CHINESE GENERAL HOSPITAL

College of Nursing and Liberal Arts

NURSING CARE PLAN

Patient’s Name: Teresita Lim Age: 55 years old Diagnosis: Obstructive Jaundice

ASSESSMENT Nx DIAGNOSIS INFERENCE GOAL INTERVENTION RATIONALE EVALUATION

SUBJECTIVE: Imbalanced Impaction at SHORT TERM: INDEPENDENT: SHORT TERM:

nutrition: less than cystic and bile
body duct After 2 days of 1. Assess nutritional After 2 days of
 Verbalization of requirements nursing intervention, status continually, Provides the nursing intervention,
discomfort when related indigestion the patient will during daily nursing opportunity to goals are FULLY MET
eating due to demonstrate care, noting energy observe deviations as evidenced by:
possibility of Bile not excreted progressive weight level; condition of from normal patient
vomiting to doudenum gain as evidenced by: skin, nails, hair, oral baseline, and
cavity; desire to influences choice of  Progressive
OBJECTIVE: eat/anorexia. interventions. increase in body
Backflow of bile  Progressive weight
and goes to the increase in body
 Body weight 10% weight  Normal bowel
under ideal circulation 2. Weigh daily and
compare with Establishes baseline, movement
 Normal bowel admission weight. aids in monitoring
 Decreased Fat not
movement effectiveness of LONG TERM:
subcutaneous emulsified therapeutic
fat/muscle mass LONG TERM: regimen, and alerts After 6 days of
No absorption of nurse to nursing intervention,
 poor muscle tone After 6 days of inappropriate goals are FULLY MET
fat in the
intestines nursing intervention, trends in weight as evidenced by:
 Changes in gastric the patient will loss/gain.
motility demonstrate no signs 3. Ensure accurate
INDIGESTION of malnutirtion as collection Inaccurate  Normalization of
of
 Poor bowel evidenced by: collection can alter laboratory values
movement specimens (urine and
stool) for nitrogen test results, leading
VIT ADEK DEF. to improper  Normal bowel
 Grayish stools balance studies.
 Normalization of interpretation of movement
 laboratory values patient’s current
status and needs.  Ideal body weight
 Normal bowel
movement
REFERENCE: 4. Schedule activities Conserves
www.ehow.com  Ideal body weight with adequate rest energy/reduces
periods. Promote calorie needs.
relaxation
techniques.

COLLABORATIVE:
Aids in
1. Refer to nutritional identification of
team/registered nutrient deficits and
dietitian. need for
parenteral/enteral
nutritional
intervention.

REFERENCE:
Doenges, M.,
Moorhouse, M.F.,
Murr, A. (2006).
Nurse’s Pocket
Guide: Diagnoses,
Prioritized
Interventions, and
Rationales (11th ed.,
pp478-483).
Philadelphia: F.A.
Davis Company.

Student: Ramon Timothy B. Legaspi, SN Section: III – D Group 4 Clinical Instructor: Ms. Hope Guillermo Area: Charity - Female
 CHINESE GENERAL HOSPITAL
College of Nursing and Liberal Arts

NURSING CARE PLAN

Patient’s Name: Teresita Lim Age: 55 years old Diagnosis: Obstructive Jaundice

ASSESSMENT Nx DIAGNOSIS INFERENCE GOAL INTERVENTION RATIONALE EVALUATION

SUBJECTIVE: Impaired physical Alteration in SHORT TERM: INDEPENDENT: SHORT TERM:

mobility related to mobility may be a
decreased muscle temporary or more After 8 hours of 1. Assess the patient’s After 8 hours of
 “Ang payat payat mass and strength permanent problem. nursing intervention, ability to perform Restricted nursing intervention,
na niya kaya hirap Most disease and the patient will ADLs effectively and movements affect goals are FULLY MET
na siya gumalaw”, rehabilitative states demonstrate safely on a daily basis the ability to as evidenced by:
as verbalized by involve some degree techniques/behavior using appropriate perform most ADLs.
the relative. of immobility. that enable assessment tool.
resumption of  Improvement in
OBJECTIVE: Mobility is activities as 2. Assess degree of physical activities.
related to body evidenced by: pain, listening to To identify
changes from aging. client’s description. causative/contributi  Willingness to
 (+) General body ng factors. participate in
Restricted
weakness
movement affects  Improved physical 3. Encourage activities
the performance of movements participation in self- To enhance self-
 Limited range of concept and sense  Improvement
most activities of care, in
motion (ROM)
daily living (ADLs).  Willingness to occupational/diversi of independence. the range of
Nursing goals are to participate in onal/recreational motion (ROM)
 Inability to move activities
maintain functional activities.
purposefully
within the bed ability, prevent
additional  Improved range of 4. Encourage
impairment of motion (ROM) adequate intake of It promotes well-
 Difficulty turning being and
physical activity, fluids/nutritious
and ensure a safe LONG TERM: foods. maximizes energy LONG TERM:
 Slowed and production.
 restricted body environment.
movements After 2 days of After 2 days of
nursing intervention, nursing intervention,
the patient will goals are FULLY MET
verbalize as evidenced by:
REFERENCE: understanding of REFERENCE:
Pillitteri, A. individual treatment Doenges, M.,
(2003). Nursing regimen and safety Moorhouse, M.F.,  Progressive
diagnostis care measures as Murr, A. (2006). physical
plans. Philadelphia: evidenced by: Nurse’s Pocket movements
Lippincott Williams Guide: Diagnoses,
& Wilkins. Prioritized  ( - ) General body
 Progressive Interventions, and weakness
physical Rationales (11th ed.,
movements pp130-135).  Ability to move
Philadelphia: F.A. independently
 ( - ) General body Davis Company.
weakness

 Ability to move
independently

Student: Ramon Timothy B. Legaspi, SN Section: III – D Group 4 Clinical Instructor: Ms. Hope Guillermo Area: Charity - Female
 CHINESE GENERAL HOSPITAL
College of Nursing and Liberal Arts

NURSING CARE PLAN

Patient’s Name: Teresita Lim Age: 55 years old Diagnosis: Obstructive Jaundice

ASSESSMENT Nx DIAGNOSIS INFERENCE GOAL INTERVENTION RATIONALE EVALUATION

SUBJECTIVE: Deficient fluid Impaction at SHORT TERM: INDEPENDENT: SHORT TERM:

volume related to cystic and bile
vomiting duct After 1 day of 1. Maintain accurate After 1 day of
 Refusal to drink nursing intervention, record of I&O, noting Provides nursing intervention,
oral food because the patient will output less than information about goals are FULLY MET
of possible demonstrate intake, increased fluid as evidenced by:
vomiting Bile not excreted adequate fluid urine specific gravity. status/circulating
to doudenum balance as evidenced Assess skin/mucous volume and
OBJECTIVE: by: membranes, replacement needs.  Stable vital signs
peripheral pulses,
 Unstable vital Backflow of bile and capillary refill.  Moist mucous
signs and goes to the  Stable vital signs membranes
circulation 2. Monitor for
 Moist mucous signs/symptoms of Prolonged vomiting,  Appropriate
 Decreased urine membranes gastric aspiration, urinary output
output Fat not increased/continued
nausea or vomiting, and restricted oral
emulsified  Appropriate intake can lead to LONG TERM:
 Weight loss abdominal cramps,
urinary output weakness, twitching, deficits in sodium,
No absorption of seizures, irregular potassium, and After 4 day of
 Poor skin turgor LONG TERM: chloride. nursing intervention,
fat in the heart rate,
intestines
 Dry skin and lips paresthesia, goals are FULLY MET
After 4 day of hypoactive or absent as evidenced by:
 (+) General body nursing intervention, bowel sounds,
weakness N&V the patient will depressed
maintain fluid respirations.  Stable vital signs
volume at functional 3. Eliminate noxious
level as evidenced by: sights/smells from Reduces stimulation  Adequate urinary
environment. of vomiting center. output

 Stable vital signs  Moist mucous

4. Perform frequent Decreases dryness membranes
REFERENCE:  Adequate urinary oral hygiene with of oral mucous
www.ehow.com output alcohol-free membranes;  Good skin turgor
mouthwash; apply reduces risk of oral and capillary refill
 Moist mucous lubricants. bleeding.
membranes
COLLABORATIVE: Reduces nausea and
 Good skin turgor prevents vomiting
and capillary refill 1. Administer
antiemetics, e.g.,
prochlorperazine
(Compazine). REFERENCE:
Doenges, M.,
Moorhouse, M.F.,
Murr, A. (2006).
Nurse’s Pocket
Guide: Diagnoses,
Prioritized
Interventions, and
Rationales (11th ed.,
pp320-337).
Philadelphia: F.A.
Davis Company.

Student: Ramon Timothy B. Legaspi, SN Section: III – D Group 4 Clinical Instructor: Ms. Hope Guillermo Area: Charity - Female