NURSING CARE PLAN

Marife: 45 years old

ASSESSMENT DIAGNOSIS BACKGROUND PLANNING IMPLEMENTATION RATIONALE EXPECTED

STUDY/ OUTCOME/
DEFINITION EVALUATION
Subjective: Ineffective airway Irritant After 4 hours of >Elevate head of the >Elevation of the bed Goal met:
clearance r/t retained (inhalation) nursing intervention bed or place high facilitates respiratory
“Minsan nahihirapan secretions as evidenced the ct’s secretions are pillow on the head; function by use of After 4 hours of
akong himinga dahil sa by presence of mobilize and airway is have the ct. lean on gravity. nursing intervention the
sipon.” secretions. maintain free of overhead table or sit on ct’s secretions are
Inflammatory response secretions, as the edge of the bed. mobilized and airway
Objective: evidenced by clear is maintained free of
lung sounds and ability >Keep environmental >Precipitators of secretions, as
>Presence of yellowish to effectively cough up pollution to a minimum allergic type of evidenced by clear lung
sputum Increased production of secretions like dust, and smoke. respiratory reactions sounds and ability to
>Absent cough secretions that can trigger or effectively cough up
>Teary eyes exacerbate onset of secretions
acute episode.

Airway constriction >Instruct ct. in > To improve cough

coughing and deep effectiveness and
breathing. facilitate removal of
secretions.
Dyspnea
>Increased fluid intake >Hydration helps
to 300 ml/day. Provide decrease the viscosity
warm or tepid liquids. of secretions,
Reference: facilitating
Understanding expectoration. Using
Pathophysiology warm liquid may
Huether decrease
bronchospasm.

LUWALHATI B. CENSON
BSN-2B Grp. 2
 NURSING CARE PLAN

Ana: 24 years old

ASSESSMENT DIAGNOSIS BACKGROUND PLANNING IMPLEMENTATION RATIONALE EXPECTED

STUDY/ OUTCOME/
DEFINITION EVALUATION
Subjective: Stress overload r/t Stress is an e After 2 days of nursing >Assess ct.’s level of >Stress is highly Goal met:
inadequate resources vent or set of intervention the ct will stress. Validate by individualized, normal,
“Naiistress ako sa (financial) as circumstances causing be able: saying to ct. “Are you physical, and After 2 days of nursing
pagbubuntis dahil hindi verbalized by the ct. a disrupted response; >to reduce stress rate feeling stress now?” psychological response intervention the ct was
pa kami handa “Naiistress ako sa the disruption caused from 9 to 2 to internal and external able:
financially.” pagbubuntis dahil hindi by a noxious stimuli or >report anxiety at life events. >to reduce stress rate
pa kami handa stressor. manageable level from 9 to 2
Objective: financially.” >describe and plan >Allow and reinforce >Talking or otherwise >reported anxiety at
effective ways to ct.’s personal reaction expressing feelings manageable level
>Stress rate of 9 reduce stress to discomfort and sometimes reduces >described and planned
>Demonstrate feeling threats. stress and anxiety. effective ways to
of weakness, pressure reduce stress
and tension. >Encourage to identify > Assist the ct. to
>Seems tired and her own strengths and develop appropriate
restless abilities.. strategies for coping
>Pale skin and lips based on personal
>Poor eye contact strengths and previous
>Facial tension experiences. Improves
self concept and sense
of ability to manage
stress.

Reference:: >Identify the degree of >Assessing family

Fundamentals of family support.. interaction serves as a
Nursing basis for identifying
Barbara Kozier support systems or lack
thereof.

LUWALHATI B. CENSON
BSN-2B Grp. 2
 NURSING CARE PLAN

Jinggoy: 8 years old

ASSESSMENT DIAGNOSIS BACKGROUND PLANNING IMPLEMENTATION RATIONALE EXPECTED

STUDY/ DEFINITION OUTCOME/
EVALUATION
Subjective: Impaired dentition Tooth decay, which is After 3 days of nursing >Teach and >To gain knowledge Goal met:
r/t ineffective oral also called dental cavities intervention the ct will be able demonstrate the correct about proper way of
>“Minsan lang ako hygiene as or dental caries, is the to: way of brushing and removing debris on After 3 days of
magtoothbrush, manifested by destruction of the outer >lessen the toothache felt by the flossing the teet the teeth nursing intervention
pagnaisipan.” toothache and surface (enamel) of a client the ct was able to:
>Toothache halitosis. tooth. Decay results from >improve breath odor >To loosen left food >lessened the
the action of bacteria that >perform correct way of >Advice to rinse with particles, washes toothache felt by the
Objective: live in plaque, which is a brushing and flossing the teeth mouthwash or sol of out already client
sticky, whitish film independently. warm water and salt or loosened particles >improved breath
>Enamel formed by a protein in baking soda and improve breath odor
discoloration saliva (mucin) and sugary odor >performed correct
>Erosion of tooth substances in the mouth. way of brushing and
enamel The plaque bacteria > To check the flossing the teeth
>Excessive plaque sticking to tooth enamel >Refer to a dental severity of tooth independently.
>Tooth fractures use the sugar and starch hygienist, dentist, or damage and have
>Halitosis from food particles in the clinic as needed the medication as
mouth to produce acid. needed.

Reference:
http://www.healthatoz.co
m/healthatoz/
Atoz/common/standard/tr
ans
form.jsp?requestURI=/
healthatoz/Atoz/ency/toot
h_decay.jsp

LUWALHATI B. CENSON
BSN-2B Grp. 2
 NURSING CARE PLAN

Linda: 79 y/o

ASSESSMENT DIAGNOSIS BACKGROUND PLANNING IMPLEMENTATION RATIONALE EXPECTED

STUDY/ OUTCOME/
DEFINITION EVALUATION
Subjective: Risk for falls r/t foot Risk for fall is the After 5 hours of >Assess the client’ >Assessment help th Goal met:
problem increased susceptibility nursing intervention ability to ambulate nurse recommend
to falling that may the client will have safely with or without safety measures to the After 5 hours of
Objective: cause physical harm decrease risk for fall as assistive devices. ct. and family. nursing intervention the
demonstrated by client had decreased
>age 65 and over knowledge about fall >Provide information >Obtaining knowledge risk for fall as
>foot problem prevention. on environmental can reduce the risk of demonstrated by
>gait difficulty hazards and falling. knowledge about fall
characteristics (stairs, prevention.
windows, gates).

>Ensure that the ct. >Wearing slippery and

wears proper shoes ill-fitted shoes
(nonskid shoes, secure increases the risk of
fastener). falling

Reference:: Nursing
Diagnosis Handbook
Judith Wilkinson

LUWALHATI B. CENSON
BSN-2B Grp. 2
 NURSING CARE PLAN

Totoy: 3y/o

ASSESSMENT DIAGNOSIS BACKGROUND PLANNING IMPLEMENTATION RATIONALE EXPECTED

STUDY/ OUTCOME/
DEFINITION EVALUATION
Subjective: Ineffective airway Increased amount and After 3 days of > Assess cough for > Consider possible Goal met:
clearance r/t increase viscosity of secretions nursing intervention effectiveness and causes for ineffective
“Inuubo siya at production of And/or inability to the ct will demonstrate productivity. cough (e.g., respiratory After 3 days of nursing
sinisipon” As secretions clear secretions behaviors to improve muscle fatigue, severe intervention the ct
verbalized by the through the normal airway clearance. bronchospasm, or thick demonstrated behaviors
mother cough mechanism may tenacious secretions). to improved airway
lead to pooling of clearance.
Objective: secretions in lower > Use positioning (if > These promote better
airways. Pooling of tolerated, head of bed lung expansion and
>Use of accessory secretions leads to at 45 degrees; sitting in improved air exchange.
muscle inadequate gas chair, ambulation).
>Abnormal breath exchenge.
sounds. > Encourage oral > Increased fluid
>Cough with phlegm intake of fluids within intake reduces the
the limits of cardiac viscosity of mucus
reserve. produced by the goblet
cells in the airways. It
is easier for the patient
to mobilize thinner
secretions with
coughing.

> Demonstrate and > Patient will

Reference: teach coughing, deep understand the
Nettina, Manual of breathing, and splinting rationale and
Nursing Practice techniques. appropriate techniques
to keep the airway
clear of secretions.

LUWALHATI B. CENSON
BSN-2B Grp. 2
 Health Teaching

DATE AND TIME OBJECTIVES LEARNING STRATEGY RESOURCES TARGET EXPECTED

CONTENT OUTCOME
The health teaching After health teaching The health teaching > Interactive discussion >Manpower > Pregnant After health teaching
was held at Poblacion. the client(pregnant and contains: the pregnant, children
Iba Hagonoy, Bulaca:n children) and their >Question and answer - Group 2, 2B >Children ages 6 to 12 and their significant
last March 2, 2009 at significant others will >Stress management others was able to:
8:00 in the morning be able to: -definition of stress >Books >Significant others
-ways on how to deal >gain knowledge about
>gain knowledge about with stress during -Fundamentals of stress management
stress management pregnancy. Nursing (7th Edition
By Barbara Kozier) >verbalized ways on
>formulate own coping >Family planning how to cope up with
mechanism for stress -definition of family - Maternal and Child stress
planning Health Nursing
>know what family -importance of (Care of the Child >knew what family
planning is and its family planning Bearing and Child planning was and its
importance -types of Rearing Family by importance
contraceptives Adelle Pillitteri)
>decide to plan for that could be used. >decided to plan for
their family. their family
>Hygiene
>gain knowledge and -Bathing and >gained knowledge
know the importance Grooming and knew the
of bathing, grooming -importance and importance of bathing,
and oral hygiene proper way grooming and oral
-effects or hygiene
>learn the proper ways consequences of
of performing self care lack of bathing >learned and
through hygienic -Oral Hygiene verbalized the proper
practices. -proper way of ways of performing
brushing and self care through
flossing the teeth hygienic practices.
-effects of
ineffective oral care
LUWALHATI B. CENSON
BSN-2B Grp. 2