MEDICAL WARD

Nursing Care Plan

PLANNING
NURSING
ASSESSMENT OBJECTIVE OF IMPLEMENTATION EVALUATION
DIAGNOSIS INTERVENTION RATIONALE
CARE
Subjective Cues: Ineffective After 4 hours of 1. Establish patient 1. This is to gain the client's 1. Established patient After 4 hours of
● Patient reported Breathing Pattern nursing rapport. trust and have a good rapport by greeting the nursing
that after 1 week related to interventions, the nurse-client relationship. client before interventions, the
PTA, the patient respiratory patient will be able performing nursing patient was able to
noticed easily muscle fatigue to demonstrate interventions. demonstrate
fatigability. due to improved breathing improved breathing
● Patient complains hypermetabolic pattern as evidenced 2. Provide an 2. A calm environment allows 2. Provided an pattern as
of shortness of state with by: atmosphere of the client to concentrate and atmosphere of evidenced by:
breath increased energy 1. Verbalization of respect, openness, focus more completely. respect, openness, 1. Verbalization of
requirements improved breathing. trust, and trust, and improved
Medical History: secondary to 2. Verbalization of collaboration. collaboration. breathing.
● Clinically diagnosed hyperthyroidism decreased fatigue
2. Verbalization of
Hyperthyroidism as evidenced by 3. Improvement of 3. Assess and monitor 3. Assessment of respiratory 3. Assessed and
decreased fatigue
(2019) reports of easy Laboratory values respiratory patterns, patterns helps in identifying monitored respiratory
Family History: fatigability, to normal range including rate, depth, the severity of the patient’s patterns, including 3. Improvement of
● Positive shortness of breath, 4. Demonstration of and effort. complaints. rate, depth, and effort. Laboratory values
hyperthyroidism at increased effective methods ● Rate: 28 to normal range
maternal side respiratory rate, (breathing breaths/min 4. Demonstration of
and tachycardia exercises) effective methods
Objective Cues: with irregular rate 4. Assess the skin color 4. Pallor and cyanosis may be 4. Assessed the skin (breathing
● Patient is and rhythm. and mucus indicators for deficient gas color and appeared exercises)
tachycardic with membranes. exchange and perfusion. slightly pale.
irregular rate and
rhythm
5. Assess the nail beds 5. Pale or blue nail beds may 5. Assessed the nail
Vital Signs by performing indicate a lack of perfusion. beds and performed
● Respiratory Rate: capillary refill. capillary refill.
28 breaths/min ● Capillary Refill: 2
seconds

Laboratory Values:
⮚ CBG: 50mg/dL 6. Monitor blood gas 6. An oxygen saturation of less 6. The blood gas values
Complete Blood Count values and pulse than 90% indicates and pulse oxygen
(CBC) oxygen saturation problems with oxygenation. saturation levels as
⮚ Hematocrit: levels as available. Although the patient SpO2 was monitored.
0.33% within the normal range it is ● Sp02: 96%
⮚ FT4: 75.00 important to note that
⮚ TSH: 0.03 Hypoxemia can result from
ventilation-perfusion
mismatches secondary to
respiratory secretions.
7. Continuously 7. Hypertension and 7. Continuously
monitor the patient’s tachycardia might be related monitored the
vital signs. to increased work of patient’s vital signs.
breathing, leading to ● HR: 98beats/min
increased respiratory ● BP: 100/60 mmHg
distress and hypoxia. An ● RR: 98
elevated temperature can breaths/min
occur as a response to an ● Temperature:
infectious or inflammatory 36.3𝆩C
process.

8. Elevate the head of 8. Head elevation and proper 8. Elevated the head of
the bed and assist positioning help improve the the bed and assisted
the patient to expansion of the lungs, the patient to assume
assume enabling the patient to semi-Fowler’s
semi-Fowler’s breathe more effectively. position.
position.

9. Assist the patient to 9. Movement aids in 9. Assisted the patient to

turn every 2 hours. If facilitating airway turn every 2 hours. If
ambulatory, allow the clearance and help ambulatory, helped
patient to ambulate improve lung expansion. the patient to
as tolerated. ambulate as tolerated.
10. Educate the patient 10. The proper sitting position 10. Educated the patient
in the following: promotes effective in the following:
✔ Optimal positioning breathing. Pursed-lip ✔ Optimal positioning
(sitting position) breathing technique helps (sitting position)
to keep airways open ✔ Pursed-lip breathing
✔ Pursed-lip breathing
longer so that you can technique
technique remove the air that is
trapped in your lungs by
slowing down your
breathing rate and relieving
shortness of breath.

11. Encourage the 11. Fluids help minimize 11. Encouraged the
patient to increase mucosal drying and patient to increase
fluid intake to 3 maximize ciliary action to fluid intake to 3 liters
liters per day within move secretions. Some per day within the
the limits of cardiac clients cannot tolerate limits of cardiac
reserve and renal increased fluids because of reserve and renal
function. underlying disease. function.

12. Provide the patient 12. Reduces stimuli that can 12. Provided the patient
with a calm make the patient agitated with a calm
environment, room or increase fatigue. environment by:
with preferred ● closing curtains
 temperature, and
reduced sensory
stimuli.

13. Document every 13. This is to have a record of 13. Documented every
procedure done the procedures done to the procedure done with
with the patient in patient that will later on the patient in the
the patient’s chart. serve as a basis for future patient’s chart.
reference.

Reference/s:

Doenges, M., Moorhouse, M., Murr, A. (2019). Nursing Care Plans: Guidelines for Individualizing Client Care Across the Life Span (10th ed). F.A. Davis Company.

Sparks, S., & Taylor, C. (2020). Nursing Diagnosis Reference Manual 11th ed. Lippincott Williams & Wilkins.
 PLANNING
NURSING
ASSESSMENT OBJECTIVE OF IMPLEMENTATION EVALUATION
DIAGNOSIS INTERVENTION RATIONALE
CARE
Subjective Cues: Imbalanced After 8 hours of 1. Establish patient rapport. 1. This is to gain the client's 1. Rapport was At the end of 8 hours
● Patient reported Nutrition: Less nursing trust and have a good established to the nursing interventions,
that after 1 week Than Body interventions, the nurse-client relationship. patient. the goal was partially
PTA, the patient Requirements patient will be able met. The client was
noticed yellowish related to to: 2. Monitor daily food intake. 2. The failure of antithyroid 2. Daily food intake was able to:
sclera, jaundice, metabolic ● Manifest little to Weigh daily and report medication may be monitored and ● Manifest little signs
weight loss, and imbalance no signs of losses. indicated by persistent weighed daily. of malnutrition as
easily fatigability. secondary to malnutrition as weight loss in the face of evidenced by
hyperthyroidism evidenced by: sufficient calorie intake. increased appetite
Medical History: as evidenced by ○ Increased and verbalization
● Clinically diagnosed weight loss, fatigue, appetite 3. Encourage the patient to 3. Aids in maintaining calorie 3. The patient was of decreased
Hyperthyroidism and hypoglycemia ○ Verbalization of eat and increase the intake levels high enough encouraged to eat fatigue.
(2019) Decreased number of meals and to keep up with the high and increase the ● Demonstrate
Family History: fatigue snacks. Give or suggest rate of calorie expenditure number of meals and behaviors and
● Positive ● Demonstrate high-calorie foods that are brought on by the snacks. High-calorie lifestyle changes
hyperthyroidism at behaviors, lifestyle easily digested. hypermetabolic state. foods were such as food
maternal side changes such as suggested. choices. The
food choices results of blood
Objective Cues: 4. Provide a balanced diet, 4. To encourage weight 4. Balanced diet was glucose tests are
Laboratory Values: with six meals per day. gain. Recommend a provided to the fluctuating from
⮚ CBG: 50mg/dL low-sodium diet if the patient. normal to higher
patient has edema. value
Complete Blood Count
(CBC) 5. Consult with a dietitian to 5. Assistance may be 5. Consulted with a
⮚ Hemoglobin:10 provide a diet high in required to determine the dietitian to provide a
7g/L calories, protein, right supplements and diet high in calories,
⮚ Hematocrit: carbohydrates, and guarantee sufficient protein,
0.33% vitamins. nutritional consumption. carbohydrates, and
⮚ MCH: 26.4pg vitamins.
⮚ RDW: 15.6%
6. Assess the patient’s 6. Particularly if the patient's 6. The patient’s
⮚ FT4: 75.00 nutritional history with the perception is nutritional history
⮚ TSH: 0.03 help of significant others. compromised, family was assessed with
members may be able to the help of SO.
give the patient's eating
habits more precise
information.

7. Examine the laboratory 7. In order to determine a 7. The laboratory

results of the patient and patient's nutritional status, results were
determine if they indicate laboratory tests are examined.
well-being or deterioration. important. Several
Include the serum albumin, possible causes may be
transferrin, RBC and WBC indicated by an abnormal
count, and the serum result from a single
electrolyte values diagnostic test.
 8. Administer medications as 8. Given in order to meet 8. Medications were
indicated: glucose, vitamin energy needs and prevent administered as
B complex, insulin (small or treat hypoglycemia. ordered.
doses). Insulin aids in controlling
serum glucose if elevated.

Reference/s:

Doenges, M., Moorhouse, M., Murr, A. (2019). Nursing Care Plans: Guidelines for Individualizing Client Care Across the Life Span (10th ed). F.A. Davis Company.

Vera, M. (2022, March 8). 7 Hyperthyroidism Nursing Care Plans. Nurseslabs: https://nurseslabs.com/7-hyperthyroidism-nursing-care-plan-ncp/4/

Ackley, B. J., Ladwig, G. B., Makic, M. B., Martinez-Kratz, M. R., & Zanotti, M. (2020). Nursing diagnoses handbook: An evidence-based guide to planning care. St. Louis, MO:
Elsevier.

Wayne, G. (2022, May 9). Imbalanced Nutrition: Less Than Body Requirements Nursing Care Plan. Nurseslabs:
https://nurseslabs.com/imbalanced-nutrition-less-body-requirements/