IX.

NURSING CARE PLAN

ASSESSMENT NURSING SCIENTIFIC PLANNING INTERVENTION RATIONALE EVALUATION

DIAGNOSIS EXPLANATION

Subjective: “May dugo Ineffective Protection Thrombocytopenia Short-Term Goal: Independent: Early detection of Short-Term Goal:
po sa gilagid ko related to impaired causes impaired clot Within 30 minutes of Assess for any signs of bleeding (e.g., Within 30 minutes of
” as verbalized by the hemostasis formation, increasing nursing intervention, active bleeding every petechiae, gum nursing intervention,
patient. (decreased platelet the risk of bleeding. the patient will shift. bleeding, hematuria) the patient verbalized t
count), as evidenced When platelet levels verbalize at least 3 Educate the patient to allows prompt 3 bleeding precautions
Objective: by gum bleeding, drop below bleeding precautions avoid: intervention and (use soft bristle
Platelet count of petechiae, and 50,000/mm³, minor (use soft bristle prevents toothbrush, avoid force
38,000/mm³ (150,000 thrombocytopenia trauma or spontaneous toothbrush, avoid force complications. nose
and 400,000/mm³) internal/external nose blowing,assistance in
presence of petechiae bleeding can occur. blowing,assistance in walking to avoid)
and gum bleeding, walking to avoid ) 1. Brushing teeth with Brushing teeth with
cold clammy skin. hard bristles hard bristles
Rationale: Prevents
Long-Term Goal: trauma to already Long-Term Goal:
Within 4 hours 0f fragile oral mucosa Within 8 hours 0f
nursing intervention, which could worsen nursing intervention,
the patient will remain bleeding. the patient remain free
free from new bleeding 2. Forceful nose Forceful nose blowing from new bleeding
episodes blowing Rationale: May rupture episodes
fragile nasal blood
vessels, especially
with thrombocytopenia.

Maintains intravascular
Dependent: volume and tissue
Administer prescribed perfusion, which are
IV fluids. critical in patients with
low platelet count and
 risk for circulatory
compromise.

Tracks trends in
Monitor CBC and platelet levels,
coagulation profile as hemoglobin, and
ordered. clotting factors to
evaluate bleeding risk
and guide treatment
decisions.

Collaborative: Platelet transfusion

Coordinate with may be needed to
physician for platelet prevent spontaneous
transfusion if condition hemorrhage when
worsens. platelet counts fall
below critical levels.

Iron helps support

Refer to a dietitian to hemoglobin synthesis;
promote foods rich in vitamin C improves
vitamin C and iron iron absorption and
supports vascular
integrity to minimize
bleeding risk
ASSESSMENT DIAGNOSIS SCIENTIFIC PLANNING INTERVENTION RATIONALE EVALUATION
EXPLANATION

Subjective: “Nahihilo Deficient fluid volume Fever and vomiting Short-Term Goal: Independent: Tracks fluid balance Short-Term Goal:
ako,” as verbalized by related to active fluid cause continuous fluid Within 30 minutes of •Monitor intake/output and detects early signs Within 30 minutes of
the patient. loss(vomiting and loss, while poor oral nursing intervention, and daily weight. of fluid loss or nursing intervention,
fever) as evidenced by intake limits fluid the patient will show retention. the patient shows
hypotension, delayed replacement. This improved hydration •Encourage small, Promotes gradual improved hydration
Objective: Hypotension capillary refill, and dry results in decreased (urine output >30 frequent oral fluids if rehydration without (urine output >30
(BP 80/60 mmHg), mucosa. circulating blood mL/hr, capillary refill <2 tolerated. overloading the GI mL/hr, capillary refill <2
delayed capillary refill volume, leading to seconds). tract, especially helpful seconds).
3 seconds, dry mucous hypotension and poor in patients with nausea
membranes, perfusion. As Long-Term Goal: or vomiting. Long-Term Goal:
decreased urine output compensation fails, Within 4 hours of Within 4 hours of
<30ml/hr signs like delayed nursing intervention, •Educate on signs of Early recognition of nursing intervention,
capillary refill and dry the patient will dehydration to report symptoms allows the patient maintains
mucous membranes maintain normal (dry mouth, persistent timely intervention and normal hydration
appear, indicating hydration status with dizziness) prevents status with stable vital
deficient fluid volume. stable vital signs. complications. signs

Dependent:
•Administer prescribed Replaces lost
IV fluids. intravascular volume
and restores tissue
perfusion.

•Monitor serum Evaluates the

electrolytes and vital effectiveness of fluid
signs. therapy and detects
imbalances that can
affect cardiac and
neurological function.
Collaborative:
•Coordinate with Ensures appropriate
 physician for fluid fluid type and volume
adjustments. are administered
based on the patient’s
current status.

•Work with nutritionists Supports ongoing fluid

to ensure a hydration- balance and recovery
promoting diet. through proper dietary
intake, especially in
patients with reduced
appetite.

ASSESSMENT DIAGNOSIS SCIENTIFIC PLANNING INTERVENTION RATIONALE EVALUATION

EXPLANATION

Subjective: “Ang init ng Hyperthermia related Infection triggers the Short-Term Goal: Independent: Detects changes in Short-Term Goal:
katawan ko,” as to increased metabolic release of pyrogens, •Monitor temperature temperature trends for
verbalized by the rate secondary to which raise the Within 30 minutes of every 2 hours. early intervention. Within 30 minutes of
patient. infection, as evidenced hypothalamic set point, nursing intervention, nursing intervention,
by elevated leading to •Apply cool Helps lower body
temperature, flushed hyperthermia. The the patient’s compresses to axillae temperature through the patient’s
Objective: skin, and tachycardia. body responds with temperature will and forehead. conduction and temperature decreased
Temperature at increased metabolic evaporation.
39.2°C, flushed skin, rate, flushed skin, and decrease to ≤38°C. to ≤38°C.
increased heart rate tachycardia as it •Promote light clothing Prevents heat
124bpm, restlessness. attempts to regulate and well-ventilated retention and promotes
and dissipate heat. Long-Term Goal: room. natural cooling. Long-Term Goal:
Within 8 hours of Within 8 hours of
nursing intervention, nursing intervention,
the patient will Dependent: Reduces fever by the patient maintained
maintain normothermia •Administer acting on the normothermia (36.5–
(36.5–37.5°C) antipyretics hypothalamic heat- 37.5°C)
 (paracetamol) as regulating center.
prescribed.

Evaluates
•Monitor response to effectiveness of
medications. medication and
ensures safety.

Collaborative: Allows timely

•Notify physician if adjustment of
temperature persists or treatment to prevent
rises. complications.

ASSESSMENT DIAGNOSIS SCIENTIFIC PLANNING INTERVENTION RATIONALE EVALUATION

EXPLANATION

Subjective: “Ang sakit Acute Pain related to Tissue injury from Short-Term Goal: Independent: Pain assessment helps Patient verbalized a
ng tiyan ko, parang physiological injury infection triggers the Within 30 minutes to 1 •Assess pain evaluate severity and decrease in pain from
tumutusok” agent as evidenced by release of hour of nursing characteristics guide intervention. 8/10 to 3/10.
verbal report of inflammatory interventions, the (location, intensity, Patient appears
Objective: abdominal pain, facial mediators like patient will report a duration) every 2 relaxed, no longer
Pain scale:9/10 grimacing, guarding prostaglandins and reduction in abdominal hours. guarding abdomen.
verbal report of sharp behavior, restlessness, bradykinin, which pain from 8/10 to 4/10 •Encourage relaxation Relaxation and Vitals stabilized; heart
pain on the right lower and increased heart stimulate pain on a pain scale. techniques (deep comfort reduce stress rate returned to
quadrant rate. receptors. This leads breathing, distraction). and can decrease pain baseline.
to the sensation of Long-Term Goal: •Provide a quiet and perception. Patient was able to
Facial grimacing, pain. The body reacts Within 48–72 hours, comfortable sleep and participate in
guarding abdomen, through sympathetic the patient will report environment to care without signs of
restlessness, activation, causing sustained relief of minimize stress. discomfort.
increased heart rate signs such as facial abdominal pain,
124bpm grimacing, guarding, demonstrate relaxed Dependent:
restlessness, and posture, and engage in •Administer prescribed Analgesics
increased heart rate — activities without signs analgesics as ordered block pain pathways,
all indicating acute of discomfort. •Monitor and document providing symptom
pain. effectiveness of pain relief.
medications.
•Assist in positioning
(semi-Fowler’s) to
relieve abdominal Proper positioning
tension. reduces intra-
abdominal pressure.
Collaborative:
•Coordinate with the
physician for re- Collaboration
evaluation of pain ensures a
management plan if multidisciplinary
unrelieved. approach to
•Collaborate with unresolved pain.
dietitians if pain
worsens with food
intake.
•Refer to a pain
management team if
pain persists beyond
expected period.