CEBU INSTITUTE OF TECHNOLOGY - UNIVERSITY

COLLEGE OF NURSING

NURSING CARE PLAN

ASSESSMENT NURSING SCIENTIFIC PLANNING INTERVENTIONS RATIONALE EVALUATION

(Subjective & DIAGNOSIS ANALYSIS
Objective)
Subjective Cues: Impaired ability After nurse-patient Independent *Helping the patient Patient safely
“Baho kaayo ako 1.Self Care to perform self - interaction, The -Establish short-term goals with setting realistic executes self-
hubag sa tiyan Deficit care activities patient will with the patient. goals will reduce care activities to
dong”as (bathing, participate and -Guide the patient in frustration. utmost
verbalized by the 2.Low Self- dressing, eating, cooperate in self- accepting the needed amount *Patient may capability.
patient . Esteem toileting) care. of dependence. require help in
Objective Cues: -Present positive determining the safe
3.Risk for Social reinforcement for all activities limits of trying to be
*Inability bath / attempted; note partial independent versus
cleanse Isolation
achievements. asking for assistance
themselves -Render supervision for each when necessary.
marked with dirty activity until the patient *External resources
hair, dirty teeth, a exhibits the skill effectively of positive
lot of dirt and and is secured in independent reinforcement may
smelling skin, care; reevaluate regularly to promote ongoing
long and dirty be certain that the patient is efforts. Patients
nails. keeping the skill level and often have difficulty
*Inability dressed remains safe in the seeing progress.
/ decorated environment. *The patient’s
characterized by -Implement measures to ability to perform
unkempt hair, promote independence, but self-care measures
dirty clothes and intervene when the patient may change often
unkempt, clothes cannot function. over time and will
do not fit, do not Dependent need to be assessed
shave. -Use appropriate assistive regularly.
*The inability to devices for dressing as *An appropriate
eat independently assessed by the nurse and level of assistive
characterized by occupational therapist. care can prevent
its own inability injury from
to take food, food Collaborative activities without
splattered. -Refer to physician any causing frustration.
*Inability to abnormalities that may
urinate / defecate observed
independently
characterized by
urination /
defecation are not
in place, do not
clean themselves
properly after
urination /
defecation.

CEBU INSTITUTE OF TECHNOLOGY - UNIVERSITY

COLLEGE OF NURSING
 NURSING CARE PLAN

ASSESSMEN NURSING SCIENTIFIC PLANNING INTERVENTIONS RATIONALE EVALUATIO

T (Subjective DIAGNOSIS ANALYSIS N
& Objective)
Subjective Acute pain Complex After 10 hours of Independent: -To alleviate After 10 hours
Cues: related to responses of nursing  Instructed the patient pain by of nursing
“sakit akong ruptured post tissue and intervention to use relaxation promoting non intervention
tiyan dapit sa operation nerve endings patient will have techniques such as re- pharmacologic patient pain
operasyon abscess due to trauma a pain score from positioning in a al pain will be
tungod sa from post 7/10 to 5/10 and comfortable position management decrease from
hubag”as operative will not manifest  Instruct patient to use -To reduce 7/10 to 5/10 as
verbalized by incision and signs and supportive materials pain especially manifested by
the client causing symptoms of such as bedside when moving pain relievers
Pain Score 7/10 hypersensitivit worsening pain railing and SO -It promotes and without
y and abscess assistance when healing of worsening
to the tissue getting up or sitting surgical complain
that causes  Assess reports of wounds and about pain
swelling and pain, note location, reduce
unpleasant duration, and swelling of
physical and intensity, note non- abscess
Objective Cues: emotional verbal and verbal
 Facial reactions and clues -Provides
 grimace responses relief of
with pain  Check vital signs discomfort
score of every 30 minutes /pain and
7/10 facilitates rest
 Protective participation in
gesture to Dependent: postoperative
avoid pain  Administer therapy
in incision narcotics/analge -To provide
sight sics as indicated immediate
 Expressiv by the physician medical
e behavior . interventions
(painful) -Checking of
vital signs
Collaborative: every 30
 Refer to minutes is
physician any important, to
abnormalities know that your
that may interventions
observed are providing
positive effects
on the clients
health.

CEBU INSTITUTE OF TECHNOLOGY - UNIVERSITY

COLLEGE OF NURSING
 NURSING CARE PLAN

ASSESSMEN NURSING SCIENTIFIC PLANNING INTERVENTI RATIONALE EVALUATION

T (Subjective DIAGNOSIS ANALYSIS ONS
& Objective)
Subjective Impaired Mobility After 6 hours of Independent: 1. Helpful in After 6 hours of
Cues: physical impairment nursing 1. Note daily determining nursing
“Maglisod kog mobility related refers to the interventions, the patterns. patterns of interventions, goal
liho sa akong to inability of a client will state activities. met, as evidenced
lawas”, as neuromuscular person to use understanding and 2. Use side rails by client’s able to
verbalized by movement. one or more of willingness to of bed. 2. To prevent state
the patient. his or her cooperate in the patient from understanding and
Objective Cues: extremities, or maximizing 3. Evaluate possible fall or willingness to
 Restless a lack of activity level. need for accident that cooperate
 Slowed strength to individual might happen. In maximizing
movement walk, grasp, or assistance. activity level.
 Facial lift objects. 3. To
grimace when 4. Advise determine
trying to move patient to avoid impact on life.
from side to any necessary
side movements. 4.Prevent any
further injuries.
Dependent:
5. Refer to 5. To promote
counseling. wellness.

6. Helps relieve
Collaborative: pain.
6. Provide and
implement 7. To maintain
prescribed increase
dietary strength and
modifications. muscle tone
and to enhance
7. Refer to sense of well
occupational being.
therapy for
programmed
daily exercise
and activities.