UNIVERSITY OF EASTERN PHILIPPINES

University Town, Northern Samar

COLLEGE of NURSING and ALLIED HEALTH SCIENCES

NURSING CARE PLAN

Name of Patient:____PIA ANGELA ALONZO_______ Date Admitted:_09-16-20____ Chief Complaint:_________FATIGUE________________ Case Number: 1
Age: 26 Gender:_____F_________ Civil Status:_ S Address:___________PALAPAG_____________________ Ward: 2

ASSESSMENT NURSING SCIENTIFIC OBJECTIVES/ NURSING INTERVENTIONS SCIENTIFIC RATIONALE EVALUATION

DIAGNOSIS RATIONALE PLANNING

Subjective Data: Activity Intolerance Insufficient • Identify negative factors  Ask client/significant other to identify potential problems
“katanglay saak related to Imbalance physiological or affecting activity tolerance and (SO) about usual level of and/or client’s/SO’s
lawas kaluya ko” as between oxygen supply psychological energy to eliminate or reduce their energy perception • Response to interventions,
stated by the patient and demand endure or complete effects when possible.
of client’s energy and ability teaching, and actions
required or desired • Use identified techniques to
daily activities. enhance activity tolerance. to perform needed performed
• Participate willingly in or desired activities.
necessary/desired activities.  Provide positive atmosphere  This helps to minimize • Implemented changes to
Objective Data: • Report measurable increase while acknowledging the frustration and rechannel plan of care based on
BP: 160/100 mmHg in activity tolerance. difficulty of the situation for energy. assessment/
• Demonstrate a decrease in
the client.
PR: 90 physiological signs of
 Assist client/SO(s) with to improve the client’s ability reassessment fi ndings
intolerance
client’s normal range). planning for changes that may to participate in desired
RR: 22 become necessary, such as use activities. • Teaching plan and
of supplemental oxygen understanding of material
 Give client information that to sustain motivation. presented
M. Doenges, Nurses provides evidence of
pocket guide, 15th daily/weekly progress • Attainment or progress
edition  Identify and discuss symptoms providing for timely toward desired outcome(s)
for which the client needs to intervention.
seek medical
assistance/evaluation

STUDENT NURSE: ___JOSEF ANGELO POLDO______ CLINICAL INSTRUCTOR: ___JEANETTE ROJO______

 UNIVERSITY OF EASTERN PHILIPPINES
University Town, Northern Samar

COLLEGE of NURSING and ALLIED HEALTH SCIENCES

NURSING CARE PLAN

Name of Patient:____PIA ANGELA ALONZO_______ Date Admitted:_09-16-20____ Chief Complaint:_________WEAKNESS________________ Case Number: 2
Age: 26 Gender:_____F_________ Civil Status:_ S Address:___________PALAPAG_____________________ Ward: 2

ASSESSMENT NURSING SCIENTIFIC OBJECTIVES/ NURSING INTERVENTIONS SCIENTIFIC RATIONALE EVALUATION

DIAGNOSIS RATIONALE PLANNING

Subjective Data: imbalanced Intake of nutrients • Verbalize understanding of Ascertain client’s to determine informational Implementation/Evaluati
NUTRITION : less insufficient to meet causative factors when known understanding of individual needs of client/significant on
“ diak than body requirements metabolic needs. and necessary interventions. nutritional needs and ways other (SO)
related to Insufficient • Demonstrate behaviors and
nahingangakaon” as client is meeting those needs • Client’s responses to
lifestyle changes to regain
stated by the patient dietary intake Collaborate with to set nutritional goals when
and/or maintain appropriate interventions, teaching,
weight. interdisciplinary team client has specific dietary
and actions performed
Objective Data: needs, malnutrition is
Weight loss with profound, or long-term
adequate food intake feeding problems exist. • Results of periodic
to reduce possibility of early weigh-in

Food intake less than fluid intake. Limit fluids 1hr satiety.
recommended daily prior to meal • Attainment or progress
allowances M. Doenges, Nurses  Develop individual strategies to identify appropriate toward desired
pocket guide, 15th when problem is assistive devices outcome(s)
edition mechanical(e.g., wired jaws or
paralysis following stroke). • Modifi cations to plan of
Consult occupational therapist care
 Consult with dietitian or for long-term needs.
nutritional support team, as
necessary

STUDENT NURSE: ___JOSEF ANGELO POLDO______ CLINICAL INSTRUCTOR: ___JEANETTE ROJO______


Name of Patient:____PIA ANGELA ALONZO_______ Date Admitted:_09-16-20____ Chief Complaint:___DIFFICULTY OF BREATHIN__________ Case Number:
Age: 26 Gender:_____F_________ Civil Status:_ S
ASSESSMENT
Subjective Data:
“diak nakakahinga, mahapo”
stated by the patient
Objective Data:
Diminished breath sounds;
adventitious breath sounds [rales,
crackles, rhonchi, or wheezes]
Excessive sputum
Alteration in respiratory rate or
pattern
Difficulty verbalizing
Wide-eyed look; restlessness
Orthopnea
Cyanosis
STUDENT NURSE: ___JOSEF ANGELO POLDO______
UNIVERSITY OF EASTERN PHILIPPINES
University Town, Northern Samar
COLLEGE of NURSING and ALLIED HEALTH SCIENCES
NURSING CARE PLAN
3
Address:___________PALAPAG_____________________ Ward: 2
NURSING SCIENTIFIC OBJECTIVES/ NURSING SCIENTIFIC RATIONALE EVALUATION
DIAGNOS RATIONALE PLANNING INTERVENTIONS
IS
ineffective Inability to  Maintain airway patency. Monitor respirations and indicative of respiratory distress • Client’s response to
AIRWAY clear • Expectorate/clear secretions readily. breath sounds, noting rate and/or accumulation of secretions. interventions, teaching,
CLEARAN secretions or • Demonstrate absence/reduction of and sounds (e.g., tachypnea,
obstructions
and actions performed
CE related congestion with breath sounding clear, stridor, crackles, or to determine ability to protectown
from the noiseless respirations, and improved
to wheezes) airway.
respiratory oxygen exchange (e.g., absence of • Use of respiratory
Excessive tract to  Evaluate client’s cough/gag
cyanosis and arterial blood gas devices/airway adjuncts
mucus, maintain a [ABG]/pulse oximetry results within refl ex, amount and type of
retained clear airway. secretions, and swallowing to open or maintain open airway
client norms).
secretions in an at-rest or compromised • Response to
 Verbalize understanding of cause(s) ability
and therapeutic management  Position head appropriately individual. medications
regimen. for age and condition to clear airway when excessive or administered
• Demonstrate behaviors to improve or viscous secretions are blocking
maintain clear airway. airway or client is unable to • Attainment or progress
 Suction nose, mouth, and
• Identify potential complications and
trachea prn using correct- swallow or cough effectively. toward desired
how to initiate appropriate preventive
M. or corrective actions. size catheter and suction  to maintain anatomical position outcome(s)
Doenges, timing for child or adult of tongue and natural airway,
Nurses especially when tongue/laryngeal • Modifi cations to plan
pocket  Insert oral airway (using edema or thick secretions may of care
guide, 15th correct size for adult or block airway.
edition child) when needed
CLINICAL INSTRUCTOR: ___JEANETTE ROJO______