NURSING CARE PLAN

NURSING NURSING NURSING

ASSESSMENT PLANNING INTERVENTION RATIONALE EVALUATION
DIAGNOSIS THEORY BEHAVIOR
Objective: Independent:
• VS taken as: Decreased The patient will Have pt. lie down Positioning the pt Florence Changing or Goal partially met.
BP=140/100mmHg cardiac output r/t demonstrate or in a promotes proper Nightingale’s manipulating the BP=120/90
CR=57 bpm vascular adequate cardiac comfortable and adequate Environmental environment to mmHG
RR=24 bpm resistance output as position ventilation Nursing theory facilitate health.
AR=61 bpm
PR=60 bpm secondary to evidenced by BP
and pulse rate PR=59bpm
T=37.2OC hypertension Monitored intake Decrease cardiac Helping the
and rhythm within RR=24bpm
and ouput output results in Lydia Hall’s Care, patient toward
normal values.
decreased Core, Cure some goals.
perfusion of the
kidneys, with a
resulting
decrease in urine Ernestine
output. Weidenbach’s
Prescriptive
theory
Have a patient Getting out of
use a commode bed to use a
or urinal. commode or
urinal does not
stress the heart
any more than
staying in bed to
toilet.

Provided a restful Rest helps lower

environment by arterial pressure
minimizing and reduce the
controllable workload of the
stressors and myocardium by
unnecessary diminishing the
disturbances. requirement for
cardiac output.
Dependent:
Administered Amlodipine is an
Amlodipine, 5mg; antihypertensive
as ordered by the drug which lowers
physician. BP.
 NURSING NURSING NURSING
ASSESSMENT PLANNING INTERVENTION RATIONALE EVALUATION
DIAGNOSIS THEORY BEHAVIOR
Subjectives: Independent:
“Di ko katakod mag Altered Patient will Slow the pace of Lydia Hall’s Helping the Goal not met.
tindog kag peripheral tissue altered care. Allow the Care, Core, person toward
maghulag,” as perfusion r/t peripheral pt. extra time to Cure some goal.
Patient is still
verbalized. decrease tissue carry out
weak.
circulating perfusion r/t activities.
hemoglobin decrease
Objectives: circulating
hemoglobin Promotes
• VS taken as: Provided
healthy rest.
peaceful
BP=140/100mmHg
environment
CR=57 bpm Food provides
RR=24 bpm energy
PR=60 bpm Encouraged to Ernestine
T=37.2OC eat serve meals Weidenbach’s
Prescriptive
• HgB=46 Theory
Collaborative: Weakness is
• Weak and pale cause by low O2
appearance Transfused Blood in the blood.
as ordered by the
physician. To asses any
adverse effects
Monitor post BT to transfusion.
reactions.
 NURSING NURSING NURSING
ASSESSMENT PLANNING INTERVENTION RATIONALE EVALUATION
DIAGNOSIS THEORY BEHAVIOR
Subjective: Independent: Goal partially
“Nabudlayan ako Impaired gas The patient will Position pt in Semi- Upright position Florence Changing or met.
magginhawa ” as exchange r/t demonstrate fowler’s position. increased Nightingale’s manipulating the
verbalized ventilation- improved oxygenation and Environmental environment to BP=120/90
perfusion ventilation and ventilation. Nursing theory facilitate health. mmHG
imbalance. adequate O2
Objective: Encouraged AR=61 bpm
supply.
• VS taken as: increased fluid intake Water helps PR=59bpm
promote normal Dorothy
BP=140/100mmHg RR=24bpm
breathing Johnson’s
CR=57 bpm
RR=24 bpm Behaviour
PR=60 bpm Improved System
T=37.2OC Encouraged/Assisted nutrition can help
the pt. to eat small increase muscle
• HgB=46 meals frequently. aerobic capacity
• Weak and pale and exercise
appearance tolerance.
• Drowsy
• Cold clammy Provided and A body in rest
skin encourage peaceful requires less
• Prolonged environment to rest oxygen demand.
capillary and sleep.
reflex[3 sec]
 NURSING NURSING NURSING
ASSESSMENT PLANNING INTERVENTION RATIONALE EVALUATION
DIAGNOSIS THEORY BEHAVIOR
Subjective: Independent: Goal not met.
“Amo gid man Imbalance The patient will Position the pt in Comfortable Florence Changing or
nah suya wala nutrition: less than demonstrate a comfortable position enhances Nightingale’s manipulating the Patient still not
gana magkaon ” body requirement increased position. appetite. Environmental environment to fully consumed
as verbalized by r/t inadequate appetite and Nursing theory facilitate health. served meal.
the folks food intake as consumed
Provide relaxing Promotes calm
evidenced by lack adequate
environment while and relaxing
of appetite. nourishment.
Objective: eating. feeling for eating. Dorothy
• Lack of Johnson’s
interest in Allow patient to Increases Behaviour System
food choose foods she personal control
• Weak and likes.
pale
• Pale Provide Often, patients
conjunctiva companionship or will eat more food
• Consumed ¼ assist the pt while if other people are
of served eating to present at meal
meals encourage time.
nutritional intake

Dependent:
Administer
Heraclene
Heraclene-
stimulated
Dibencozide,3
appetite.
mg, as
physician’s order. .
 NURSING NURSING NURSING
ASSESSMENT PLANNING INTERVENTION RATIONALE EVALUATION
DIAGNOSIS THEORY BEHAVIOR
Subjective: Independent: Goal met.
“Wala ako Disturbed sleep The patient will Keep environment Provides more Florence Changing or
matulogan kagab- pattern r/t fear of take enough rest quiet for sleeping, relaxing and Nightingale’s manipulating the Patient had
I, hadlok ko sa therapeutic and sleep eliminate noise. comfortable Environmental environment to adequate,
dugo” as regimen [blood environment for Nursing theory facilitate health.
undisturbed sleep
verbalized transfusion] sleeping.
during shift.

Objective:
Perform nursing
• Dark-big procedures all at Reduces
eyebags the same time if disturbances in
• Weak and possible before sleeping.
pale patient to go to
sleep.
• Drowsy
• Was not able
to sleep the Adjust lighting by Light may alter or
entire night providing curtains. disturb patient’s
sleep.
 NURSING NURSING NURSING
ASSESSMENT PLANNING INTERVENTION RATIONALE EVALUATION
DIAGNOSIS THEORY BEHAVIOR
Independent: Goal not met.
Subjective: Impaired urinary The patient will Provide an Environmental Florence Changing or
“Mabudlay elimination r/t void urine volume environment that factors may Nightingale’s manipulating the Patient still has
mangihi, gamay urinary retention in a normal value. encourages contribute to Environmental environment to less urine output.
lang tana” as toileting. functional Nursing theory facilitate health.
verbalized incontinence.

Objective:
• Urine Dependent: Ernestine
volume/fluid Administer Furosemide is Weidenbach’s
output= 100 Furosemide, 60 diuretic and Prescriptive
cc within 8 mg and Rowatinex is Theory
hours. Rowatinex 2 caps antiurolithic drug
• + edema as ordered. which both aide in
noted on both easy and
cheeks unpainful voiding.
• Difficulty in
voiding