PROBLEM-FOCUSED NURSING CARE PLAN

ASSESSMEN NURSING
T DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATION

SUBJECTIVE: Impaired physical GOAL: INDEPENDENT:  Having the  The client is

mobility r/t activity right exercise able to display
intolerance and  The client is program for physiological
“Hindi ko po kayang
decrease in edurance  Develop
maka-keep up sa able to your type of improvements
as evidenced by proper
physical activities sa display body will lead over time
“Hindi ko po kayang exercise
school. Mabilis po physiological to the proper
maka-keep up sa programs and
ako hingalin.” As improvements ensure they
way of weight - GOAL
physical activities sa loss.
verbalized by the over time. are followed MET
school. Mabilis po
client. regularly.
ako hingalin.” As  Having rest
verbalized by the DESIRED  After 2 weeks,
OBJECTIVE: periods is
client. OUTCOME:  Allow and client is able
essential
encourage to perform
because it will
 Height: 157 proper rest activities
 After 2 weeks, give the client
cm (5’2”) periods in without
client is able a sense of
 Weight: between excessive
to perform motivation to
147.71 lb exercises. exhaustion
activities continue. And
(67kg) not treat the and loss of
without
 BMI: 27 kg/m2  Help patient routine as a energy.
excessive
develop a task he/she
exhaustion
proper diet needs to - GOAL
and loss of
and eating perform.
energy.
habits. MET

 Having a
proper diet
ensures that
the body is
getting the
right amount
of nutrients
that the client
needs.
 HEALTH PROMOTION NURSING CARE PLAN

ASSESSMEN NURSING
T DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATION

SUBJECTIVE: Readiness for GOAL:  Encourage  Jotting down  The client will
enhanced sleep r/t client to jot notes, will maintain an 8-
client’s eagerness  The client will down how keep he hour sleeping
“Gusto ko makakuha
for enhancement of maintain an 8- many hours client pattern.
ng 8 hours na tulog.”
his/her sleep as hour sleeping of sleep updated on
As verbalized by the
evidenced by pattern. he/she gets a the progress
client.
“Gusto ko - GOAL
day. he/she is
makakuha ng 8 doing. Which PARTIALLY
OBJECTIVE: DESIRED
hours na tulog.” As  Develop will create a MET
verbalized by the OUTCOME: proper time sense of
 Expresses client. management motivation.  After 2 hours of
desire to  After 2 hours and ensure nursing
enhance of nursing that they stick  Creating a intervention,
sleep intervention, to it as much proper time client is able to
client is able as possible. plan will verbalize
to verbalize remove bad understanding of
understanding  Promote habits such the information
of the bedtime as given.
information comfort cramming.
given. regimens. - GOAL MET
 Having
bedtime
comfort
regimens
such as milk,
warm bath
can help the
client have
an early nice
sleep.
 RISK NURSING CARE PLAN

ASSESSMEN NURSING
T DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATION

SUBJECTIVE: Risk for self- GOAL:  Encourage  Having a  Patient will feel
directed violence client to write journal in the
r/t patterns of  Patient will feel a journal hand, will connectedness
“Kapag ginagawa ko
difficulties of the expressing help in with others to
yun, nababawasan
family background connectedness thoughts and suppressing share thoughts,
yung sakit kahit
such as broken with others to reflections feelings that feelings and
sandal lang.” As
family as share daily. the client is beliefs.
verbalized by the
evidenced by thoughts, too afraid to
client.
“Kapag ginagawa feelings and  Discuss with tell others.
ko yun, - GOAL MET
OBJECTIVE: beliefs. the client
nababawasan what has  Client is in a
yung sakit kahit given comfort state of in  After 3 weeks,
 Self- inflicted sandal lang.” As DESIRED client is able to
and meaning which all they
scars verbalized by the OUTCOME: to the person can think of is state that she/he
client. in the past. negative feels a sense of
 Feeling of  After 3 weeks, things. forgiveness and
helplessness client is able to  Encourage acceptance.
state that clients to  Client can
 Anhedonism she/he feels a express learn - GOAL
sense of feelings alternative PARTIALLY
forgiveness (anger, ways in MET
and sadness, dealing with
acceptance. guilt) and overwhelming
come up with emotions and
alternative gain a sense
ways to of control
handle over his/her
feelings of life.
anger and
frustration.
 SYNDROME NURSING CARE PLAN

ASSESSMEN NURSING
T DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATION

SUBJECTIVE: Post-trauma GOAL: INDEPENDENT:  Giving client  The client is able

syndrome r/t space and his to deal with
 Encourage to
destruction to  The client is own initiative emotional
“Hindi ko po talk about the
one’s home as able to deal in talking reactions
makalimutan yung trauma at their
evidenced by with about appropriately.
paghihiwalay ng own pace.
“Hindi ko po emotional sensitive
parents ko, lagi ko
makalimutan yung reactions topics will - GOAL MET
na lang po iniiyak  Evaluate
paghihiwalay ng appropriately. establish trust
para makatulog resources and
parents ko, lagi ko and rapport
ako” As verbalized support  After a month,
na lang po iniiyak between the
by the client. DESIRED systems the client will
para makatulog relationship of
ako” As verbalized OUTCOME: available to the demonstrate
nurse and
OBJECTIVE: by the client. client. progress in
client.
dealing with
 After a stages of
 Has a hard DEPENDENT:  Giving
month, the acceptance and
time falling client will  Administer medications
asleep antidepressant, express sense of
demonstrate such as
normally. such as optimism and
progress in antidepressan
trazodone. hope for the
dealing with t will help the
future.
 Sensitivity to stages of client from
topics about acceptance COLLABORATIVE: overthinking
and has side - GOAL
family and express  Set client to an
sense of appointment effects which PARTIALLY
optimism and with a can help them MET
hope for the psychiatrist/ sleep.
future. psychologist.
 Referring
client to a
therapy whom
are expertised
in this kind of
case.
 UNIVERSITY OF MAKATI
COLLEGE OF ALLIED HEALTH STUDIES
J. P. Rizal Extension, West Rembo, 1215 Makati

NURSING CARE PLAN

4 TYPES OF NURSING DIAGNOSIS

ALCARAZ, Alejandra Bien V.

1-AN BSN
Prof. Jerieco Batario