MISSION

“MABINI COLLEGES provides quality

VISION instruction, research and extension service programs
“MABINI COLLEGES shall cultivate a CULTUREof EXCELLENCE in Education.” at all educational levels as its monumental
MABINI COLLEGES contribution to national and global growth and
College of Nursing and Midwifery development.
Specifically, it transforms students into:
Daet, Camarines Norte · God – fearing
· Nation – loving
· Law abiding
· Earth caring
· Productive, and
· Locally and Globally competitive
persons

CASE: MEASLES
Assessment Diagnosis Planning Intervention Rationale Evaluation

SUBJECTIVE DATA: Risk for impaired After 8 hours of 1. Keep nails short and clean. To minimize the trauma and secondary Goal met.
“Lagi nyang nakakamot skin integrity nursing intervention, infection. After the nursing
yung mga kati-kati nya” related to raking the patient will able to 2. Wear gloves or elbow To prevent scratching. implementation the
as verbalized by the pruritus. maintain intact skin patient’s mother was
restrain from scratching.
mother. integrity. able to perform
instructions and the
OBJECTIVE DATA: 3. Give clothes that are Because excessive heat can increase patient was able to
 Rashes thin,loose and not irritating. itching. maintain intact skin.
 Skin redness
4. Close area of pain (long To prevent scratching
sleeves, long pants,
underwear layer.)
5. Avoid exposure to sunlight Exposure to sun rays or heat can cause
or heat. rashes.

MISSION
“MABINI COLLEGES provides quality
instruction, research and extension service programs
at all educational levels as its monumental
contribution to national and global growth and
development.
MABINI COLLEGES Specifically, it transforms students into:
· God – fearing
·
Hernandez, Shermayne ·
Nation – loving
Law abiding
Nursing Care Plan · Earth caring
· Productive, and
· Locally and Globally competitive
persons
 College of Nursing and Midwifery
Daet, Camarines Norte

CASE: PNEUMONIA
Assessment Diagnosis Planning Intervention Rationale Evaluation

SUBJECTIVE DATA: Ineffective Short term goal: INDEPENDENT: After 8 hours of

“Nahihirapan akong airway clearance After 8 hrs of  Encourage deep breathing  Deep breathing promotes nursing
huminga (It’s difficult to related to the nursing exercise oxygenation before controlled intervention, goal
breathe)” as verbalized by increased
intervention, coughing partially met. The
the patient. production of
respiratory
secretions will be  Assist patient in coughing  To improve productivity of patient able to
Objective data: secretions mobilized, airway exercises the cough demonstrate less
 Rapid patency will be  Increase fluid intake as  Adequate fluid intake coughing and
breathing/tachypnea maintaned free of appropriate. enhances liquefaction of deep breathing
 Cough with yellow secretions, as pulmonary secretions and exercise every 1-2
sputum production evidenced patient’s facilitates expectoration of hours during the
 Diminished and cough out  Monitor rate,rhythm, depth mucus. day.
adventitious breath secretions, clear and effort of respiration.  Provides a basis for evaluating > Client’s RR is
sounds (crackles) lung sound and  Assist patient into moderate adequacy of ventilation. within normal
 Dyspnea uncompromised high back rest position  To promote drainage of range (RR-19)
respiratory rate.  Auscultate lung fields, secretions and better lung >Inspiratory
noting areas of decreased of expansion crackles can still
absent airflow and  Decreased airflow occurs in be heard at the
adventitious breath sounds consolidated with fluid. lower lobe
Bronchial breath sounds > cough continues
(normal over bronchus) can to be productive
also occur on consolidated
areas. Crackles, rhonchi, and
wheezes are heard on
inspiration and/or expiration

Hernandez, Shermayne
Nursing Care Plan
 VISION
“MABINI COLLEGES shall cultivate a CULTUREof EXCELLENCE in Education.”
DEPENDENT:
 Administer ordered
medications such as
mucolytic agents,
bronchodilators,
expectorants
 Administer nebulization as
needed
MABINI COLLEGES
College of Nursing and Midwifery
Dreporaet, Camarines Norte
Hernandez, Shermayne
Nursing Care Plan
in response to fluid
accumulation, thick
secretions, and airway
spasm/obstruction.
 To help loosen and clear the
mucus from the airways
(mucolytics); decrease
resistance in the respiratory
airway nd increase airflow to
the lungs (bronchodilators)
and to loosen and clear mucus
and phlegm from the
respiratory tract (expectorant).
 A variety of respiratory
therapy treatments may be
used to open constricted
airways and liquefy
secretions.
MISSION
“MABINI COLLEGES provides quality
instruction, research and extension service programs
at all educational levels as its monumental
contribution to national and global growth and
development.
Specifically, it transforms students into:
· God – fearing
· Nation – loving
· Law abiding
· Earth caring
· Productive, and
· Locally and Globally competitive
persons
CASE: AIDS/HIV
Assessment Diagnosis Planning Intervention Rationale Evaluation

SUBJECTIVE DATA: Fatigue may be After 8 hours of INDEPENDENT: After 8 hours of nursing
“ I always feel tired and
related to nursing interventions,  Assess sleep patterns  Multiple factors can interventions, the patient
lately I’m prone to degrease in the patient will: and other factors that cause and aggravate was able to maintain
infections”as verbalizedmetabolic  Report improved may be aggravating fatigue, including adequate fluid volume as
by the patient. energy sense of energy fatigue sleep deprivation, evidenced by good skin
production,  Participate in  Encourage timely emotional distress, turgor and balance intake
OBJECTIVE increased desired activities at evaluation of fatigue if side effects of drugs and output.
energy level of ability new medications have and developing central
 Overwhelming lack requirement,  Identify individual been added to the nervous system
of energy overwhelming areas of control regimen. disease.
 Inability to maintain psychological  Engage in energy  Discuss reality of  Fatigue is present in
usual routines and physical conservation patient’s feelings of variable degrees as
 Decrease demands, and techniques exhaustion and identity part of HIV infection
performance altered body limitations imposed by process but is often
chemistry such fatigue state. aggravated by
as side effects  Assist patient to set nutritional deficiencies
of medication realistic activity goals, and side effects of
or insulin determining individual certain medications.
resistance. priorities and  Helpful in planning
responsibilities activities within
 Discuss energy tolerance levels.
conservation techniques  Patient may need to
such as sitting instead of alter priorities and
standing for activities, delegate some
as appropriate. responsibilities to
 Encourage adequate rest manage fatigue and
periods during the day. optimize performance.

Hernandez, Shermayne
Nursing Care Plan
 VISION
“MABINI COLLEGES shall cultivate a CULTUREof EXCELLENCE in Education.”  Instruct in stress  Enables patient to
management techniques, become aware in
such as breathing which energy
exercises, visualization expenditures can be
and music and light maximized to
therapy. complete necessary
tasks.
 Helps patient recoup
energy to manage
desired activities.
 Reduction of stress
factors in patient’s life
can minimize energy
COLLABORATIVE: output.
 Administer IV Fluid as
prescribed
 Identify available
resource and support
systems.

MISSION
“MABINI COLLEGES provides quality
instruction, research and extension service programs
at all educational levels as its monumental
MABINI COLLEGES contribution to national and global growth and
College of Nursing and Midwifery development.
Specifically, it transforms students into:
Dreporaet, Camarines Norte · God – fearing
· Nation – loving
· Law abiding
· Earth caring
· Productive, and
· Locally and Globally competitive
CASE: SCABIES persons

Assessment Diagnosis Planning Intervention Rationale Evaluation

Hernandez, Shermayne
Nursing Care Plan
 VISION
“MABINI COLLEGES shall cultivate a CULTUREof EXCELLENCE in Education.”

SUBJECTIVE DATA: Impaired skin After 3 weeks of  Wear gloves when caring  To avoid direct contact and After 3 weeks of nursing
“Makati ang sugat ko lalo integrity r/t nursing intervention, for the client with lesion transmission of infectious agent. intervention, goal was
na sa gabi”as verbalized invasion of skin client will regain skin  Cleanse the skin  Cleaning the skin will help to wash met as evidenced by
by the patient. structures by integrity as out the mites in the skin. Cleansing healed skin rashes and
thoroughly, but gently.
pathogenic manifested by skin it gently will prevent excessive moist and less scaly skin.
 In the case of bacterial
OBJECTIVE DATA: organism rashes will heal, dry erosions of the skin.
 Rash draining skin will becomed infections or lesions with  Kills bacteria
serosanguinous fluid moit and scaly kin secondary infections, use
 Dry scaly skin on the will lessen. an antibacterial soap.
feet  Gently remove  Cleaning the area first before
crust,scales and traces of putting any cream makes the cream
old medication before absorbed by the skin.
applying fresh creams or
lotions
 Encourage to comply to
 Medications are given to treat
prescribed medication if
infection. One must comply so it
any will not become worse
 Apply cream and lotion.  It gives moisture to the skin
Monitor their  To evaluate the effectiveness of
effectiveness management.

MISSION
“MABINI COLLEGES provides quality
instruction, research and extension service programs
at all educational levels as its monumental
MABINI COLLEGES contribution to national and global growth and
College of Nursing and Midwifery development.
Specifically, it transforms students into:
Daet, Camarines Norte · God – fearing
· Nation – loving
· Law abiding
· Earth caring
· Productive, and
· Locally and Globally competitive
persons

PROBLEM: TUBERCULOSIS MENINGITIS

Hernandez, Shermayne
Nursing Care Plan
 Assessment Diagnosis Planning Intervention Rationale Evaluation
INDEPENDENT:
SUBJECTIVE DATA: Risk for After 4 hours of  Maintain head or neck in  Turning head to one side After 4 hours of nursing
“masakit ang ulo ko” as ineffective nursing intervention, midline or neutral compresses the jugular veins and intervention, the client
verbalized by the patient cerebral tissue the patient will position, support with inhibits cerebral venous drainage, was able to demonstrate
OBJECTIVE DATA: perfusion related demonstrate absence thereby increasing ICP. absence of signs of ICP.
towel rolls and pillows.
 Restlessness to cerebral edema of signs of ICP.
 Provide rest periods
 Changes in motor or  Continual activity can increase ICP.
sensory response. between care activities
and limit duration of
procedures.
 Decrease extraneous  Provides calming effect, reduces
stimuli and provide adverse physiological response and
comfort measures such as promotes rest to maintain or lower
back massage, quiet ICP.
environment, soft voice.
 Help patient avoid or
 These activities increase thoracic
limit coughing, vomiting,
and itra-abdominal pressure which
straining at stool, bearing can increase ICP.
down as possible.
 Observe for seizure  Seizure can occur as result of
activity and protect cerebral irritation, hypoxia or
patient from injury. increase ICP.

COLLABORATIVE:
 Restrict fluid intake as
indicated.
 Administer supplemental
oxygen as indicated.
 Fluid restriction may be needed to
reduce cerebral edema.
 Reduces edema.

Hernandez, Shermayne
Nursing Care Plan
 VISION
“MABINI COLLEGES shall cultivate a CULTUREof EXCELLENCE in Education.”

MISSION
“MABINI COLLEGES provides quality
instruction, research and extension service programs
at all educational levels as its monumental
MABINI COLLEGES contribution to national and global growth and
College of Nursing and Midwifery development.
Specifically, it transforms students into:
Daet, Camarines Norte · God – fearing
· Nation – loving
· Law abiding
· Earth caring
· Productive, and
· Locally and Globally competitive
persons
PROBLEM: DENGUE
Assessment Diagnosis Planning Intervention Rationale Evaluation
INDEPENDENT:
SUBJECTIVE: Risk for After 3 hours of  Assess the signs and  The GI tract is the most usual source  After 3 hours of
“dumudugo anf labi ng hemorrhage nursing interventions, symptoms of GI bleeding. of bleeding of its mucosal fragility.. nursing
kapatid ko” as verbalized related to altered the client will be able  Check for secretions. interventions, the
by the patient’s sister. clotting factor. to demonstrate client is able to
 Observe color and
behaviors that reduce demonstrate
consistency of stools or
OBJECTIVE: the risk of bleeding. behavior that reduce
 Weakness and vomitus. the rsik of bleeding.
irritability  Observe for presence of  Sub acute disseminate intravascular
 restlessness petichiae, ecchymosis, coagulation may develop secondary
bleeding from one more to altered clotting factor.
sites.
 Note changes in level of  Changes may indicate cerebral
conciousness. perfusion problems.
 Encourage use of soft  Minimal trauma can cause mucosal
toothbrush. Avoid bleeding.
straining in tool and
forceful nose blowing.
 Use small needles for  Minimize damage to tissues, reduce

Hernandez, Shermayne
Nursing Care Plan
 injections. Apply pressure risk for bleeding and hematoma.
to veni puncture sites for
longer than usual.

DEPENDENT:  To prevent spontaneous bleeding

 Don’t administer aspirin

COLLABORATIVE:
 Check for platelet count
 Check for hematocrit
 Report to physician if
there’s a continuous
bleeding.

Hernandez, Shermayne
Nursing Care Plan
 MISSION
“MABINI COLLEGES provides quality
VISION instruction, research and extension service programs
“MABINI COLLEGES shall cultivate a CULTUREof EXCELLENCE in Education.” at all educational levels as its monumental
MABINI COLLEGES contribution to national and global growth and
College of Nursing and Midwifery development.
Specifically, it transforms students into:
Daet, Camarines Norte · God – fearing
· Nation – loving
· Law abiding
· Earth caring
· Productive, and
· Locally and Globally competitive
persons
CASE: MULTIPLE SCLEROSIS
Assessment Diagnosis Planning Intervention Rationale Evaluation

SUBJECTIVE DATA: Fatigue r/t decreased After 8 hours of INDEPENDENT: After 8 hours of nursing
“Bigla akong nanghina at energy nursing intervention,  Note and accept presence  Persistent fatigue is the most intervention, the patient
parang pagod na pagod”, production,increased the patient will able to of fatigue commonly reported symptom. was able to identify risk
as verbalized by the requirements to identify risks factors  Knowledge of these factors factors and individual
 Identify or review factors
patient. perform activities. and individual actions provides an opportunity to develop actions affecting fatigue;
affecting ability to be
affecting fatigue; effective measure to maintain or identify alternatives to
OBJECTIVE DATA: identify alternatives active, such as improve mobility. help maintain desired
 Decreased fine to help maintain temperature extremes, activity level; participate
motor skills desired activity level; food intake, insomnia, in recommended
 Decreased muscle participate in use of medications, or treatment and program
tone and mass recommended time of day. and report improved
 restlessness treatment program  Accept when client is  Activity intolerance can vary from sense of energy.
and report improved unable to do activities. moment to moment.
sense of energy  Determine need for  Mobility ads can decrease fatigue,
mobility aids such as enhance independence and comfort
and promotes safety.
canes, walker,
wheelchair, etc.
 Schedule activity of daily  Fatigue commonly worsens when
living and outside exposed to high temperature due to
activities in the morning weather.
or overtime throughout
the course of the day.
 Plan care with consistent  Consistent rest and activity reduces
rest periods between fatigue.
activities.

Hernandez, Shermayne
Nursing Care Plan
 VISION
“MABINI COLLEGES shall cultivate a CULTUREof EXCELLENCE in Education.”

MISSION
“MABINI COLLEGES provides quality
instruction, research and extension service programs
at all educational levels as its monumental
MABINI COLLEGES contribution to national and global growth and
College of Nursing and Midwifery development.
Specifically, it transforms students into:
Daet, Camarines Norte · God – fearing
· Nation – loving
· Law abiding
· Earth caring
· Productive, and
· Locally and Globally competitive
persons
CASE: RABIES
Assessment Diagnosis Planning Intervention Rationale Evaluation

Hernandez, Shermayne
Nursing Care Plan
 VISION
“MABINI COLLEGES shall cultivate a CULTUREof EXCELLENCE in Education.”

SUBJECTIVE DATA: Impaired skin After 8 hours of INDEPENDENT:
“Nakagat ako ng aso integrity r/t nursing intervention,  Assess or document
habang pauwi ako”, as disruption of skin the patient will size,color, depth of
verbalized by the patient. surface with achieve timely wound
wound and condition of
destruction of kin healing.
surrounding skin.
OBJECTIVE DATA: layers.
 Facial grimace  Thoroughly wash the
 irritability wound as soon as
possible with soap and
water for approximately 5
minutes.
 After washing, an
antiseptic solution should
be applied in the wound
such as providine iodine
and alcohol.
 Keep skin free from
pressure
 Implement contact
isolation for respiratory
secretions especially
saliva in the duration of
the illness.
MABINI COLLEGES
College of Nursing and Midwifery
Daet, Camarines Norte
CASE:CHRONIC KIDNEY DISEASE
Assessment Diagnosis Planning Intervention
After 8 hours of nursing
 Provide baseline information about intervention, the patient
the wound and possible clues about was able to achieve
the blood circulation in the affected timely wound healing.
area.
 Washing the affected area is very
effective at reducing the number of
viral particles.
 To hasten the spread of the viral
disease in the surrounding area.
 Tp promote circulation
 To reduce the risk of cross
contamination.
MISSION
“MABINI COLLEGES provides quality
instruction, research and extension service programs
at all educational levels as its monumental
contribution to national and global growth and
development.
Specifically, it transforms students into:
· God – fearing
· Nation – loving
· Law abiding
· Earth caring
· Productive, and
· Locally and Globally competitive
persons
Rationale Evaluation

Hernandez, Shermayne
Nursing Care Plan
SUBJECTIVE DATA: Fluid volume After 8 hours of INDEPENDENT: After 8 hours of nursing
“Namamanas ako”, as excess r/t nursing intervention,  Record accurate intake  Accurate I&O is necessary for intervention, the patient
verbalized by the patient. compromised the patient will and output. determining renal function and fluid was able to achieve
regulatory display appropriate replacement needs and reducing risk timely wound healing.
OBJECTIVE DATA: mechanism (renal urinary output with of fluid overload.
 Venous distention failure) specific gravity or
 Generalized edema laboratory stuidies  Weigh daily at same time  Daily body weight is best monitor if
near normal; stable of day, on same scale, fluid status.
weight and absence of with same equipment and
edema. clothing.
 Assess skin, face,  Edema occurs primarily in
dependent areas for dependent tissues of he body, e.g.,
edema. hand, feet, lumbosacral area. Patient
can gain up to 10lb (4.5 kg) of fluid
before pitting edema is detected.

 Helps avoid periods without fluids,

 Plan oral fluid minimizes boredom of limited
replacement with pt, choices and reduces sense of
within multiple deprivation and thirst
restrictions.

COLLABORATIVE:  Fluid management is usually

 Administer/restrict fluids calculated to replace output from all
as inidcated. sources plus estimated insensible
losses.

 Given early in oliguric phase of

 Administer medication as
indicated; Diuretics
renal failure in an effort to convert
to non-oliguric phase, flush the
tubular lumen of debris, reduce
hyperkalemia and promote adequate
urine volume.

 May be given to treat hypertension

Hernandez, Shermayne
Nursing Care Plan
 VISION
“MABINI COLLEGES shall cultivate a CULTUREof EXCELLENCE in Education.”
 Antihypertensive by counteracting effects of decresed
renal blood flow and/or circulating
volume overload.

MISSION
“MABINI COLLEGES provides quality
instruction, research and extension service programs
at all educational levels as its monumental
MABINI COLLEGES contribution to national and global growth and
College of Nursing and Midwifery development.
Specifically, it transforms students into:
Daet, Camarines Norte · God – fearing
· Nation – loving
· Law abiding
· Earth caring
· Productive, and
· Locally and Globally competitive
persons
CASE: Diarrhea
Assessment Diagnosis Planning Intervention Rationale Evaluation

Hernandez, Shermayne
Nursing Care Plan
SUBJECTIVE DATA: Impaired skin After 8 hours of INDEPENDENT: After 8 hours of nursing
“Nakagat ako ng aso integrity r/t nursing intervention,  Assess or document  Provide baseline information about intervention, the patient
habang pauwi ako”, as disruption of skin the patient will size,color, depth of the wound and possible clues about was able to achieve
verbalized by the patient. surface with achieve timely wound the blood circulation in the affected timely wound healing.
wound and condition of
destruction of kin healing. area.
surrounding skin.
OBJECTIVE DATA: layers.
 Facial grimace  Thoroughly wash the  Washing the affected area is very
 irritability wound as soon as effective at reducing the number of
possible with soap and viral particles.
water for approximately 5
minutes.
 After washing, an  To hasten the spread of the viral
antiseptic solution should disease in the surrounding area.
be applied in the wound
such as providine iodine
and alcohol.
 Tp promote circulation
 Keep skin free from
pressure
 Implement contact  To reduce the risk of cross
isolation for respiratory contamination.
secretions especially
saliva in the duration of
the illness.

Hernandez, Shermayne
Nursing Care Plan