Nursing Care Plan Outcomes docx.

NURSING CARE PLAN
1) Tran, Thi Minh
Actual
problem
Assessment Nursing
outcome
intervention rationale implementation
Dehydration
related to
less fluid
intake/
output, and
decreased
blood flow
Sunken
eyes,
mucous
membrane,
poor skin
turgor,
patient not
passed
urine and
blood
pressure of
90/50mmhg
After 8hours
of nursing
intervention,
the fluid
balance will
have been
stabilized
and the
patient
mucus
membrane
will be
moist
Monitor vital
signs, capillary
refill, the
status of
capillary
mucous
membrane/skin
and assess
peripheral
pulses
Monitor input
and out
To determine
the severity
of
dehydration
and
circulating
volume
(Ogero et al.
2018) for
more
intervention
to be taken if
there is no
improvement.
To determine
the
replacement
volume
needed
Vital signs,
fluid
intake/output,
assessment of
mucus
membrane and
skin done by
nurse Amanda
Risk of
infection
A high
temperature
of 38.8
degrees
Foul urine
smell due
Patient to
have
reduced risk
of infection
with
temperatures
Specimen of
urine, sputum
and
Blood to be
obtained for
culture and
Identifying
the organism
causing
sepsis is vital
for treatment
as it will be
Specimen of
blood and
sputum were
taken to the
laboratory by
nurse Amanda.

to UTI,
Agitation,
Confusion
and pyrexia
normalizing,
reduced
confusion
and pyrexia
sensitivity.
Administer
medication as
prescribed by
the doctor that
is 1gram of
ampicillin and
gentamicin
6hourly and
8hourly
respectively
based on
susceptibility
to specific
antibiotics
(Stupar et al.
2017)
Specific
antibiotics
treat specific
bacteria
based on
culture and
sensitivity
test
Nurse Amanda
administered
1gram of
ampicillin and
gentamicin.
2) Noble, Nicholas
Actual
problem
Assessme
nt
Nursing
outcome
interventi
on
rationale implementati
on
evaluati
on
Impaired
physical
mobility
related to old
age
Loss of
sensation
and
movemen
t in his
right arm
After 8
hours of
nursing,
interventio
n patient
will be
able to
restore,
Asses the
ability to
perform a
range of
motion to
all joints
Assessment
of ROM
gives data on
the extent of
the physical
problem, and
it helps in
guiding
Nurse Mary
did the
strength of
the range of
motion and
assessment
of the ability
to perfume

preserve to
maintain
mobility
and to be
functional
as possible
Asses
patients
ability to
perform
activities
of daily
living
treatment to
be given
(Horvat et al.
2018)
Inability to
move
influences
the ability of
the patient to
perform
activities of
daily living
activities of
daily living
Impaired
verbal
communicati
on as
evidenced by
difficult in
vocalizing
words and
slurred
speech
Slurred
speech
Patient to
be able to
express
thoughts
and
feelings in
a logical
way and to
be able to
communic
ate in a
way that
will be
understood
by others
Nurse
Learn
needs of
the
patient
and
understan
d the non-
verbal
cues
Involve
speech
pathologis
t
Delivering
care may
take longer if
there is a
communicati
on barrier
(Graci,
Hachez, and
Lavin, 2019.
p.355-372).
To determine
the cause of
the inability
of the patient
to speak and
Nurses were
able to learn
patient needs
by use of
non- verbal
cues such as
eye contact
and deliver
care
appropriately
Speech
pathologist
informed of
the need to
review the
patient

Neurologi
c
assessmen
t of the
patient
provide
necessary
treatment
To determine
the mental
status of the
patient as it
might be
contributing
factors
Neurologic
assessment is
done, and
there was no
neurologic
deficit.

Reference
Ogero, M., Ayieko, P., Boniface Makone, T.J., Malla, L., Oliwa, J., Irimu, G. and English, M.,
2018. An observational study of monitoring of vital signs in children admitted to Kenyan
hospitals: an insight into the quality of nursing care?. Journal of global health, 8(1).
Stupar, P., Opota, O., Longo, G., Prod'Hom, G., Dietler, G., Greub, G., & Kasas, S. (2017).
Nanomechanical sensor applied to blood culture pellets: a fast approach to determine the
antibiotic susceptibility against agents of bloodstream infections. Clinical Microbiology and
Infection, 23(6), 400-405.
Horvat, M., Kelly, L., Block, M. and Croce, R., 2018. Developmental and Adapted Physical
Activity Assessment, 2E. Human Kinetics.
Graci, A., Hachez, E. and Lavin, D., 2019. Medical Nursing Care and Communication Barriers.
In Inpatient Geriatric Psychiatry (pp. 355-372). Springer, Cham.