NURSING CARE PLAN

Name of Patient: X Medical Diagnosis: Chronic renal failure secondary to DM nephropathy.

Nursing Diagnosis: Risk for ineffective protection related to abnormal blood profile.

Findings Expected Outcome Nursing Interventions and Rationale Actual Evaluation

O= Received patient on bed, Within 8 hours of nursing -Hand washing and observe proper medical asepsis and limit visitors. After 7-8 hours of nursing
awake, conscious with intervention, the patient will R= to limit transmission of infections since the patient has a weak intervention, the patient was:
intravenous fluid of # 1 D5 be able to: immune system.
0.3% NaCl 500cc @ KVO, 1. Still in coma, no signs of
infusing well at left arm. 1. Experience no signs/ -Note reports of increasing fatigue, weakness. Observe for tachycardia, increased ICP noted.
> With ventriculostomy tube symptoms of bleeding. pallor of skin/ mucous membranes, dyspnea , and chest pain. Plan patient
freely draining to blood bag; activities to avoid fatigue. 2. Displayed no further
dressing is dry and intact. 2. Maintain / demonstrate R=May reflect effects of anemia and cardiac response. To let the patient deterioration.
> With traeostomy attached improvement in laboratory rest.
to mechanical ventilator, values. 3. With stable vital signs of
with FIO2 of 80%. -Note for the sign of infections in the operative site and change the >T=36.8oC.
> With nasogastric tube for dressing regularly. >P= 101 bpm.
feeding. R= since the patient undergone ventriculostomy, noting and changing the >R= 21 cpm.
WBC= 20T dressing can help minimize the infection. >BP=140/80mmhg
RBC= 3.5 million/uL
> With the following vital
signs of:
>T=36.5oC.
>P=100bpm.
>R= 22 cpm.
>BP=130/80mmhg

Noted By:

Senior/ Staff Nurse & Nurse Supervisor

NURSING CARE PLAN

Name of Patient: X Medical Diagnosis: Acute Myocardial Infarction

Nursing Diagnosis: Infective Tissue Perfusion related to Poor Myocardial Contractility

Findings Expected Outcome Nursing Interventions and Rationale Actual Evaluation

O= Received patient on bed, Within 8 hours of nursing -Hand washing and observe proper medical asepsis and limit visitors. After 7-8 hours of nursing
awake, conscious with intervention, the patient will R= to limit transmission of infections since the patient has a weak intervention, the patient was:
intravenous fluid of # 1 D5 be able to: immune system.
0.3% NaCl 500cc @ KVO, 1. Still in coma, no signs of
infusing well at left arm. 1. Experience no signs/ -Note reports of increasing fatigue, weakness. Observe for tachycardia, increased ICP noted.
> With ventriculostomy tube symptoms of bleeding. pallor of skin/ mucous membranes, dyspnea , and chest pain. Plan patient
freely draining to blood bag; activities to avoid fatigue. 2. Displayed no further
dressing is dry and intact. 2. Maintain / demonstrate R=May reflect effects of anemia and cardiac response. To let the patient deterioration.
> With traeostomy attached improvement in laboratory rest.
to mechanical ventilator, values. 3. With stable vital signs of
with FIO2 of 80%. -Note for the sign of infections in the operative site and change the >T=36.8oC.
> With nasogastric tube for dressing regularly. >P= 101 bpm.
feeding. R= since the patient undergone ventriculostomy, noting and changing the >R= 21 cpm.
WBC= 20T dressing can help minimize the infection. >BP=140/80mmhg
RBC= 3.5 million/uL
> With the following vital
signs of:
>T=36.5oC.
>P=100bpm.
>R= 22 cpm.
>BP=130/80mmhg

Noted By:

Senior/ Staff Nurse & Nurse Supervisor

NURSING CARE PLAN

Name of Patient: X Medical Diagnosis:

Nursing Diagnosis: Infective Tissue Perfusion related to Poor Myocardial Contractility

Findings Expected Outcome Nursing Interventions and Rationale Actual Evaluation

O= Received patient on bed, Within 8 hours of nursing -Hand washing and observe proper medical asepsis and limit visitors. After 7-8 hours of nursing
awake, conscious with intervention, the patient will R= to limit transmission of infections since the patient has a weak intervention, the patient was:
intravenous fluid of # 1 D5 be able to: immune system.
0.3% NaCl 500cc @ KVO, 1. Still in coma, no signs of
infusing well at left arm. 1. Experience no signs/ -Note reports of increasing fatigue, weakness. Observe for tachycardia, increased ICP noted.
> With ventriculostomy tube symptoms of bleeding. pallor of skin/ mucous membranes, dyspnea , and chest pain. Plan patient
freely draining to blood bag; activities to avoid fatigue. 2. Displayed no further
dressing is dry and intact. 2. Maintain / demonstrate R=May reflect effects of anemia and cardiac response. To let the patient deterioration.
> With traeostomy attached improvement in laboratory rest.
to mechanical ventilator, values. 3. With stable vital signs of
with FIO2 of 80%. -Note for the sign of infections in the operative site and change the >T=36.8oC.
> With nasogastric tube for dressing regularly. >P= 101 bpm.
feeding. R= since the patient undergone ventriculostomy, noting and changing the >R= 21 cpm.
WBC= 20T dressing can help minimize the infection. >BP=140/80mmhg
RBC= 3.5 million/uL
> With the following vital
signs of:
>T=36.5oC.
>P=100bpm.
>R= 22 cpm.
>BP=130/80mmhg

Noted By:

Senior/ Staff Nurse & Nurse Supervisor

NURSING CARE PLAN

Name of Patient: X Medical Diagnosis:

Nursing Diagnosis: Infective Tissue Perfusion related to Poor Myocardial Contractility

Findings Expected Outcome Nursing Interventions and Rationale Actual Evaluation

O= Received patient on bed, Within 8 hours of nursing -Hand washing and observe proper medical asepsis and limit visitors. After 7-8 hours of nursing
awake, conscious with intervention, the patient will R= to limit transmission of infections since the patient has a weak intervention, the patient was:
intravenous fluid of # 1 D5 be able to: immune system.
0.3% NaCl 500cc @ KVO, 1. Still in coma, no signs of
infusing well at left arm. 1. Experience no signs/ -Note reports of increasing fatigue, weakness. Observe for tachycardia, increased ICP noted.
> With ventriculostomy tube symptoms of bleeding. pallor of skin/ mucous membranes, dyspnea , and chest pain. Plan patient
freely draining to blood bag; activities to avoid fatigue. 2. Displayed no further
dressing is dry and intact. 2. Maintain / demonstrate R=May reflect effects of anemia and cardiac response. To let the patient deterioration.
> With traeostomy attached improvement in laboratory rest.
to mechanical ventilator, values. 3. With stable vital signs of
with FIO2 of 80%. -Note for the sign of infections in the operative site and change the >T=36.8oC.
> With nasogastric tube for dressing regularly. >P= 101 bpm.
feeding. R= since the patient undergone ventriculostomy, noting and changing the >R= 21 cpm.
WBC= 20T dressing can help minimize the infection. >BP=140/80mmhg
RBC= 3.5 million/uL
> With the following vital
signs of:
>T=36.5oC.
>P=100bpm.
>R= 22 cpm.
>BP=130/80mmhg

Noted By:

Senior/ Staff Nurse & Nurse Supervisor

NURSING CARE PLAN

Name of Patient: X Medical Diagnosis:

Nursing Diagnosis: Infective Tissue Perfusion related to Poor Myocardial Contractility

Findings Expected Outcome Nursing Interventions and Rationale Actual Evaluation

O= Received patient on bed, Within 8 hours of nursing -Hand washing and observe proper medical asepsis and limit visitors. After 7-8 hours of nursing
awake, conscious with intervention, the patient will R= to limit transmission of infections since the patient has a weak intervention, the patient was:
intravenous fluid of # 1 D5 be able to: immune system.
0.3% NaCl 500cc @ KVO, 1. Still in coma, no signs of
infusing well at left arm. 1. Experience no signs/ -Note reports of increasing fatigue, weakness. Observe for tachycardia, increased ICP noted.
> With ventriculostomy tube symptoms of bleeding. pallor of skin/ mucous membranes, dyspnea , and chest pain. Plan patient
freely draining to blood bag; activities to avoid fatigue. 2. Displayed no further
dressing is dry and intact. 2. Maintain / demonstrate R=May reflect effects of anemia and cardiac response. To let the patient deterioration.
> With traeostomy attached improvement in laboratory rest.
to mechanical ventilator, values. 3. With stable vital signs of
with FIO2 of 80%. -Note for the sign of infections in the operative site and change the >T=36.8oC.
> With nasogastric tube for dressing regularly. >P= 101 bpm.
feeding. R= since the patient undergone ventriculostomy, noting and changing the >R= 21 cpm.
WBC= 20T dressing can help minimize the infection. >BP=140/80mmhg
RBC= 3.5 million/uL
> With the following vital
signs of:
>T=36.5oC.
>P=100bpm.
>R= 22 cpm.
>BP=130/80mmhg

Noted By:

Senior/ Staff Nurse & Nurse Supervisor