LYCEUM-NORTHWESTERN UNIVERSITY

COLLEGE OF NURSING
DAGUPAN CITY

NURSING CARE PLAN

Name of Student: JASMINE DE VERA JARAP/BSN IV
Name of Hospital/Area of Assignment/Shift: BLESSED FAMILY DOCTORS GENERAL HOSPITAL/ 8:00 – 4:00 PM

ASSESSMENT EXPLANATION OF THE OBJECTIVES/ GOALS NURSING INTERVENTIONS RATIONALE EVALUATION

PROBLEM

Problem: DOB without Left side body weakness Short-Term Goal: Independent: Short-Term Goal: Goal
ventilator Met

After 30 mins of nursing 1. Monitor respirations and 1. Indication if there is

interventions, the pt will be Breath sounds. an accumulation of After 30 mins of nursing
Weak Respirations free from the retained secretions. interventions, the pt is
Subjective Data: secretions free from the retained
secretions.
“Parang meron siyang 2. Suction mouth and trachea
plema palagi sa baga niya” PRN 2. to clear airway when
as verbalized by the pt’s excessive or viscous
Inability to expectorate
watcher. secretions are blocking
secretions
the airway.
Long-Term Goal: Goal
3. It helps in the Met
drainage of excess
3. Mobilize client via Postural secretions.
Objective Data:
Secretions Retained Long-Term Goal: drainage. After 8 hrs of nursing
- (+) Crackles interventions, the pt will
After 8 hrs of nursing
be free from the retained
- ineffective cough interventions, the pt will be
Dependent: secretions
free from the retained
- hooked on a mech. vent secretions
Ineffective airway clearance 1. administer medication as
1. to lessen the
prescribe by the physician
secretions.
Nursing Diagnosis:

Ineffective airway clearance

r/to retained secretions as
manifested by (+) crackles
in the lungs w/ ineffective
coughing.
Assessment Nursing diagnosis Objectives/ goals Nursing interventions Rationale EVALUATION

Subjective: IMPAIRED PHYSICAL SHORT TERM GOALS: INDEPENDENT: GOAL MET:

MOBILITY RELATED TO
“NANGHIHINA AKO” GENERALIZED BODY AFTER 2 HOURS OF NURSING >MONITOR VITAL SIGNS >TO EVALUATE •AFTER 2 HOURS OF
AS VERBALIZED BY WEAKNESS INTERVENTION THE PATIENT EFFECTIVENESS OF NURSING
THE PATIENT WILL VERBALIZE WILLINGNESS INTERVENTIONS INTERVENTION THE
TO PARTICIPATE IN ACTIVITIES PATIENT VERBALIZED
>NOTE EMOTIONAL AND >PHYSICAL CHANGES WILLINGNESS TO
AFTER 8 HOURS OF NURSING BEHAVIORAL RESPONSES AND LOSS OF PARTICIPATE IN
INTERVENTION THE PATIENT TO ALTERED ABILITY INDEPENDENCE ACTIVITIES
WILL DEMONSTRATE OFTEN CREATE
Objective:
TECHNIQUES THAT ENABLE FEELINGS OF • AFTER 8
VITAL SIGNS: CONTINUATION AND ANGER, FRUSTATION HOURS OF NURSING
RESUMPTION OF ACTIVITIES AND DEPRESSION INTERVENTION THE
BP: 120/80 MMHG THAT MAY BE PATIENT
MANIFESTED AS DEMONSTRATED
PR: 87 BPM RELUCTANCE TO TECHNIQUES THAT
LONG TERM GOALS:
ENGAGE IN ACTIVITY ENABLE CONTINUATION
RR:26 CPM AND RESUMPTION OF
AFTER 2 DAYS OF NURSING
>PREVENT ACTIVITIES
TEMP: 38.2OC INTERVENTION THE PATIENT >ASSISST WITH ACCIDENTAL FALLS
WILL MAINTAIN AND INCREASE TRANSFER AND AND INJURY • AFTER 2 DAYS
O2SAT: 99% THE STRENGTH AND FUCTION OF AMBULATION IF OF NURSING
AFFECTED BODY PARTS INDICATED; TEACH
GENERALIZED INTERVENTION THE
PATIENT WAYS TO MOVE PATIENT MAINTAINED
WEAKNESS AFTER 2 DAYS OF NURSING EASILY AND INCREASED THE
INTERVENTION THE PATIENT
LIMITED JOINT ROM WILL BE ABLE TO PERFORM >PROMOTES STRENGTH AND
>ENCOURAGE
ACTIVITIES OF DAILY LIVING INDEPENDENCE AND FUCTION OF AFFECTED
RELUCTANCE TO PARTICIPATION IN SELF
WITHOUT ASSISTANCE SELF ESTEEM, MAY BODY PARTS
MOVE CARE
ENHANCE
• AFTER 2 DAYS
INABILITY TO WILLINGNESS TO
OF NURSING
PERFORM ACTIVITIES PARTICIPATE
INTERVENTION THE
OF DAILY LIVING PATIENT WAS BE ABLE
>IMPROVES TISSUE
>REPOSITION CIRCULATION AND TO PERFORM
PERIODICALLY AND JOINT MOBILITY ACTIVITIES OF DAILY
ASSIST WITH GENTLE LIVING WITHOUT
ROM EXERCISES ASSISTANCE
 ASSESSMENT EXPLANATION OF THE OBJECTIVES/ GOALS NURSING RATIONALE EVALUATION
PROBLEM INTERVENTIONS
PROBLEM: MODIFIABLE SHORT TERM GOAL: INDEPENDENT  SHORT
 Monitor and  Notes changes TERM GOAL:
high blood pressure  SEDENTARY  After 30 record vital signs and and
LIFESTYLE minutes especially the progress in GOAL MET
Subjective:  ↑NA IN Diet of blood pressure. patient’s After 30 minutes of
condition nursing intervention the
“Ilang araw ng mataas ang  HX OF KIDNEY nursing  Establish rapport  To gain client patient was able to
nakukukuhang bp nya” as DISEASE interventi and relative’s participate in activities
verbalized by the patient. ↓ on the trust that reduce bp/cardiac
 Check laboratory workload.
patient data (Blood Urea  To identify
Objective: RENAL MALFUNCTION will Nitrogen, contributing GOAL PARTIALLY MET
 blood pressure ↓ participat Creatinine and factors  After 2 hours
Electrolytes. of nursing
above normal ↑ RELEASE OF RENIN e in intervention
range ↓ activities  Auscultate heart  Impaired the patient
 shortness of ANGIOTENSIN I that tones and breath functioning of was able to
sounds. the heart and maintain bp
breath ↓ reduce within
crackles and
 Nail beds ANGIOTENSIN II bp/cardia wheezes may individually
pale ↓ c indicate acceptable
pulmonary range as
STIMULATE ADRENAL CORTEX workload. evidenced by
congestion.
TO  After 2  Observe skin  Presence of 130/90
hours of mmHg.
Vital signs taken as follows: RELEASE ALDOSTERONE color, moisture pallor, cool
and temperature moist skin and
T:36.5 C ↓ nursing and capillary delayed Long Term Goal:
PR: 91 bpm ↑NA AND FLUID interventi refill time. capillary refill
on the GOAL MET
RR:31 cpm ABSORPTION/RETENTION time may be
After 12 hours of nursing intervention
due to
BP: 140/90 ↓ patient peripheral the patient was able to demonstrate
 Note dependent
02 Saturation: 84% EDEMA/ANASARCA will and general vasoconstrictio behaviors to reduce blood pressure
maintain edema n. and will be free from signs of
↓ recurrent hypertension.
bp within  May indicate
↑PERIPHERAL RESISTANCE heart failure,
↓ individual renal or
NURSING DIAGNOSIS: VASOCONTRICTION ly  Evaluate client vascular
acceptabl for fatigue, impairment.
Decreased cardiac output related ↓ activity
to vascular and peripheral ↑ BLOOD PRESSURE e range. intolerance,  To assess for
resistance as evidenced by sudden weight signs of poor
generalized edema. gain and ventricular
shortness of function or
LONG TERM GOAL: breath. impending
After 2 weeks of nursing cardiac failure.
intervention the patient will  Decrease stimuli
in the
demonstrate behaviors to environment.
reduce blood pressure and  Helps lessen
will be free from signs of DEPENDENT: sympathetic
 Administer stimulation;
recurrent hypertension. diuretics and promotes
anti-hypertensive circulation.
drugs as
prescribed by the  To decrease
physician. edema and
resolves
COLLABORATIVE: hypertension.
Provide:
 Low sodium
 Low cholesterol  To decrease
 Low fluid edema,
 Low protein decrease blood
DIET pressure and
decrease the
end product of
protein which is
creatinine.