XIV.

NURSING CARE PLAN

ASSESSMENT DIAGNOSIS BACKGROUND PLANNING IMPLEMENTATION RATIONALE EVALUATION
STUDY
Risk for Defined as the
noncomplianc state in which an Within my  Established  To gain Goal met as
e with individual has a span of care, rapport trust andevidenced by
prescribed limitation in the patient will elicits patient
treatment, independent, be able to  VS taken and cooperatiunderstand the
related to lack purposeful understand the monitored on importance of
of physical importance of therapeutic
understanding movement of the therapeutic  Provide  To have regimen
and resources body or of one or regimen therapy that baseline
more extremities. is short and data
simple
 Complian
 Explain the ce
side effects increases
can be when the
controlled or therapy is
eliminated short and
easy to
 Educate the understa
patient and nd
the family
member on  Side
the treatment effects of
regimen that medicatio
the patient n is
will undergo usually a
 Provide commonl
specific y
instruction as reported
problem
53
 needed  The
increase
 Involve awarenes
patient in s about
planning the the
proper importan
treatment for ce of
her completin
g the
 Evaluate the prescribe
patients d
insights about treatment
the treatment . It
regimen provides
 Evaluate the increased
patients complian
insights about ce to
the regimen . such
treatment

 Informati
on allows
the
patient to
better
take
control in
selecting
and
implemen
ting
required
changes

54
 in
behavior.
 Patients
who are
included
in the
planning
have
greater
stake in
achieving
a positive
outcome
 Understa
nding
and
consideri
ng each
patients
worries
and mis-
conceptio
ns about
the
treatment
plan help
in future
interventi
on

ASSESSMENT DIAGNOSIS BACKGROUND PLANNING IMPLEMENTATION RATIONALE EVALUATION

STUDY
Imbalanced Intake of

55
S: nutrition: less nutrients Within my 2  Established  To gain Goal partially
“nagapayat siya than body insufficient to days span of rapport trust andmet as
maam .dili pod requirements meet metabolic care, the patient elicits evidenced by
sya ganahan mo related to poor needs will be ablr to cooperatipatient able to
kaon” appetite and demonstrate a on demonstrate a
O: ingest in behaviors to behaviors to
adequate achieve  VS taken and  To have achieve
 Weight nutrients appropriate monitored baseline appropriate
35kg. weight data weight
 Lack of
interest in  IVF regulated
eating @ prescribed
nutritious rate
food  To
 Loss of  Encourage provide
appetite client to comfort
choose foods
or have  .to
family stimulate
member bring appetite
foods that
seem  To
appealing provide
 Assess comperat
weight, ive
age baseline
,bodybuild,
strength  To
,activity rest appeal to
level the
 Discuss to patients
the patient like to eat
eating habits,

56
 including food  To
preferences enhance
 Administer patient
vitamins as intake
ordered
 Encourage  To
patient for conserve
adequate rest energy
period especiall
 Promote y in
adequate, metabolic
and timely requirem
fluid intake . ents
limit fluids
1hr.prior to  Toreduce
meal possibility
 Encourage for early
patient to satiety
weigh
regularly and  To
graph result monitor
. effectiven
ess of
efforts

57
ASSESSMEN DIAGNOSIS BACKGROU PLANNING INTERVENTION RATIONALE EVALUATI
T ND STUDY ON
Ineffective Inability to Within my  Establishe  To gain Goal met ,
airway clear span of care d rapport trust and as evidence
S:”gina-ubo clearance secretions or the patient by patient
 Monitor VS elicit
japon ko related obstructions will be able to able to
 Monitor cooperatio
maam”
to bloody from the maintain respiration n maintain
As patient secretions as respiratory airways and breath  To have a airway
verbalized evidence by : tract to patency as sounds baseline patency as
maintain clear evidence by:  Evaluate data and evidence by:
O:  dyspne airway monitor (-)dyspnea
 (-)dysp clients
 Producti a cough abnormalit
nea RR20cpm
ve  RR:22c amount ies
 RR
cough pm 20cpm and type of  Indicative
noted secretions of
 RR  Place respiratory
24cpm patient on distress or
 dyspne moderate accumulati
a high back on of
rest secretions
 Encourage  To
patient to determine
do deep ability
breathing ability to
exercise protect
 Encourage own
patient to airway
increase  To
oral fluid maintain
intake open
 Administer airway in
medication or at rest

58
like or
bronchodil compromi
ator sed
individual
 To
maximize
effort
 Hydration
can help
prevent
the
accumulati
on of
viscous
secretions
and
improve
secretion
clearance
 To relax
smooth
respiratory
musculatu
re ,reduce
airway
edema ,
and
mobilize
secretions

59