IX.

NURSING CARE PLAN

ASSESSMENT DIAGNOSIS SCIENTIFIC PLANNING IMPLEMENTATION RATIONALE EVALUATION
EXPLANATION
After 3 hours of  Support  Reduce risk After series of
SUBJECTIVE nursing affected part of pressure nursing
Activity CVD can be
interventions, with pillows. ulcers. interventions, the
“Hindi ko maigalaw Intolerance caused by an
the client and  Give rest  Helps client and
ang kanang bahagi related to occlusion in the
relatives will be periods to reduce relatives were
ng aking katawan.” neuromuscular blood flow. This
able to able to participate
activities fatigue and
damage can lead to↓O2
participate in O2 demand in therapeutic
OBJECTIVE: involvement as and the cause
therapeutic . regimen and
 Asymmetry of evidenced by failure to nourish
face. Right-sided body the tissues at the
regimen.  Encourage  Increases client displayed
 Have adequate energy eagerness in
weakness. capillary level and
difficulties in fluids and production. performing ADL
that can cause
performing right diet as with
neuromuscular
ADL. necessary to independence.
damage w/c can
 With Right- the client.
cause impaired
sided
physical mobility.  Helps
weakness of  Encourage to
the body. maintain
perform
 flexibility and
Range of
mobility of
Motion
Medical- the joints.
Exercises
SurgicalNursing,
vol.2, 9th edition,
Brunner &
Suddarths, page
768.
ASSESSMENT DIAGNOSIS SCIENTIFIC PLANNING IMPLEMENTATION RATIONALE EVALUATION
EXPLANATION
Hypertension is defined After 1 hour of  
SUBJECTIVE as a condition where in nursing
there is an increase in interventions,
“Nahihilo ako.” BP beyond the normal the client shall
range. Hypertensive have no
OBJECTIVE: emergency is used for elevation in
 Restless BPs above 160/100 blood pressure
 BP=
mmHg. With and
170/100
hypertension, the blood
vessels constrict. When
blood vessels are
constricted, there is a
decrease in blood
volume, decrease in
cardiac output and
increase in BP as blood
passes through the
narrowed lumen of the
vessels.
Reference

https://www.mayoclinic.org/diseases-
conditions/high-blood-
pressure/symptoms-causes/syc-
20373410
ASSESSMENT DIAGNOSIS SCIENTIFIC PLANNING IMPLEMENTATION RATIONALE EVALUATION
EXPLANATION
 A disturbance  Encourage  Acceptance of
SUBJECTIVE or alteration in After 30 minutes the client to this feeling as
“Hindi ganito dati ang Disturbed body After series of
the attitude of of nursing acknowledge normal
itsura ko.” image related to nursing
person has interventions, the and accept response to
physical changes interventions, the
about the actual client will be able expression of what has
OBJECTIVE: brought about by client was able to
or perceived to verbalize feelings of occurred
 Irritable chemotherapy as
structure or feelings about the
verbalize feelings
frustration, facilitates
 Has dry and evidenced by about the
function of all or changes on her grief and resolution.
scaly skin dry, scaly skin changes on her
part of the physical hostility.
 Pale and poor hair physical
 Hair is poorly
body. This appearance and  Provide a  Promotes
distribution. appearance and
attitude is develop an support ventilation of
distributed in develop an
the scalp. dynamic and enhanced self- system. feelings and
enhanced self-
 Scheduled for altered through esteem. allow more
esteem.
insertion of interaction with helpful
Chest other persons responses to
Thoracostomy and situations patient.
Tube and is
influenced by  Help patient  Patients may
age and identify actual perceive
developmental changes. changes that
level. are not
present/real.
 Encourage
patient to look  To begin to
at/touch incorporate
affected body changes in
part. body image.