Bulacan State University

COLLEGE OF NURSING
City of Malolos, Bulacan

INDIVIDUAL NURSING CARE PLAN

Patient’s Initial: E.S. Age: 20 Gender: Female Date Handled: Octobe 22, 2019
Medical Diagnosis: Chief Complaint
Clinical Area:

ASSESSMENT NURSING DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATION

Subjective:  Disturbed sleeping Short term goal: Independent: Short term evaluation:
“Sumasakit palagi ang pattern related to After 1 ½ hour of ▪ To provide comparative After 1 ½ hours of
ulo ko, minsan kasi frequent urination at nursing intervention, the ▪ Determine client usual sleep baseline. nursing intervention,
nahihirapan na akong night as manifested by client will be able to pattern. goals to identify
the subject data. identify individually ▪ Helps identify techniques to increase
makaaninaw.” As
appropriate ▪ Determine interventions appropriate options. hours of sleep were:
verbalized by the client has tried in the past.
interventions to promote
client. Objective:  sleep as evidenced by: ▪ These factors are - met
Pain scale of 8/10  ▪Encourage client to develop known to disrupt sleep -partially met
Facial expression of 1. State significance of plan to restrict caffeine and pattern and increase -unmet
pain  Positioning to complete sleep to the other stimulating substances urination.
ease the pain health of the client and from late afternoon, evening, As a evidence by:
her baby. and late night meals.
Vital Signs:  BP: 1. Verbalized of
120/70 mmHg  T: 2. Demonstrate the side Dependent: significance of complete
36.4 C  PR: 64 bpm effects of drinking of ▪ If medications found to sleep to the health of the
beverages. ▪Review medication being be interfering. client and her baby.
 RR: 19 rpm
taken and their effect can
sleep suggesting modifications 2. Demonstration of side
in regimen. effects of drinking
diuretics beverages.
Long term goal: Interdependent/Collaborative
: ▪To feel refresh and it
helps to promote sleep.
▪ Determine sleep routine and Long term evaluation:
state the significance of
cleaning and changing clothes
before sleeping.
 Bulacan State University
COLLEGE OF NURSING
City of Malolos, Bulacan

INDIVIDUAL NURSING CARE PLAN

Patient’s Initial: E.S. Age: 20 Gender: Female Date Handled: Octobe 22, 2019
Medical Diagnosis: Chief Complaint
Clinical Area:

ASSESSMENT NURSING DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATION

Subjective:  Deficient knowledge Short term goal: Independent: Short term evaluation:
“Medyo kinakabahan related to insufficient After an hour of ▪ Assessing level of After an hours of
ako sa aking information to nursing intervetion, the ▪ To assess readiness to learn knowledge and ability nursing intervention, the
panganganak dahil pregnancy. client will gain and individual learning needs. will allow the facilitator client gained and
information and aquire on what to inform the acquired learning about
unang beses ko palang
learning about ▪ Assertion level of client. pregnancy:
ito” As verbalized by pregnancy as evidenced knowledge, including
the client. by verbalization of the anticipatory needs ▪Assessing her - met
client, “Naiintindihan ko motivation will let the -partially met
Objective: na ngayon kung paano ▪Determine client’s ability, facilitator know if the -unmet
 Primigravida alagaan ang aking sarili readiness and barriers to client needs to be
pregnancy sa paghahanda sa aking learning. positively reinforced and As a evidence by:
 Teenage Pregnancy panganganak.” motivated.
 Unplanned Dependent: “Naiintindihan ko na
pregnancy ▪ Identifying the methods ngayon kung paano
▪To assess the client’s source to use will make it easy alagaan ang aking sarili
of motivation. for the facilitator and the sa paghahanda sa aking
Vital Signs:
Long term goal: client to understand and panganganak.”
 BP: 120/70 mmHg ▪Provide information relevant disseminate information.
 T: 36.4 C only to the situation to Long term evaluation:
 PR: 64 bpm prevent overload.
 RR: 19 rpm
▪Provide positive
reinforcement.

▪This could encourage

continuation of efforts
Interdependent/Collaborative:

▪To identify teaching method

to be used with the:

▪Determine the client’s

method of assessing
information and include in
teaching plan.

▪Involve the client’s source

with others who have the
same problems, needs or
concerns. This provides a role
model and sharing of
information.