CHAPTER THREE
PLANNING OF CARE ON THE PATIENT AND FAMILY CARE
Planning involves the development of strategies designed to prevent, minimize and correct the
problems identified in the nursing diagnosis. It is therefore a written document formulated to
help the nurses and other health staff members deliver quality care to the patient.
The care plan forms a communication link between members of the health team and
encourages the nurses to use their initiatives in nursing the patient. It prevents duplication and
helps with the continuity of care; it also serves as legal document for both the nurses and the
patient. In an attempt to maintain a positive client-nurse relationship, the goals were planned
with both patient and mother so that it can reflect both their ability and readiness to work
towards the attainment of the set objectives.
OBJECTIVES OF NURSING CARE PLAN
Objectives are the specific goals or aims that an individual wishes to achieve within a time
frame with the available resources. Objectives are basic tools that underline all planning and
strategic activities. As part of the planning objectives, both short- and long-term goals were set
as bases for the care and for evaluation.
1. Patient temperature will reduce by 1⁰C within 30 minutes as evidenced by;
a. Patient verbalizing absence of warmness when touched
b. Nurse recording patient's temperature reading between (36.2⁰C - 37.9⁰C) degree Celsius
2. Patient will demonstrate a relieve of pain (joint pain and headache) within 2 hours as
evidenced by;
a. Patient rating pain as 1 on the numeric pain rating scale.
b. Nurse observing that patient is looking relaxed, having a cheerful facial expression.
3. Patient will have an improved sleeping pattern within 48hours as evidenced by;
a. Patient verbalizing she was able to sleep for 6-8hours uninterruptedly in the night
b. The nurse observing patient being able to sleep for 6hours in the night
4. Patient will attain adequate nutrition throughout hospitalization as evidenced by;
a. Patient verbalizing that there is an improvement in appetite
b. Nurse observing patient eat two third of food served
5. Patient will have an improved hemoglobin level within 72hours as evidenced by;
a. Patient verbalizing absence of pallor such as pale skin and conjunctiva
b. Nurse observing patient having an absence of pallor such as pale skin and conjunctiva
6. Patient will demonstrate reduced signs of yellowish sclera discoloration within 48 hours as
evidenced by;
a. Patient verbalizing a cleared sclera
b. Nurse observing patient having a cleared sclera
7. Patient will be free from fall throughout hospitalization as evidenced by;
a. Patient verbalizing no incidence of fall and reduction of dizziness
b. Nurse recording no incidence of fall
TABLER 6: NURSING CARE PLAN
DATE/ NURSING OBJECTIVE/ NURSING ORDERS NURSING INTERVENTION DATE/ EVALUATION SIGN
TIME DIAGNOSIS
OUTCOME TIME
CRITERIA
11/08/24 Hyperthermia Patient 1. Reassure 1. Patient and mother were 21/08/2 Goal met as R.M
at (38.90C) temperature will patient and reassured that temperature 4 at Patient
related to reduce by 10C mother would be restored to normal and verbalized an
8:45pm 10:15am
abnormally within 30 minutes this will allay fear and anxiety absence of
high levels of as evidenced by; warmness when
2. Patient’s vital signs such as
white blood touched and
I. Patient temperature, pulse, respiration,
cells secondary
verbalizing 2. Monitor vital blood pressure was checked and Nurse recorded
to infection
absence of signs especially recorded at regular intervals a temperature
warmness when temperature. reading
3. Patient was tepid sponged using
touched of(37.90C)
six cleaned towels dipped in
II. Nurse warm water and cleaning patient
3. Tepid sponge
recording with it, leaving dump water on
patient if
patient’s his body to dry up by
temperature is
temperature evaporation thereby reducing
above
reading between body temperature to normal.
(36.20C37.90C)
(36.2°C-37.9°C)
4. Patient was encouraged to take
degree Celsius.
in more fluids to help reduce
body temperature.
4. Serve copious 5. Cold drinks like cold milo, cold
fluids. water and orange juices were
served to help reduce patient’s
5. Serve cold
temperature.
drinks
6. Adequate ventilation was
ensured by opening nearby
6. Ensure
windows to allow fresh air and
adequate
the nearby fans were also put
ventilation.
on.
7. Antipyretic such as Intravenous
Paracetamol 1g was served to
reduce temperature.
7. Administer
prescribed
analgesics
DATE/ NURSING OBJECTIVE/ NURSING ORDERS NURSING INTERVENTIONS DATE/ EVALUATION SIGN
TIME DIAGNOSIS
OUTCOME TIME
CRITERIA
16/08/2 Acute Patient will [Link] patient 1. Patient level of pain was assessed 16/08/25 Goal fully met as R.G.N
5 pain(joint demonstrate a level of pain. using the numeric pain rating scale of 0 a. patient rated
10:15pm
pain and relieve of pain to 10 and patient indicated 7 pain as 1 on the
8:45pm
headache) within 2hours as numeric pain
[Link] vital signs was checked and
related to evidenced by; 2. Check vital signs rating scale and
recorded as follows temperature-
hemolytic nurse observed
a. Patient rating 38.9degree Celsius, pulse-76bpm,
crisis patient having a
pain as 1 on the respiration19cpm, blood pressure-
relaxed, cheerful
numeric pain 113/75mmHg to obtain baseline data
face
rating scale. for comparison and evaluating the
effectiveness of care rendered to him.
b. Nurse observing 3. Engage patient in
that patient is diversional therapy. 3. The television was set on for patient
looking relaxed, to watch her favorite program so as to
having a cheerful take off his mind from the pain
facial expression. [Link] warm /cool
4. Warm compress was applied to the
compress.
joint to cause vasodilation of the blood
vessel to improve circulation and
5. Ensure physical relieve pain.
rest [Link] was made to rest from
[Link] activities that might aggravate the pain
prescribed [Link] such as Intravenous
medication paracetamol 1g was administered
NURSING CARE PLAN
DATE/ NURSING OBJECTIVE/ NURSING ORDERS NURSING INTERVENTIONS DATE/ EVALUATION SIGN
DIAGNOSIS
TIME OUTCOME TIME
CRITERIA
17/08/25 Disturbed Patient will have 1. Reassure 1. Patient was reassured of competent 19/08/2 Goals met as R.M
at sleeping an improved patient of nursing care. 5 patient
pattern sleeping pattern effective verbalized being
9:30am at
related to within 48hours nursing care. able to sleep for
change of as evidence by; 2. Warm milo was given to patient to 9:30am at least 6hours in
2. Serve warm
environment induce sleep. the night
a. Patient’s beverages
pain and
ability to before patient
headache
sleep for goes to sleep
at least at night.
6hours 3. Warm compresses applied to the
3. Apply warm
uninterru affected joints to help reduce pain
compresses to
ptedly in
the affected
the night
joints.
continuo
usly 4. Provide bulk
4. All nursing activities to perform were
nursing care.
b. The organized and performed on the
nurse patient at the same time such as
observing checking of vital signs and serving of
patient medication.
being 5. Patient’s bed was made free from
able to particles, creases and crumps by
5. Make patient’s
sleep for changing the bed linen. This was done
bed
6hours in
comfortable.
the night to induce sleep and promote comfort.
6. A quiet environment was ensured by
restricting visitors and reducing the
volumes of radio and television sets to
6. Ensure quiet avoid disturbance of patient’s sleep.
environment.
7. Lights on the ward were dimmed in
the evening to enable patient sleep.
7. Provide dim
light
NURSING CARE PLAN
DATE/ NURSING OBJECTIVE/ NURSING ORDERS NURSING INTERVENTIONS DATE/ EVALUATION SIGN
TIME DIAGNOSIS OUTCOME TIME
CRITERIA
18/08/2 Imbalance Patient will attain [Link] patient [Link] was reassured that she will 21/08/2 Goal was met as R.M
4 at nutrition (less adequate regain her appetite soon after all 5 at patient verbalized
8:30am than body nutrition nursing measures have been put in an improved
8:30am
requirements) throughout place appetite and
related to loss hospitalization as nurse observed
[Link] was assisted to care for her
of appetite evidenced by; patient consume
mouth to boost her appetite such as
2. Assist patient to
a. Patient brushing the teeth with toothbrush at least half of
maintain care of his
verbalizin and toothpaste the meal served
mouth.
g that
3. All nauseating substances such as
there is an
bedpans were removed from her
improvem
3. Remove all bedside before meal to stimulate
ent in
nauseating substances appetite.
appetite
before serving his
4. Meals were planned with patient
b. Nurse meals.
and her preferences such as rice with
observing
[Link] meals with kontomire were taken into
patient
patient and take into consideration.
eat at two
consideration his
third of 5. Fruit juice such as ceres fruit drink
preference.
food was served in between meals. Patient
served [Link] fruit juices was congratulated for the efforts
between meals made to eat.
[Link]’s meals were served
attractively to stimulate his appetite
[Link] meals
and encouraged to eat
attractively and
encourage patient to
eat. [Link] was encouraged to take
more vegetables such as carrots,
7. Encourage patient to
cabbage, kontomire etc in diet
take more vegetables
and fruits.
NURSING CARE PLAN
DATE/ NURSING OBJECTIVE/ NURSING ORDERS NURSING INTERVENTIONS DATE/ EVALUATION SIGN
DIAGNOSIS
TIME OUTCOME TIME
CRITERIA
13/08/2 Ineffective Patient will have [Link] patient 1. patient was reassured that measures 15/08/2 Goal was fully R.M
4 at peripheral an improved will be put in place to help improve her 4 at met as patient
tissue haemoglobin condition having a normal
9:40am 9:40am
perfusion level within 72 [Link] for signs of capillary refill in
2. Signs of decreased tissue perfusion
related to low hours as decreased tissue the palms and
were assessed. Example pallor, cold
haemoglobin nurse observing
(6.84g/dL) evidence by; perfusion clammy skin, cyanosis patient having
an absence of
a. Patient 3. Laboratory result especially
pallor such as
having a haemoglobin was monitored
3. Monitor laboratory pale skin
normal
result 4. Pulse oximeter was used to monitor
rate of
oxygen concentration and pulse rate
capillary 4. Monitor oxygen
and read as ranged 60 to 100 beat per
refill in concentration and pule
minute
the rate.
palms 5. Patient’s vital signs were checked and
5. Monitor vital signs.
monitored four hourly and read
b. Nurse
6. Administer
observing 6. Prescribed intravenous infusion such
prescribed intravenous
patient normal saline and whole blood were
infusion.
having an administered.
absence 7. Monitor strict intake
7. A strict intake and output chart were
of pallor and output chart
monitored every 5hours
such as
8. Administer
pale skin [Link] such tab Folic acid 5mg
prescribed Haematinics
and was served daily
conjuncti
va
NURSING CARE PLAN
DATE/ NURSING OBJECTIVE/ NURSING ORDERS NURSING INTERVENTIONS DATE/ EVALUATION SIGN
DIAGNOSIS
TIME OUTCOME TIME
CRITERIA
13/08/2 Disturbed Patient will 1. Examine 1. Patient’s eyes were examined and 15/08/24 Goal fully met as R.G.N
4 body image demonstrate patient the sclera was observed to be at patient
related to reduced signs of eyes and yellowish 9:45am verbalized an
at
yellowish yellowish sclera skin for acceptance of
9:45am discoloration discoloration change in self-image and
of the within 48 hours as colour 2. Patient was reassured that eye color nurse observed
eyes(sclera) evidenced by will change to normal with an absence of
2. Reassure
secondary to intervention discoloration of
a. Patient patient
high level of the skin
verbalizing 3. Intravenous fluids such as 1 liters of
bilirubin
a cleared Normal Saline,1 liter of Ringers
sclera. 3. Serve Lactate,1liter of Dextrose Normal
prescribed Saline were administered
b. Nurse
intravenous
observing 4. Serial urine collection was done and
infusion
patient the color and consistency
having a monitored.
cleared
sclera. 4. Monitor
urine for
5. Haematinics such as tablet 5mg of Folic
color and
acid was served daily
consistency
.
[Link]
prescribed vitamin
supplement
NURSING CARE PLAN
DATE/ NURSING OBJECTIVE/ NURSING ORDERS NURSING INTERVENTIONS DATE/ EVALUATION SIGN
DIAGNOSIS
TIME OUTCOME TIME
CRITERIA
14/08/2 Risk for fall Patient will be free 1. Reassure patient. 1. Patient reassured of good nursing care. 16/08/2 Goal fully met as R.G.N
4 related to from fall 4 at
2. Assess patient 2. Patient activity level was assessed a. Patient
dizziness throughout 9:00am
8:30am level of activity everyday by observing how patient move verbalized no
secondary to hospitalization as
incidence of fall
tissue hypoxia evidenced by; 3. Encourage 3. Patient was encouraged to move slowly
and reduction of
and reduction patient to have a out of bed and stand by the bed side and
a. Patient dizziness
of red blood gradual activity. take some footsteps.
verbalizing no
cells (RBC)
incidence of fall 4. Assist patient to 4. Patient was assisted to brush her tooth
and reduction of maintain her oral with close up toothpaste and toothbrush
dizziness hygiene. and her tongue was also cleaned to
prevent halitosis and dental caries as well
as mouth infections and odour.
b. Nurse observing 5. Floor kept dry and free from spillages to
no incidence of fall prevent injury.
5. Ensure that the
floor is kept dry and
free from spillages.
6. Prescribed medication such as folic acid
6. Administer 5mg was administered.
prescribed
medication.
7. Patient’s relatives were encouraged to
7. Encourage
provide iron rich foods to patient like leafy
patient to take iron
greens, read meat and legumes to help
rich diet.
increase patient’s hemoglobin level.