Activity 1

1. Identify the nursing interventions in the case scenario.

2. Classify the nursing interventions into INDEPENDENT, DEPENDENT OR
COLLABORATIVE.
3. Use this format:

INDEPENDENT DEPENDENT COLLABORATIVE

  
  
  

Case Scenario:

Ms. Nadine was admitted yesterday with cough. Her medical diagnosis is Pneumonia.
She is 26 years of age and resides alone in the house.
Ms. Nadine verbalized, “I’ve been coughing for 3 days and it’s difficult to remove the
phlegm”. The nursing diagnosis formulated by the nurse is “Ineffective airway clearance
related to retained bronchial secretions as manifested by client reported difficulty of
expectorating the phlegm.
The nurse developed an outcome that after 2 days the client will be able to expectorate
cough without difficulty.
The nurse implemented her plan of care: Assessed respiratory rate and lung sounds;
advised client to perform deep breathing exercises, advised to increase oral fluid intake
and avoid eating foods such as pineapple for it may irritate the throat. She also referred
the client to a respiratory therapist. She also administered antibiotics as her medications.
After 3 days of nursing intervention the nurse evaluated the plan of care as “Goal met.
On the 3rd day she was able to expectorate her phlegm effectively and without difficulty.”
 Activity 2
Formulate a Nursing Care Plan based on the Case Scenario Given

• Diagnosis: Acute Cerebrovascular Disease (Stroke)

• CHIEF COMPLAINT: generalized weakness
• HISTORY: Ms liza is a 58-year-old woman who experienced weakness for 2 days
days prior to being admitted in the hospital.
• PHYSICAL EXAMINATION: The patient is a woman who appears tired haggard
and thin. She cannot tolerate activities such as moving on the bed, bathing and
eating without the assistance of her family. Vital signs are as follows: blood
pressure 110/90, apical heart rate 100/minute and regular, respiratory rate
18/minute, temperature 36.5 deg C.
• During the interview she verbalized “mahina ako, nahirapan ako kumilos kung
walang mag assist sa akin”
• Medication ordered for stroke: Mannitol 100 mL every 6 hours IVTT
• She was also referred to physical therapist and her schedule is every 3 days

--------

• Supposed you have implemented your nursing care plan to patient Liza.
• During evaluation phase Liza told you “ mahina parin ako, pero kaya ko nang
kumilos mag isa sa higaan ko, medyo matagal nga lang”.
 Activity 2
Formulate a Nursing Care Plan based on the Case Scenario Given

• Diagnosis: open wound at Left Leg

• Complain: pain in the affected area
• HISTORY: Ms liza is a 58-year-old woman who was admitted due to open leg
wound
• PHYSICAL EXAMINATION: The patient is a woman who appears tired and
haggard. She is crying and complaining about her wound. Inflammation was also
noted. Vital signs are as follows: blood pressure 110/90, apical heart rate
100/minute and regular, respiratory rate 18/minute, temperature 37.1 deg C.
• During the interview she verbalized “ Masakit masyado yung sugat ko”
• Pain scale: 9
• Medication ordered for her pain: Celecoxib 200 mg 2x a day.

--------

• Supposed you have implemented your nursing care plan to patient Liza.
• During evaluation phase Liza told you “masakit parin yung sugat ko pero 4 nalang
ang sakit niya”.
 NOTRE DAME OF TACURONG COLLEGE
COLLEGE OF NURSING
Lapu-Lapu St., Tacurong City, Sultan Kudarat, Philippines
Telephone No.: (064) 200-3631 Fax No.: (064) 200-4131
NURSING CARE PLAN

Name of Patient: __________________ Diagnosis:___________________

ASSESSMENT NEEDS NURSING GOALS NURSING RATIONALE EVALUATION

DIAGNOSIS INTERVENTION
Subjective Data:
Independent

Objective Data:

Dependent

References

Collaborative

Prepared by: __________________________________________ Year &Section: ____________ Date: ___________________________