Republic of the Philippines

Western Mindanao State University

College of Nursing
SY: 2ND SEM 2020-2021

NCM 103 A -Fundamentals in Nursing Practice

1. Nursing Care Plan

PLANNING
NURSING
ASSESSMENT OBJECTIVE OF IMPLEMENTATION EVALUATION
DIAGNOSIS INTERVENTION RATIONALE
CARE
At the end of 48 hours after
ubjective Cues: Hyperthermia related nursing intervention the Submit client’s stool for A culture is a test that Encourage to take warm Patient has norma
According to the mother to cough as evidence client will: culture identifies that are the fluids to soothe the cough temperature: 36.3 ℃
nagka fever siya tapos by high temperature. causative agents and if
ung ubo at colds niya 3 - The patient’s temperature there is any infection
ays na” will be normal
Objective Cues: Patient doesn’t have
- The cough and colds will Encourage warm water cough and colds
TEMPERATURE: 38.2 ℃ subdue Ask the client on intolerance Diarrhea is an vapor to breath in to loosen anymore
ULSE RATE: 109 bpm on food and dairy. indication of lactose mucus
RESPIRATORY RATE: intolerance.
4 b/m
BLOOD PRESSURE:
00/80 mmhg Administer Paracetamol 5ml
Assess perineal area Perineal area may be P.O. in syrup form
irritated due to
diarrhea stool being
corrosive

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 Reference/s:
U.S. National Library of Medicine. (2021, May 12). Diarrhea. MedlinePlus.
https://medlineplus.gov/diarrhea.html#:~:text=Diarrhea%20is%20loose%2C%20watery%20stools,but%20it
%20may%20last%20longer.
Jay W. Marks, M. D. (2016, September 12). How to Test for Lactose Intolerance: Stool Acidity Test. MedicineNet.
https://www.medicinenet.com/stool_acidity_test/article.htm#what_is_lactose_intolerance.

B. Rubric for ALS

4 3 2 1
Follows and
Exceeds Follows some Demonstrates
CATEGORY Follows
expectations but not all little
instructions
noted in instructions comprehension
instructions
III. NURSING CARE PLAN (total score = 36 points)
6. Nursing Care Plan (2)
 Utilizes the Nursing Process
 Assessment
 Diagnosis
 Planning
 Objective of Care
 Interventions
 Rationale
 Implementation
 Evaluation
 Cites reference/s

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 TOTAL POINTS

35 – 36 = 1.0
33 – 34 = 1.25
31 – 32 = 1.5
29 – 30 = 1.75
28 = 2.0
26 – 27 = 2.25
24 – 25 = 2.5
23 = 2.75
22 = 3.0

Prepared by:

LEVEL II FACULTY

Noted:

DR. MARIA SOCORRO C. DOMINGO FREDIE M. OMAR, MAN, RN

Clinical Coordinator Curriculum Chair

Approved:

DR. MARY JOSELYN C. BIONG

Dean

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