REPUBLIC OF THE PHILIPPINES

UNIVERSITY OF NORTHERN PHILIPPINES

TAMAG, VIGAN CITY
2700 ILOCOS SUR

Room No: Male Ward Name: ORLANDO, TAPURO AGRESORA Student Nurse: Carlos Joshua L. Ponce Date: 11/25/20

NURSING CARE PLAN

ASSESSMENT NURSING SCIENTIFIC GOAL/OBJECTIVE NURSING RATIONALE EVALUATION
DIAGNOSIS BACKGROUND INTERVENTION
Subjective: Activity intolerance A sudden impairment STG: Independent: STG:
Body related to body of cerebral circulation After 6 hours of giving After 6 hours of giving
weakness weakness secondary in one or more blood effective nursing Monitored and To help determine effective nursing
Dizziness to altered cerebral vessels. It interrupts or interventions, the patient current health interventions, the
recorded vital
headache diminishes oxygen patient will be able to status and evaluate patient was able to
blood supply. signs.
supply causes serious cope with fatigue as coped with fatigue as
effectiveness of
damage or necrosis in evidenced by evidenced by
Objective: the brain tissue. the verbalized feelings of nursing intervention verbalized feelings of
brain cells cease to comfort and increase rendered. comfort and increased
Vital Signs: function and can activity participation. activity participation.
BP: 150/100 mmHg neither store glucose or To gain the clients’
PR: 75 bpm glycogen for use in Established trust.
CR: 74 bpm anaerobic metabolism. LTG: rapport with the LTG:
RR: 20 cpm This decreases the After 4 days of effective After 4 days of effective
client.
T: 36.6 0C ability of tissues to nursing interventions, nursing interventions,
O2 Sat: 99% perform their basic task the patient will be able the patient was able to
To gain the client’s
causing body to maintain activity maintain activity level
Explained every cooperation.
weakness. level within within capabilities as
capabilities as procedure can be evidenced by normal
evidenced by normal done to the client. vital signs during
vital signs during activity, as well as
activity, as well as Assess clients To identify risk for absence of weakness
absence of weakness muscle strength falls. pain, and difficulty
pain, and difficulty gross and fine accomplishing tasks.
accomplishing tasks. Goal met
motor
coordination.
If patient lacks of To provide enough
strength, schedule energy to perform
rest periods. activities of daily
 living.
Provided
assistance Maintains mobility
for range of and functions of joints
motion exercise. alignment of
extremities and
reduces venous stasis.

Kept necessary Keeping all in reach,

utensils within can greatly reduce the
reach of the risk of accident to the
patient. patient.

Encouraged This is to enable the

patient to do self- patient to regain
care activities such muscle strength and
as oral care, keeping himself clean,
walking exercise. and will gain
independence.

Collaborative:

Incorporate
physical therapy
exercise in the To prevent muscle
patient care. atrophy and to
maintain the mobility
required for daily
Encouraged activities.
recreational
Can provide
therapy as well
diversion, improved
as family visits. the patients outlook
and increase tolerance
physical activity as
well.
 REPUBLIC OF THE PHILIPPINES
UNIVERSITY OF NORTHERN PHILIPPINES
TAMAG, VIGAN CITY
2700 ILOCOS SUR

Room No: Male Ward Name: ORLANDO, TAPURO AGRESORA Student Nurse: Carlos Joshua L. Ponce Date: 11/25/20
 NURSING CARE PLAN
ASSESSMENT NURSING SCIENTIFIC GOAL/OBJECTIVE NURSING RATIONALE EVALUATION
DIAGNOSIS BACKGROUND INTERVENTION
Subjective: Risk for injury At risk of injury as a STG: Independent: STG:
Headache related to fall result of After 3 hours of After 3 hours of giving
Dizziness secondary to body environmental giving effective Monitored and To help determine effective nursing
Body weakness. conditions nursing interventions, recorded vital signs. patient current health interventions, the
weakness the patient status and evaluate patient was able
interacting with the
understands the risk understands the risk
Objective:
individual’s adaptive factors that contribute
effectiveness of
factors that contribute
and defensive to possibility of falls. nursing intervention to possibility of falls.
Vital Signs: resources. rendered.
BP: 150/100 mmHg
PR: 75 bpm LTG: To gain the clients’ LTG:
CR: 74 bpm After 4 days of effective Established rapport trust. After 4 days of effective
RR: 20 cpm nursing interventions, with the client. nursing interventions,
T: 36.6 0C the patient the patient was able
O2 Sat: 99% demonstrates demonstrates
behaviors that To gain the client’s behaviors that
reduce risk factors Explained every cooperation. reduce risk factors
and protection from procedure can be done and protection from
self-injury. to the client. self-injury.
Goal met
To identify risk for
Assess clients muscle falls.
strength gross and
fine.

Keeping all in reach,

Kept necessary can greatly reduce the
utensils within reach risk of accident to the
of the patient. patient.

It is helpful to
Assess the patient determine the client’s
ability to ambulate functional abilities to
safely with or without plan for ways of
assistive devices. improving the
problem areas.
Thoroughly orient the For the client to
patient to familiarize the
environment. surroundings.

Assess vision and To provide well-

provide adequate lighted environment
lighting to clearly see and avoid the
the pathway. occurrence of injury.

To ensure clients
Ask the significant safety.
others to always stay
with the client.

To prevent the patient

Instruct the patient to from falling on bed.
call for assistance
when moving. To reduce the risk of
falling.
Put side rails.
For the client support.

Provide assistive
devices for walking
such as cane, crutches
and/o wheelchairs. To prevent from
slippering.
Ensure that the patient
wears proper shoes.

Collaborative:
Gait training in
Refer to physical physical therapy has
therapy for been shown to be
strengthening exercises effective for
and gait training to preventing falls.
increase mobility.