CHAPTER THREE
PLANNING FOR PATIENT/FAMILY CARE
Planning is the third phase of the nursing process and it involves setting of goals, determination
of priorities and planning a care to prevent or eliminate client’s health problems and identifying
nursing intervention to meet the set goals.
The client and the family members must be involved in the nursing care plan.
GOALS AND OBJECTIVES
1. Patient’s will maintain a normal body temperature of 36.2oC-37.2oC within 3 hours as
evidenced by the nurse taking her temperature and observing that it has dropped to the normal
range.
2. Patient’s pain level will reduce after 1 hour as evidenced by;
a) Nurse assess and patient pain scale record as 3/10
b) patient’s verbalizing relieve of headache and being cheerful.
3. Patient’s and her relative will be relieved from anxiety within 24hr as evidenced by patient
and mother having cheerful facial expression and being cooperative.
4. Patient’s will maintain normal nutritional balance throughout hospitalization as evidence by;
a) Nurse ensuring patient oral hygiene and encourage patient to take balance diet.
b) patient’s taking adequate food and water every day.
5. After 48 hours patient will perform activities of daily living without being assist as evidence
by,
a) Nurse observing patient’s performing activities of daily living such as mouth care, bathing,
and washing of hands regularly after visiting the washroom.
b) patient performing activities of daily living without being assist.
6. Patient will maintain normal sleeping pattern throughout the period of hospitalization as
evidenced by patient sleeping at least 3 hours during the day and 6-8 hours in the night.
7. Patient and family will have insight into her disease condition before discharge as evidenced
by patient answering question on her condition correctly.
TABLE FOUR: NURSING CARE PLAN
DATE NURSING OBJECTIVE / NURSING NURSING INTERVENTION DATE EVALUATION SIGNATURE
AND DIAGNOSIS OUTCOME ORDERS AND
TIME CRITERIA TIME
19/11/24 Hyperthermia Patient’s will 1. Reassure 1. Patient was reassured that 19/11/24 Goal fully
9:00 am related to maintain a normal patient that measures will be put in place to @ achieved as
inflammation body temperature everything will reduce her temperature to 12:00 evidence by
process as of 36.2oC-37.2oC be done to normal range. pm. patient
evidence by within 3 hours as reduce her temperature
patient body evidenced by the temperature to assess and
temperature nurse taking her normal level. recorded within
assess and temperature and normal range of
2. Institute 2. Patient was tepid sponge
recorded as observing that it (37.0Oc).
measures to using sweep stroke leaving
39.4°C. has dropped to
reduce client’s damp water on patient’s body to
the normal range.
temperature. dry up by evaporation by
reducing the temperature in
every 15 minutes.
3. Administer 3. Prescribed medications were
prescribed administered ( IV Ciprofloxacin
medication. 400mg and IV Paracetamol
500ml) were administered.
4. Light clothing was used to
cover the client to prevent her
from generating heat. Adequate
ventilation was ensured by
4. Monitor opening nearby windows and
vital signs. her vital signs were checked
and recorded.
DATE NURSING OBJECTIVE/ NURSING NURSING INTERVENTION DATE EVALUATION SIGNATURE
AND DIAGNOSIS OUTCOME ORDERS AND STATEMENT
TIME CRITERIA TIME
19/11/24 Acute pain Patient’s pain level 1. Reassure 1. Client and mother were 19/11/24 Goal fully met as
10:30pm (headache ) will reduce after 1 patient and reassured that patient is in the 11:30pm evidenced by
related to an hour as evidence mother that hands of competent personnel a) patient relaxed
increase in by everything and that everything possible in bed and
frontal arterial a) Nurse assessing will be done will be done to reduce the pain. verbalized she
load as patient pain scale to reduce the was relieve of
evidenced by and recorded as pain. pain.
patient report 3/10. b) nurse observed
of a 7/10 b) patient 2. Assess the 2. Patient’s pain was assessed. reduction in pain.
throbbing verbalizing relieve level of pain.
headache, of pain and being 3. Diclofenac 10mg IM and
head being cheerful. paracetamol 500mg were
warm to touch administered.
and onset of 3. Administer
symptoms 2 prescribed 4. Patient was made
hours ago. pain comfortable in bed and was
medication. assisted to assume a left
lateral position.
4. Put the
5. Patient’s attention was taken
patient on a
of the pain by engaging her in a
comfortable
conversation about her past
bed in a
pleasant experiences and
comfortable
listening to music.
position.
5. Engage
patient in a
diversional
therapy.
DATE NURSING OBJECTIVE/ NURSING NURSING INTERVENTION DATE EVALUATION SIGNATURE
AND DIAGNOSIS OUTCOME ORDERS AND
TIME CRITERIA TIME
19/11/24 Anxiety Patient and her 1. Reassure 1. Patient’s and mother were 20/11/24 Goal fully met,
7:00am related to mother will be patient and her reassured that everything 6:00am. as evidenced by
unknown relieved from mother to allay possible will be done to alleviate patient and
outcome of anxiety within any fear and their fears and all measures will mother
diseases 24hrs as anxiety. be put in place to make patient expressed a
condition as evidenced by comfortable as early as possible. cheerful face
evidence by patient and and were co-
patient and mother having operative more
her mother cheerful facial 2. Educate the 2. Patient’s and mother were than before.
expression and patient and her
being restless. being mother about the educated on
cooperative. disease Typhoid fever and how it can be
condition. prevented. They were also
allowed to ask question about
the condition and answers were
given in simple terms.
3. Ask for
feedback. 3. Patient and mother were asked
questions on the condition and
they were able to give
appropriate answers.
4. Put the patient
in a comfortable Admission bed was made for a
bed. patient.
DATE NURSING OBJECTIVE/ NURSING NURSING INTERVENTION DATE EVALUATION SIGNATURE
AND DIAGNOSIS OUTCOME ORDERS AND
TIME CRITERIA TIME
20/11/2 Risk for Patient’s will 1. Reassure 1. Patient’s and her mother was 25/11/24 Goal fully
4 nutritional and maintain patient and reassured. 9:30am achieved as
8:00 electrolytes normal mother about evidence by
pm imbalance nutritional and competent patient
related to electrolytes nursing care. maintaining
inadequate oral balance normal nutritional
intake ( food throughout and electrolytes
and water ). hospitalization balance .
as evidence by: 2. Ensure patient 2. Patient’s oral hygiene was
a). Nurse oral hygiene ensured morning and evening.
ensuring (morning and
patient oral evening ).
hygiene and
encouraging 3. Encourage 3. Adequate water and balance
patients to eat patient to take in diet was given to the patient.
balance diet. adequate oral
b). Patient’s fluid and balance
taking diet.
adequate food
and water 4. Prepare a 4. Admission bed was made for a
every day. comfortable bed patient
for a patient’s
5. administer 5. Vitamins B complex was
prescribed administered to boost the patient
medication. appetite.
DATE NURSING OBJECTIVE/ NURSING NURSING INTERVENTION DATE EVALUATION SIGNATURE
AND DIAGNOSIS OUTCOME ORDERS AND
TIME CRITERIA TIME
21/11/24 Impaired After 48 hours 1. Reassure 1. Patient’s was reassured that 23/11/24 Goal fully met as
6:00 am ability to patient will patient to allay she will be able to care for 6:00am evidenced by
perform perform fear and herself and do normal activities Nurse observed
personal activities of daily anxiety. as soon as possible but at the patient maintain
hygiene related living without moment, she needs temporal her personal
to fatigue as being assist as assistance in doing them. hygiene with no
evidence by evidence by assistance, patient
patient nurse observing 2. Serve bed 2. On request, bed pan was verbalized that
decrease patient’s pan served warm. After voiding, the she is able to do
ability to performing amount, colour and consistency normal daily
perform activities of daily was observed and documented. Activities by
activities of living such as 1010mls. 0f normal colour urine herself.
daily living. mouth care, was emptied .
bathing, and
regular hand
hygiene after
visiting the 3. Assist 3. Patient’s was assisted to bath
washroom. patient to bath. with warm water, soap and
sponge twice daily to improve
blood circulation. Pressure
areas such as elbow, heals,
scapula and sacral region were
massage with mild soap and
water. Vaseline was applied
afterward to prevent formation
of bed sores.
4. Assist [Link] assistance was given to
patient to patient’s to maintain her oral
ensure her oral hygiene with toothpaste and
hygiene. toothbrush twice daily to
prevent
mouth odour and improve
freshness. Vaseline was applied
on the mouth to prevent crack
lips.
5. Ensure early 5. Patient was given support to
ambulation walk around her bed and in the
ward till she was able to walk
alone.
SIGNATURE
DATE NURSING OBJECTIVES / NURSING NURSING INTERVENTION DATE EV
AND DIAGNOSIS OUTCOME ORDERS AND
TIME CRITERIA TIME
22/11/24 Insomnia Patient’s will 1. Reassure 1. Client was reassured that 25/11/24 Goa
8:00pm related to have a normal patient that her measures are in place to enable 9:30am evid
unfamiliar sleeping pattern normal sleep her have a normal sleep pattern pati
hospital throughout the pattern will be to sl
environment period of maintained thro
as evidenced hospitalization as of h
by patient evidenced by 2. Minimize 2. Movement of visitors are
report of patient sleeping noise, organized regulated, volume of radio and
sleepless at least 3 hours nursing care television set turned down and
night. during the day and do at a go, nursing procedures carried on
and 6 – 8 hours provide client were organized and
in the night. adequate performed at once to
ventilation and prevent interruption and noise.
good clothing Nearby windows were opened,
ceiling fan switched on to
promote ventilation and induce
sleep.
3. Assist patient 3. Client was assisted to have a
to take a warm warm bath to relax her muscles.
bath, groom and She was assisted to groom and
provide a put on a comfortable bed free
comfortable bed from creases and crumps to
induce sleep.
4. Serve 4. Prescribed injection
prescribed diclofenac (I.M) 10mg was
medication. administered to relieve pain and
promote sleep.
NURSING OBJECTIVES / NURSING NURSING INTERVENTION DATE EVALUATION SIG
IAGNOSIS OUTCOME ORDERS AND
CRITERIA TIME
eficit Patient’s and 1. Reassure 1. Patient’s and family were 25/11/24 Goal fully
owledge family will have patient and reassured that all the necessary 9:00 am. achieved as
ated to lack insight into her family. information about typhoid fever evidenced by
information disease condition will be given to enable them patient’s and
out disease before discharge understand the management of family can now
ndition as as evidenced by; the condition. answer correctly
idenced by patient question about the
tient not answering 2. Establish an 2. A good friendly relationship disease condition.
ing able to question on her environment of was established to enhance
swer condition mutual trust and learning.
estions correctly. cooperation to
ked about enhance
r condition learning.
3. Educate 3. Patient’s and family were
patient and educated on the causes,
family on predisposing factors, signs and
typhoid fever. symptoms and the prevention of
the condition.
4. Give room 4. Patient’s and family were
for patient and allowed to ask questions
family to ask beyond their understanding and
questions answers were provided in
simple terms.
5. Ask patient 5. Patient’s and family were
and family asked to give feedback on the
questions to preventive measures of typhoid
know their level fever where they did correctly.
of insight into Patient and family were
the condition. thanked for their effort and
Thank patient cooperation.
and family for Procedure was documented in
their the nurses’ notes.
cooperation and
document in the
nurses’ notes.