the strength a independent, will be able to record VS
patient. manifested by the purposeful physical participate in ADLs  advise pt. to have  to regain strength
patient’s limited movement of the and desired adequate rest
Objective cues: movements, limited body or of one or activities as  encourage pt to  to increase energy
 with limited ability to perform more extremities. evidenced by an eat foods rich in level
movements gross/fine motor Mobility is also increase in the pt.’s carbohydrates
 limited ability to skills, difficulty related to body movements, ability  advise pt. to do  to promote energy
perform gross/fine turning, and slowed changes from aging. to perform deep breathing
motor skills movements. Reduction in gross/fine motor  advise pt. to take  to prevent
 with difficulty muscle strength and skills, can turn adequate fluid dehydration
turning function, stiffer and easily, and an intake
 with slowed less mobile joints increase in motor  encourage pt. to  to promote energy
movements affecting balance agility. rest between and regain
can significantly activities strength
compromise the
 encourage pt. to  to reduce fatigue
mobility of elderly
engage in ROM
patients.
exercise
Restricted
movement affects
the performance of
most activities of
daily living
(ADLs.)

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Fatigue

Scientific Nursing
Assessment Nursing Diagnosis Objectives Rationale Evaluation
Explanation Interventions

Subjective cues: Fatigue related to An overwhelming After 3 hours of  Establish rapport  to gain
“Medyu poor physical sustained sense of nursing cooperation
mangalambut ku”, condition as exhaustion and intervention, the  Monitor and  for baseline data
as verbalized by the manifested by the decreased capacity patient will record vital signs
patient. patient appears for physical and verbalize an  Encourage pt. to  to conserve
weak, a decreased mental work at understanding sit instead of energy
Objective cues: ability in usual level regarding the health standing in
 appears weak performing Fatigue is a teachings on how to performing
 decreased ability activities, and subjective conserve energy as activities
in performing compromised complaint with both evidenced by the  Advise pt. to have
activities concentration. acute and chronic patient appears adequate rest  to regain strength
 with illnesses. In an strong, an increase  Encourage pt. to
compromised acute illness fatigue in the ability to perform ROM  to reduce fatigue
concentration may have a perform activities, exercises
protective function and has the ability  Encourage pt. to
that keeps the to concentrate fully. eat carbohydrates-  to increase energy
person from containing food level
sustaining injury  Encourage pt. to
from overwork in a do focus breathing  to promote energy
weakened
condition. As a
common symptom,
fatigue is associated
with a variety of
physical and
psychological
conditions.

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