NURSING CARE PLAN

ASSESSMENT DIAGNOSIS PLANNING INTERVENTION EVALUATION

SUBJETIVE DATA: “Fatigue Related to Short Term Goal: INDEPENDENT: Short Term Goal:
* “Ang bilis ko Disease State as Evidenced * After 3 hours of nursing * Discuss * Goal Met, after 3 hrs of
energy
makaramdam ng pagod by Verbalization of intervention, the patient will conservation techniques and nursing intervention, the
kahit maliit lang na gawain” Unremitting And communicate his stress the importance of patient have shown signs of
as verbalized by the patient. Overwhelming Lack of understanding of the factors prioritizing activities. understanding of the factors
that contribute to fatigue as
Energy.” that contribute to fatigue. evidenced by verbal reports of
* “Tatlong araw nang ganito “Nagpahinga ako kanina dito
yung nararamdaman ko” * Emphasize the importance sa kwarto ko at wala na akong
of adequate sleep and rest. ginawang iba, gumaan
Provide the patient a pakiramdam ko dun.”
OBJECTIVE DATA: conducive sleep
environment by giving him * Goal Met, after 12 hours of
* Pallor a comfortable room and nursing intervention, the
* Limited Mobility * After 12 hours of nursing bed. patient has demonstrated an
intervention, the patient will increase in energy levels as
Vital signs demonstrate an increase in DEPENDENT: evidenced by improved
participation in activities of
T: 36.6 energy levels as evidenced * Administer Vitamin B daily living by going to the
PR: 87 by improved participation in Complex as prescribed by bathroom all by himself.
RR: 21 activities of daily living. the Physician.
BP: 110/60 Long Term Goal:
O2 Sat: 96% * Goal Met, after 3 days of
nursing intervention, the
Long Term Goal: patient has demonstrated
* After 3 days of nursing improved endurance and
intervention, the patient will ability to engage in activities
demonstrate improved without excessive fatigue as
endurance and ability to evidenced by walking around
(going in the bathroom and
engage in activities without walking inside or outside of
excessive fatigue. the ward).

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 ASSESSMENT DIAGNOSIS PLANNING INTERVENTION EVALUATION
SUBJECTIVE DATA: “Risk for Infection SHORT TERM GOAL: INDEPENDENT: SHORT TERM GOAL:
* “Patient is a known case Related to
of CLL” Immunosuppression * After 25 minutes of nursing * Assess the patient’s baseline * Goal Met, after 25 minutes of
intervention, the patient will vital signs, temperature, and any nursing intervention, the patient
Secondary to CLL and the signs of infection. Then has understood the importance
OBJECTIVE DATA: Blood Transfusion” understood the importance of
proper hygiene to avoid monitor vital signs during and of proper hygiene to avoid
infections. after each blood transfusion. infections as evidenced by the
* Vital Signs patient performing frequent
T: 36.6 * Obtain a thorough medical hand washing, hand sanitizing,
PR: 87 history, including any reactions and keeping away things that are
RR: 21 to blood products. unsanitary.
BP: 110/60 LONG TERM GOAL: * Educate the patient of proper LONG TERM GOAL:
O2 Sat: 96% hygiene. (such as hand washing) * Goal Met, after 72 hours of
* After 72 hours of nursing nursing interventions the patient
* Laboratory Results interventions, the patient will * Monitor for adverse reactions had not shown any signs of
not show any signs of such as fever, chills, and SOB. infection as evidenced by vital
WBC - 56.18 (4.0-10.0 x infection. signs of;
10^9/L) DEPENDENT: T: 36.5
PR: 63
* Administer Vitamin B RR: 17
Platelets - 66 (110-160 g/L) * After 24 hours of nursing Complex as prescribed by the BP: 140/70
intervention, the patient’s Physician. O2 Sat: 98%
%NEU - 7.9 (50.0-70.0%) immune system function will
improve. * Goal Met, after 24 hours of
%LYM - 88.6 (20.0-40.0%) COLLABORATIVE: nursing intervention, the
patients immune system
* Collaborate with the function has improved as
healthcare team to develop a evidenced by verbal report of
plan to manage feeling better “tattay mabannog
immunosuppression, which may nak duray bassit nga kuti, tatta
include medications, mayat met bassit en”.
vaccinations, and lifestyle
modifications.

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 ASSESSMENT DIAGNOSIS PLANNING INTERVENTION EVALUATION
SUBJECTIVE DATA: “Risk for Hemolytic SHORT TERM GOAL: INDEPENDENT: SHORT TERM GOAL:
* “Salsalinan ako ng dugo Transfusion Reaction
Sir”, as verbalized by the Related to Incompatibility * After 10 minutes of * Stop blood transfusion at * Goal Met, after 10
patient. as Evidenced by nursing intervention, the the first sign of minutes of nursing
Agglutination.” patient will not be able to agglutination. (rising intervention, the patient
OBJECTIVE DATA: develop hemolytic temperature) hasn’t developed any more
transfusion reactions. hemolytic transfusion
* Vital Signs * Monitor the patient reactions
T: 37.6 closely for signs of a
PR: 88 * After 4 hours of nursing hemolytic transfusion * Goal Met, after 4 hours of
RR: 20 intervention, the patient will reaction, such as fever, nursing intervention, the
BP: 120/90 be cleared for the chills, back pain, and patient has been cleared for
O2 Sat: 96% continuation of blood hematuria. the continuation of blood
transfusion. transfusion as evidenced by
* Laboratory Results * Inform the ROD the crossmatching done.
immediately of the
RBC - 2.1 (3.0-12.0%) * After 8 hours of nursing agglutination and stoppage *Goal Met, after 8 hours of
intervention, the patient’s of the transfusion. nursing intervention, the
Platelets - 66 (110-160 g/L) vital signs will be monitored patient’s vital signs has been
and maintained within the monitored and maintained
* (+) Agglutination patient’s baseline. DEPENDENT: withing the patient’s
baseline
* Keep the IV access open
with normal saline to ensure T: 36.2
access for emergency PR: 71
medications or additional RR: 19
blood products if needed. BP: 120/70
O2 Sat:: 99%

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LONG TERM GOAL: COLLABORATIVE: LONG TERM GOAL:

* After 8 hours of nursing * Collect blood samples * Goal Met, after 8 hours of
intervention, the patient will from the patient and the Nursing interventions, the
be minimized from the risk transfused blood bag to patient has been minimized
of future transfusion determine the cause of the from the risk of future
reactions. agglutination. (Deliver to transfusion reactions as
the Medical Technologists evidenced by proper
and ROD) crossmatching and negative
signs of Agglutination
symptoms.

T: 36.2

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