Bulacan State University

COLLEGE OF NURSING
City of Malolos, Bulacan

NURSING CARE PLAN

Patient’s Initial: Age: 56 years old Gender: Female Date Handled: November 9, 2021

Medical Diagnosis: Hypertensive Crisis’ Chief Complaint: Body weakness, dizziness, and vomiting Clinical Area: Medical Ward

Assessment Nursing Diagnosis Planning Intervention Rationale Evaluation

Subjective: Deficient knowledge Short Term Goal: Independent: Independent: Short Term Evaluation:
“Ano ibig sabihin nung related to insufficient After 3o minutes of ● Provided an ● To facilitate After 30 minutes of
low fat diet at ano information as nursing intervention, environment that was learning. nursing intervention,
dapat kong kainin?” as evidenced by the client will: conducive for ● To facilitate the client’s goal were:
verbalized by the insufficient knowledge ● Participate in learning. learning.
patient. regarding the low fat the learning ● Used short, simple ● To facilitate √_ met
diet process. sentences, and learning.
___ partially met
● Assume concepts. ● Reducing the
responsibility ● Used gestures and amount of ___ unmet
Objective: for their own facial expressions that information
T- 37.4 Celsius learning by help convey meaning helps to keep As evidenced by:
P- 80 bpm beginning to of information. the client ● Participate in
R- 20 rpm look for ● Provided information focused and the learning
information relevant only to the prevents the process.
- Total and ask situation. client from ● Assume
cholesterol: questions. ● Provided written feeling responsibility
206.11 mg/dl information of overwhelmed. for their own
- Diet ordered by Long Term Goal: guidelines, and self- ● To reinforce the learning by
the doctor. After 1 hour of nursing learning modules for learning beginning to
- Insufficient intervention, the the client to refer as process and look for
knowledge patient will: necessary. allow the client information
regarding the ● Verbalize their ● Included the to proceed at and ask
low fat diet. own significant others in her own pace. questions.
understanding the health teaching. ● To facilitate
regarding the ● Provided an active learning.
diet, and role for the client in ● This promotes a Long Term Evaluation:
provide the learning process. sense of control After 1 hour of nursing
examples of ● Provided positive over the intervention, the
foods that the reinforcement. situation and is client’s goal were:
client may eat. a means for
● Participate in Dependent: determining √_ met
 the treatment ● Informed the client of that the client is
regimen. her diet, as ordered. assimilating ___ partially met
and using new
___ unmet
information.
● To encourage
As evidenced by:
Interdependent/ continuation of
● Verbalize their
Collaborative: efforts.
own
● Informed dietician of ●
understanding
client’s diet. Dependent:
regarding the
● To improve the
diet, and
client’s
provide
cholesterol
examples of
levels.
foods that the
Interdependent/Collab
client may eat.
oration:
● Participate in
● Dieticians plan
the treatment
the meals of the
regimen.
client based on
doctor’s orders.

Student’s Name: Miss Vasity M. Suriwong Year & Sec/Group No. BSN 4D Group 4 Clinical Instructor: Mrs. Luzviminda Reyes