ASSESSMENT DIAGNOSIS PLANNING INTERVENTION EVALUATION

Subjective: Self-care deficit Week 1:  Assess client’s ability to Week 1:

“Gitapol kog in Pt will be able to bathe self through direct Goal was met
ligo. Usahay bathing/hygiene perform self- observation (in usual Pt was able to
Ganado ko related to care activities bathing setting only) perform self-
maligo usahay decreased or with minimal noting specific deficits care activities
pud dili.” lack of supervision or and their causes. with minimal
motivation. assistance.  Plan activities to prevent supervision or
fatigue during bathing assistance.
Objective: Week 2:  Instruct pt to select bath
 Dirty Pt will be able to time when he or she Week 2:
clothes do self-care rested and unhurried. Goal was met.
 Dirty hair activities  Encourage independence, Pt was able to
and skin without but intervene when pt do self-care
noted someone cannot perform. activities
 Long nails prompting or  Use consistent routines without
 Unpleasant telling him do and allow adequate time someone
odor noted so. for pt to complete tasks. prompting or
 Provide privacy during telling him do
Weight: 45.5 bathing/dressing as so.
kg appropriate.
Height: 160.5  Encourage use of clothing
cm one size larger.
Body temp:  Assist pt with care of
37.6-degree fingernails and toenails as
Celsius required.
Blood  Provide supervision for
Pressure: each activity until pt
120/78 mm Hg performs skill
Heart rate: 96 competently and is safe in
bpm independent care;
reevaluate regularly to be
certain that the pt is
maintaining skill level and
remains safe in
environment.
 Provide reinforcement for
every accomplishment
made.
Balasuela, Jozel Via P.

NURSING CARE PLAN

“HYGIENE”
Patient: X
Age: 17 years old
 NURSING CARE PLAN
“ACTIVITY AND EXERCISE”
Patient: Y
Age: 24 years old

ASSESSMENT DIAGNOSIS PLANNING INTERVENTION EVALUATION

Subjective: Activity Short-Term:  Monitor vital signs Short-Term:
“Maglisog kog intolerance After 6 hrs of and record. Goal partially
lihok sakong related to effective nursing  Monitor intake and met because 6
lawas labaw na’g energy interventions, the output as order. hrs of effective
ilakaw nako. requirement pt will be able to  Assess ability to nursing
Murag nawad-an s as do ADL’s alone and perform ADL. interventions,
kog kusog.” evidenced by to participate in  Assess physical the pt is able to
decrease self-care activities. mobility status. do ADL’s alone
muscle  Assist pt to do ADL’s. and to
Objective: strength.  Assist to do active participate in
 Cannot range of motion self-care
perform exercise like flexing of activities.
ADL’s alone. both extremities.
 With limited Long-Term:  Promotes rest and Long-Term:
ROM After 2 days of comfort. Goal fully met
 Weak muscle effective nursing  Encourage to because after 2
strength interventions, the verbalize feelings and days of effective
pt will be able to concern regarding his nursing
Weight: 53 kg maintain activity present condition. interventions,
Height: 168.5 cm level within  Emphasize the pt is able to
Body temp: 36.9- capabilities as importance of maintain activity
degree Celsius evidenced by frequent ambulation. level within
Blood Pressure: normal vital signs  Encourage active capabilities as
120/79 mm Hg during activity, as ROM exercises like evidenced by
Heart rate: 96 well as absence of flexing of both normal vital signs
bpm weakness, pain, extremities. during activity, as
and difficulty  Emphasize well as absence
accomplishing importance of of weakness,
tasks. compliance to pain, and
treatment and difficulty
medication. accomplishing
 Encourage adequate tasks.
rest periods.