MODEL

NURSING CARE
PLANS
 POSSIBLE NURSING DIAGNOSIS FOR PATIENT
WITH FEVER
• Hyperthermia related to lower respiratory tract infection.

• Imbalanced Nutrition: Less Than Body Requirements related to

Inability to digest foods

• Fluid volume deficit related to inadequate intake of fluids.

• Disturbed Sleep Pattern related to fever.

• Activity intolerance related to general weakness

• Self-care deficit: [Bathing / Hygiene] related to weakness

POSSIBLE • Nursing Diagnosis:
NURSING
DIAGNOSIS Hyperthermia related to
FOR lower respiratory tract
PATIENT infection.
WITH
FEVER • Goal: Patient will maintain
normal body temperature.
 POSSIBLE NURSING DIAGNOSIS FOR PATIENT WITH FEVER
Nursing Interventions Rationale/Scientific Principle
- Provide comfortable bed and position To make the client comfortable
- Check vital signs q4h To know the conditions of vital organs
- Provide calm and cool environment Helps to take adequate rest
- Switch on the fan Body heat loss by convection
- Provide good ventilation by keeping the windows Good circulation of fresh air helps in body heat loss by
open convection
The heat is transferred by conduction from the body
- Encourage for plenty of oral fluids
through oral fluids
- Advice the client to wear cotton clothes The heat is transferred by conduction from the body
through cotton clothes
- Apply tepid sponging The heat is transferred by conduction from the body
through tepid sponging
- Administer Tab. Paracetamol 500mg as per order. Antipyretics works on hypothalamus and regulates the body
temperature.
- Administer antibiotic as per order. Antibiotics control the growth of microorganism in the body
which helps for maintaining normal body temperature.
 • Nursing Diagnosis:
POSSIBLE Imbalanced Nutrition: Less Than
NURSING Body Requirements related to
increased metabolic needs and
DIAGNOSIS FOR
Inability to digest foods.
PATIENT WITH • Goal: Patient will maintain
FEVER normal nutritional pattern.
 POSSIBLE NURSING DIAGNOSIS FOR PATIENT WITH FEVER

Nursing Interventions Rationale/Scientific Principle

Assess the nutritional status of the client To know the general condition of the client

Check the body weight of the patient To know the nutritional status of a client

Assess patient likes and dislikes To improve the intake of food and fluids

Provide high calorie, easily digestible and Cellular metabolism is greatly increased during
fever and to meet increased O2 consumption by
palatable diet the body tissues

Provide small, bland and frequent diet To enhance easy digestion

Encourage for plenty of oral fluids To prevent dehydration and to eliminate waste
products
 POSSIBLE NURSING DIAGNOSIS FOR PATIENT WITH FEVER

Nursing Interventions Rationale/Scientific Principle

Serve food attractively In order to stimulate appetite
Encourage the client to take fruits To provide vitamins, minerals and also to help in
evacuating the bowels regularly
Provide frequent mouth care To minimize the effect of coated tongue and make the
client to enjoy food
Avoid procedures before meals/food To enhance the food intake even though appetite may
be slow to return
Maintain I/O chart To prevent and diagnose dehydration earlier
Administer I.V fluids as per order. To prevent dehydration
 • Fluid volume deficit
POSSIBLE NURSING
DIAGNOSIS FOR PATIENT
WITH FEVER related to inadequate
intake of fluids and fever.
• Goal: Patient will
maintain normal fluid
volume.
 POSSIBLE NURSING DIAGNOSIS FOR PATIENT WITH FEVER
Nursing Interventions Rationale/Scientific Principle
Assess vital signs Elevated temperature/prolonged fever increases metabolic
rate and fluid loss through evaporation. Reduction in
circulating volume reduces BP, initiating compensatory
mechanisms of tachycardia to improve cardiac output and
increase systemic BP
Palpate peripheral pulses Weak, easily obliterated pulses suggest hypovolemia
Assess thirst, skin turgor, Indirect indicators of adequacy of fluid volume
moisture of mucous membranes –
lips, tongue

Note reports of nausea/vomiting Presence of these symptoms reduces oral intake

 POSSIBLE NURSING DIAGNOSIS FOR PATIENT WITH FEVER
Nursing Interventions Rationale/Scientific Principle
Weight the client Provides information about adequacy of fluid volume
and replacement needs
Encourage to take oral fluids atleast Meets basic fluid needs, reducing dehydration
2500ml/day
Observe the colour and character of Provides information about adequacy of fluid volume
and replacement needs
urine
Monitor I/O chart Provides information about adequacy of fluid volume
and replacement needs
Administer Antipyretics and antiemetic It helps in reducing the fluid losses
medication as per order
Provide supplemental IV fluids as In presence of reduced intake/excessive loss, use of
parenteral route may correct/prevent deficiency
necessary
 P
• Disturbed Sleep Pattern
POSSIBLE NURSING E
DIAGNOSIS FOR PATIENT related to fever as evidenced
WITH FEVER
S/S
by verbalisation or
interrupted sleep, not feeling
as well rested and lethargy.
• Goal: Patient will maintain
normal sleep pattern.
 POSSIBLE NURSING DIAGNOSIS FOR PATIENT WITH FEVER
Nursing Interventions Rationale/Scientific Principle
Assess the usual sleep habits and changes Determines need for action and helps identify
are occurring appropriate interventions
Provide comfortable bedding and some of Increases comfort for sleep as well as
own possessions. Eg. Pillow physiologic/psychologic support
Provide back care with massage before Promotes relaxing and smoothing effect
bedtime
Provide warm glass of milk before Milk has soporific qualities, enhancing synthesis of
bedtime. serotonin, a neurotransmitter that helps patient fall
asleep faster and sleep longer
Instruct in relaxation measures Helps to induce sleep
 POSSIBLE NURSING DIAGNOSIS FOR PATIENT WITH FEVER
Nursing Interventions Rationale/Scientific Principle
 Nursing Care
Assessment
Plan For Nursing
Diagnosis
Goal Planning Rationale

SubjectivePatient
Data With
Hyperthermia
Patient says that “I have related to lower
Patient will
maintain normal
• Provide
comfortable
• To make the
client
for 4 days”.
Fever
rise in body temperature respiratory tract
infection
body
temperature
bed and
position
comfortable
Objective Data • Check vital• To know the
• Hyperthermia 1030F signs q4h conditions of
• Tachycardia – vital organs
94bt/mt • Maintain • Helps to take
• Respiration 20 br/mt calm and adequate
• Dried lips, mucus cool rest
membrane environment • Body heat
• Dull & tired • Switch on loss by
• Fatigue the fan convection
• WBC -
• Body heat
• Open the loss by
windows convection
 Nursing Care
Assessment
Plan For Nursing
Diagnosis
Goal Planning Rationale

SubjectivePatient
Data With
Hyperthermia
Patient says that “I have related to lower
Patient will
maintain normal
• Provide
comfortable
• To make the
client
for 4 days”.
Fever
rise in body temperature respiratory tract
infection
body
temperature
bed and
position
comfortable
Objective Data • Check vital• To know the
• Hyperthermia 1030F signs q4h conditions of
• Tachycardia – vital organs
94bt/mt • Maintain • Helps to take
• Respiration 20 br/mt calm and adequate
• Dried lips, mucus cool rest
membrane environment • Body heat
• Dull & tired • Switch on loss by
• Fatigue the fan convection
• WBC -
• Body heat
• Open the loss by
windows convection
 • Ineffective airway clearance related to altered level of
POSSIBLE consciousness
• Risk for injury related to decreased level of
consciousness.
NURSING • Risk for impaired skin integrity related to immobility
• Impaired urinary elimination related to impairment in
DIAGNOSES FOR sensing and control.
• Disturbed sensory perception related to neurologic
impairment.
UNCONSCIOUS • Interrupted family process related to health crisis.
• Risk for impaired nutritional status related to altered
PATIENT level of consciousness.
 • Ineffective airway clearance related to trachea bronchial

POSSIBLE
inflammation as evidenced by abnormal breath sounds,
dyspnoea, and ineffective cough without sputum.

NURSING • Impaired gas exchange related to alveolar capillary membrane

changes as evidenced by dyspnoea, tachycardia and restlessness

DIAGNOSES • Activity intolerance related to imbalance between oxygen supply

and demand as evidenced by exertional dyspnoea, tachycardia in

FOR PATIENT
response to activity, verbal reports of weakness, fatigue and
exhaustion.

WITH • Altered nutrition less than body requirements related to

dyspnoeic episode

DYSPNOEA • Risk for fluid volume deficit related to decreased fluid intake
• Knowledge deficit regarding disease condition, and treatment
needs
 • Acute Pain
POSSIBLE • Impaired Physical Mobility
NURSING • Impaired Skin Integrity

DIAGNOSES • Risk
for Peripheral Neurovascular Dysfun
FOR ction

FRACTURED • Risk for Impaired Gas Exchange

• Risk for Infection
PATIENT • Risk for Trauma
• Deficient Knowledge
1. Nursing Diagnosis: Ineffective Nursing interventions
airway clearance related to • Assess the lung sounds.
retained secretions/reduced fluid
• Assess the respiratory rate
intake/obstruction/tracheobronchi
al infection. • Administer O2
• Assess the client’s level of .hydration
Expected outcome: Patient will • Observe the sputum
maintain patent airway as
evidenced by normal lung • Advice to take lot of oral fluids
sounds/thin, white and watery • Encourage to do deep breathing and coughing exercise
sputum/ respiratory rate with in q2h
the limit of 20-24 breaths/mt in 48 • Provide comfortable position (fowlers)
hours.
• Provide chest physiotherapy
• Perform suctioning
• Administer antibiotics
2. Nursing Diagnosis:
Impaired/Ineffective breathing
• Nursing interventions
pattern related to retained
secretions/infection/hypoxia/ineff • Assess the breath sounds.
ective cough/shortness of
breath/Broncho constriction and • Assess the respiratory rate
airway irritants • Provide comfortable position (fowlers)

Expected outcome: Patient will • Give steam inhalation

maintain normal breathing • Encourage to do deep breathing and
pattern as evidenced by normal
coughing exercise q2h
lung sounds/ respiratory rate
with in the limit of 20-24 • Administer O2
breaths/mt in 48 hours.
• Perform suctioning
• Administer bronchodilators as per order
 Nursing interventions
3. Nursing Diagnosis: Pain • Assess the characteristics of pain – location,
related to drainage character, quality, intensity or severity of pain.
tubes/invasive • Provide comfortable position
procedures/surgical incision/ • Give diversional therapy
upper airway • Check the position of drainage tube
irritation/infection/inflammati
on/obstruction. • Provide psychological support
If post-operative client
Expected outcome: Patient • Assess the incision area every 8 hours for redness,
will perceive less pain/ feel warmth over the incision, induration, swelling,
comfort as evidenced by separation, and drain
verbalisation/facial • Assist or turn patient every 2 hours
expression.
• Advice the patient to support the incision area while
coughing
• Administer analgesics as per order
4. Nursing Diagnosis: Fluid volume
deficit related to vomiting/frequent Nursing interventions
passage of watery stools/altered infusion
rate/increased fluid and electrolyte loss. • Assess the patient condition
• Assess the hydration status
Expected outcome: Patient will
maintain normal fluid volume as • Check daily weight
evidenced by maintaining normal serum • Monitor serum electrolyte levels
and urinary values for sodium and
potassium/normal skin turgor/ absence • Encourage to take oral fluids
of S/S of dehydration. • Administer IV fluids as per order
• Advice to take ORS
• Monitor I/O chart
• Administer antiemetic as per order
 Nursing interventions
5. Nursing Diagnosis: Fluid volume • Assess the patient condition
excess related to oedema/altered • Assess the hydration status
•
infusion rate/ retention of sodium and Check the weight.
• Monitor serum electrolyte levels
potassium/decreased urine output/
• Elevate the oedematous body part
excess sodium intake. •
Keep the oedematous skin clean and
Expected outcomes: Patient will moist
maintain normal fluid volume as • Limit the fluid intake by prescribed
volume
evidenced by absence of oedema
• Monitor strict I/O chart
• Change the position frequently
• Administer diuretics as per order
 Nursing interventions
5. Nursing Diagnosis: Fluid volume • Assess the patient condition
excess related to oedema/altered • Assess the hydration status
•
infusion rate/ retention of sodium and Check the weight.
• Monitor serum electrolyte levels
potassium/decreased urine output/
• Elevate the oedematous body part
excess sodium intake. •
Keep the oedematous skin clean and
Expected outcomes: Patient will moist
maintain normal fluid volume as • Limit the fluid intake by prescribed
volume
evidenced by absence of oedema
• Monitor strict I/O chart
• Change the position frequently
• Administer diuretics as per order
 Nursing Interventions
6. Nursing Diagnosis: Impaired
• Assess the respiration – dyspnoea,
gas exchange related to
wheezing, crackles, loosened
ventilation-perfusion
secretions and anxiety
inequality/chronic inhalation of
toxins. • Observe the signs and symptoms of
hypoxia
Expected outcomes: Patient will • Administer O2
maintain normal gas exchange as • Administer nebulization
evidenced by decrease in •
Analyse arterial blood gases and
dyspnoea/shows an improved
compare with baseline values
expiratory flow rate.
• Encourage patient to do diaphragmatic
breathing
 Nursing Interventions
7. Nursing Diagnosis: Self-care
• Determine the wellness and current
deficit related to fatigue
secondary to increased dyspnoea, capabilities
insufficient ventilation and • Involve the patient in formulation of
oxygenation. plan of care at level of ability
• Encourage for self-care
Expected outcomes: Patient will • Provide and promote privacy
maintain /perform normal
• Assist for mouth care
activities as evidenced by doing
daily living activities without • Assist for partial bath
assistance. • Assist for Combing hair
• Provide assistive devices
• Provide adequate rest periods
8. Nursing Diagnosis: Impaired Nursing Interventions
skin integrity related to
• Assess the skin integrity – redness,
oedema/poor nutritional
discolouration, excoriation etc.
status/Prolonged bedrest/multiple
drains/surgical wound. • Provide wrinkles free bed
Expected outcomes: Patient will • Provide comfortable position by using
maintain normal skin integrity as comfort measures
evidenced by absence of oedema, • Change the position every 2 hourly
appearance of healthy • Give back massage
skin/demonstrates intact skin
• Keep the skin clean and moist
around the colostomy stoma.
• Apply skin moisturizers
• Elevate extremities if there is a edema
9. Nursing Diagnosis: Imbalanced Nursing Interventions
Nutrition: Less Than Body • Assess the nutritional status of the client
Requirements related to increased • Check the weight of the patient
metabolic needs and Inability to digest
• Provide clean and pleasant environment
foods as evidenced by refuse to take
• Assess patient likes and dislikes
fluid and food/ reported lack of interest
• Provide high calorie, easily digestible and palatable
in food/altered taste diet
sensation/anorexia/gastritis/decreased
• Provide small, bland and frequent diet
GI motility.
• Encourage for plenty of oral fluids
Expected outcome: Patient will
• Encourage the client to take fruits
maintain normal nutritional
• Provide frequent mouth care
pattern/status as evidenced by adequate
• Avoid procedures before meals/food
intake/ weight gain.
• Maintain I/O chart
• Administer I.V fluids as per order.
10. Nursing Diagnosis: Sleep Nursing Interventions
• Assess the sleeping pattern
pattern disturbance related to • Provide comfortable position
pain/fear/new environment. • Provide comfortable, wrinkle free bed.
• Provide calm and quiet environment
Expected outcome: Patient will
• Give diversional therapy
maintain normal sleeping pattern • Provide good ventilation

as evidenced by verbalisation/ • Advice to avoid day time sleep

• Provide warm milk before bedtime.
having satisfactory sleeping • Provide back care/back massage before bed time.
pattern/looks comfort and active. • Provide warm bath
• Provide books to read
• Administer sedatives as per order
11. Nursing Diagnosis:
• Nursing Interventions
Constipation related to ignoring
the urge of defecation secondary • Assess the elimination pattern
to pain during elimination/ • Advice to drink more oral fluids
depressed gastrointestinal
• Advice to take high fiber diet
function.
• Encourage the patient to do exercises
Expected outcome: Patient will • Tach the patient to make a schedule
maintain normal elimination for meals and the time for defecation
pattern as evidenced by
verbalisation of less abdominal • Administer stool softener as per order
cramping and pain/ reports • Administer enema as per order.
passage of soft and formed stools/
decreased abdominal discomfort.
12. Nursing Diagnosis: Diarrhoea • Nursing Interventions
related to inflammatory process. • Assess the characteristics of the stool
Expected outcome: Patient will • Assess the hydration status
maintain normal elimination • Advice to take lot of oral fluids
pattern as evidenced by • Advice to avoid fibre rich diet
• Minto serum electrolyte level
verbalisation that decrease in the
• Keep the environment clean and odour
frequency of passage/ passing
free
normal stool. •
Encourage to take bed rest
• Administer antidiarrheal drug
13. Nursing Diagnosis: Activity Nursing Interventions
• Assess the activity level of the patient
intolerance related to
• Assist with self-care activities when patient is
fatigue/imbalance between oxygen fatigued

supply and demand. • Promote independence in self-care activities

• Space activities to promote rest and exercise
Expected outcome: Patient will as tolerated
maintain normal activities as evidenced • Advice the patient to perform mild activities
• Note reports of weakness, fatigue
by participates in self-care
• Encourage to involve in diversional activities –
activities/reports decreased level of newspaper reading.
fatigue, breathlessness, increased level • Explain importance of rest in treatment plan
• Provide high calorie, small and easily digestible
of activity.
diet
14. Nursing Diagnosis: Nursing Interventions
Knowledge deficit regarding
• Assess the knowledge level
treatment/signs and
symptoms/follow up care/pre and • Clear all the doubts of the client
post-operative care/ about treatment/signs and
diet/exercise/hygienic measures. symptoms/follow up care/pre and
Expected outcome: Patient will post-operative care/
gain adequate knowledge as diet/exercise/hygienic measures.
evidenced by verbalisation and
answering the questions • Explain in simple terms
• Provide adequate information
15. Nursing Diagnosis: Impaired Nursing Interventions
physical mobility related to pain/use of • Assess the mobility level
immobilisation devices/weight bearing • Assist the patient in daily living activities
• Encourage the patient to do her activities
limitations/edema.
with minimal support
Expected outcome: Patient will
• Provide adequate rest period between the
maintain normal physical activity as activities
evidenced by maintains full function of • Encourage the patient to do mild activities
unimpaired extremities/participates in • If metal pins/screws/rods are used – maintain
self-care activities. the position
813. Nursing Diagnosis: Activity Nursing Interventions
• Assess the activity level of the patient
intolerance related to
• Assist with self-care activities when patient is
fatigue/imbalance between oxygen fatigued

supply and demand. • Promote independence in self-care activities

• Space activities to promote rest and exercise
Expected outcome: Patient will as tolerated
maintain normal activities as evidenced • Advice the patient to perform mild activities
• Note reports of weakness, fatigue
by participates in self-care
• Encourage to involve in diversional activities –
activities/reports decreased level of newspaper reading.
fatigue, breathlessness, increased level • Explain importance of rest in treatment plan
• Provide high calorie, small and easily digestible
of activity.
diet