Group Members: Miles Alogon, Chavie Rose Andrade, Ralph Baes, Raina Delicana, Via Dequinto Section and

Section and Group: BSN2-D/Group 1

NURSING CARE PLAN

Nutrition Assessment Nutrition Rationale/Pathophysiologi Desired Goals Nutrition Rationale Nutrition Monitoring
Diagnosis c basis /Outcomes Intervention and Evaluation

PES

Subjective Data: Definition: After eight (8) hours

Mrs. Anika verbalises Activity Intolerance:
Predisposi Precipitati
After eight (8) of proper nursing
that .“ My husband Insufficient hours of proper interventions, the
ng ng
cholesterol is high and physiological or nursing patient will be able to:
factors: factors:
i'm worried because of psychological interventions, the
family history of the energy to endure or •Male •Busy work patient will be able Independent
heart illness. “ complete required •52 years schedule to:
or desired daily old •Family
Objective Data: activities. • Family health Short Term Goals:
● Total history of history of 1.Inform proper 1. Informing the 1. Verbalize the
1. Verbalize the
Cholesterol: Related to: disease heart health teaching to client on having a understanding
understandin
428mg/dL ● Physical •Elevated disease. have a good body good and healthy of proper diet
g of proper
● LDL: 263 deconditioni cholesterol scale body scale could as evidenced
diet.
mg/dL- ng levels help achieve the by the patient
(elevated) ● Sedentary healthy and saying that he
● HDL: 28 mg/dL- lifestyle nutritional body will follow a
(low level) ● Work related lifestyle. proper diet
stress and eat
nutritious
Strength: As evidenced by: food. GOAL
● The patient’s ● Eating of Work related stress MET
family is there unhealthy
to support him. foods 2. Observe the 2. The nurse can 2. Maintain food
2. Maintain
● No exercise client on his proper update the intake as
food intake
● The client ● Sedentary food intake and access of food evidenced by
at a
landed a high Lifestyle document it. intake and also controlled
 paying job. functional the amount of food intake of
Eating foods high in fats
level. food the client.
Weakness: consumption. GOAL MET
● Unhealthy Source:
lifestyle due to Doenges, M.,
work schedule Moorhouse, M. F., Rarely taking time to eat 3. Ascertain 3. Make a precise 3. Patient who 3. Know the
● Unhealthy food Murr, A., Nurse’s healthy healthy body menu for patient to has the stand on importance of
intake due to Pocket Guide (15th weight for choose as possible what to choose an eating
busy work Edition ) age and as it can has a better schedule that
schedule height. Refer chance to choose can help in a
● Resumed his to a dietitian the preferred proper
old habit of Resumed old habit of for complete menu. balanced diet.
smoking smoking, no time for nutrition GOAL MET
exercise assessment
and methods
for nutritional
support.

Elevated Cholesterol After five (3) days of After five (3) days of
level: proper nursing proper nursing
LDL: 263 mg/dL interventions, the interventions, the
HDL: 28 mg/dL patient will be able patient will be able to
to:

Long Term Goals:

1. Maintain 1.Provide client 1. Low 1. Maintain

normal with low cholesterol cholesterol normal
Activity Intolerance: levels of diet medication can cholesterol as
Insufficient physiological cholesterol help reduce risk evidenced by
or psychological energy to of heart attack normal levels
endure or complete and stroke. of LDL and
required or desired daily HDL in the
activities related to laboratory
 result. GOAL
Physical deconditioning,
MET
Sedentary lifestyle, Work
related stress
2. Maintain a 2. Maintain a 2. To know the 2. Know the
healthy regular eating importance of an importance of
lifestyle. schedule. eating schedule an eating
can help in a schedule that
‘ proper balanced can help in a
diet. proper
balanced diet.
GOAL MET

3. Maintain a 3. Give wellbeing, 3 To provide 3. Maintain a

better education and in awareness of the healthy
awareness regards to current current condition lifestyle as
of proper conditions. of the patient. evidenced by
nutrition the patient
References: Doenges, M., requirement verbalizing
Moorhouse, M. F., Murr, A., s and that he will
Nurse’s Pocket Guide (15th benefits. eat. GOAL
Edition ) MET

4. Eliminate 4. Perform a health 4. To provide 4. Eliminate

constant teaching to the awareness to the constant
smoking client regarding the client on the long smoking
patterns. long term and short term and short patterns as
term effects of term effects of evidenced by
smoking. smoking. the client
verbalizing
. that he will
Dependent: reduce the
number of
1. Administer 1. To cigarettes.
the achieve GOAL
 prescribed the PARTIALLY
medicine normal MET
that was level of
prescribed cholester
by the ol with the
doctor. help of
medicatio
n.

2. Monitor 2. To
medication achieve
and food the proper
intake implemen
tation of
the
medicatio
n.
3. Monitor the 3. To know
weight the
weekly improvem
ent
regarding
the
client’s
weight
4. Rearrange 4. To have a
schedule to planned
avoid diet for
inappropriat the
e eating patient.

Collaborative:

1. Run 1. To identify
 Laboratory the
Tests to improvem
detect the ent of
level of cholester
Cholesterol. ol level
2. Ask for 2. To
dietitian’s properly
advice give the
appropriat
e diet

CASE#1. Elevated Cholesterol

Johnny from the Philippines moved to the United States when he was 19 yrs Old. His family has a history of heart disease and high cholesterol.
Johnny’s father and brother both died of heart attacks in their 40s. Johnny is now 52 years old, His wife Annika is worried about his health and
verbalizes “ My husband cholesterol is high and I'm worried because of the family history of the heart illness. “Annika has tried to be careful in
preparing meals. For many years, Johnny Cholesterol has been in the high normal range and he has needed medication. He recently landed a
new contract with a Fortune 500 company at work. He has been very busy with luncheons and dinner meetings eating foods high in fats like
bacon sandwiches with lot of cheese and mayo 2times a week, hamburgers 3 times a week almost every for fast meals due to busy days . He
has been taking clients to many of the classy restaurants in town for four-course meals that always include dessert like cakes and icecream. He
has been working on this contract for several months. Due to the added stress of this new lifestyle, he is rarely taking time to eat healthy. He
also has resumed his old habit of smoking. He is so busy that rarely has time for any exercise. Annika is worried and convinces Johnny to see
Physician. He was ordered for blood works and reveals a total cholesterol of 428mg/dL, an LDL of 263mg/dl and HDL of 28mg/dL which are
above normal. . Due to his family his physician orders a cholesterol-lowering medication. However, he stresses to Johnny that this is no
replacement for good nutrition and exercise.