Mark Zedrix A.

Mediario
Group 11

CASE SCENARIO #1
Mr. Tee is an employee of Coca-cola bottle Company. He is assigned
in the production area where majority of the workers are there. He is
the breadwinner and her wife stayed at home to take care of their
children. He is a workaholic guy and wants to finish the assigned task
on time. He is a smoker and prefer to smoke rather to eat during
breaktime. Recently, he’d been experiencing loss of appetite, cough
and body malaise. The assessment of the nurse is that, Mr. Tee has
more than a month of on and off fever at night that’s why he went to
the clinic for consultation. Based from the lab result he is positive of
TB.

Health Care Deficit: Diagnosed illness (tuberculosis)

Health Threat: Inadequate food intake and cigarette/tobacco smoking
Foreseeable Crisis: Being the breadwinner of his family
 NURSING CARE PLAN
Cues Nursing Background Goals Nursing Intervention Rationale Evaluation
Diagnosis Knowledge

Long Short Term Ideal Actual

Term
Subjective data: Imbalanced Imbalanced After 24 hours of  Document  The client’s After 24 hours of
nutrition: less nutrition: less than nursing weight. weight is a tool nursing interventions,
 Reports body than body body requirements interventions, the Weigh daily. used to assess the goals were met as
malaise and loss requirements is the insufficient client will: nutritional evidenced by:
of appetite related to nutrient intake to requirements.
 regain  verbalization of
body malaise meet metabolic  It provides
interest in regained
Objective data: and loss of needs. In a person knowledge to
food, interest in food,
appetite as with tuberculosis, client about his
 Positive for evidenced by body malaise and  demonstrate  Explain  increase in
condition and
tuberculosis reported lack loss of appetite are adequate nutritional nutritional
why procedures
of interest in two of the typical nutritional needs and intake, and
for nutritional
food symptoms, which intake, and how the  normal weight
support will be
may result in lack  be free of disease and laboratory
done.
of interest in food signs of process of studies.
 A record of
and inadequate malnutrition. tuberculosis
what the client
food intake. affects it.
eats can help
 Determine direct
usual dietary treatment.
pattern.
 This aids
client’s
insufficient
nutrient intake.
 Encourage
small,
frequent
meals with
foods high in
protein and  Monitor
carbohydrate intake and  This is useful
s. output. in assessing
client’s
nutritional
status and
measuring
effectiveness of
nutritional and
fluid support.
 This ensures
client’s
understanding
of the
prescribed
dietary pattern
 Discuss the and practices.
nutritional
recommendat
 Low values
ions to the
reflect
patient.
malnutrition
Encourage
and indicate
following the
need for
recommende
intervention
d type of diet
and change in
and thickness  Monitor therapeutic
 of fluid. laboratory regimen.
studies:  This provides a
BUN, serum more
protein, and specialized care
prealbumin, for the client in
albumin. terms of
nutrition and
diet plan.

 Refer to a
dietitian
and/or
nutritionist as
necessary.

CASE SCENARIO #2
Mr. Sy, 35 years old is an employee of JoBoss advertising Company.
He is 3rd in rank position in their department. Since he has a high
salary, possesses luxury car and no family yet, he is fond of going
night life to the bar after office hours and goes home past midnight
drunk and sober. He is a good-looking guy and very friendly that’s why
there are lots of women attracted to him that sometimes he has a one
night affair to them.
 Health Care Deficit: No presence of health deficits
Health Threat: Alcohol drinking and sexual promiscuity
Foreseeable Crisis: No presence of foreseeable crisis situations

NURSING CARE PLAN

Cues Nursing Background Goals Nursing Intervention Rationale Evaluation
Diagnosis Knowledge

Long Short Term Ideal Actual

Term
Subjective data: Risk for A common means After 4 hours of  Provide open  Promotes sense of After 4 hours of
infection for infectious nursing environment dignity and control nursing interventions,
 Reports related to diseases to spread interventions, the in which the goals were met as
engaging in having is by directly client will: patient feels evidenced by:
sexual activity multiple sex transferring safe to
with different  show  verbalization of
partners bacteria, viruses, or discuss
partners readiness for readiness for
other germs from feelings.
one person to STI testing  Assess STI testing and
another. One of the and history of  verbalization of
ways this can  demonstrate engagement willingness to
transpire is via willingness in sexual  To ascertain the apply STI
sexual contact. to apply STI activity. risk of client in preventive
Sexually preventive having a sexually measures.
transmitted measures. transmitted disease
infections (STIs)  Encourage
are spread in the getting tested
following ways: (1) for STI and  To obtain baseline
provide data
having unprotected  Monitor vital
information  To explain the
(without a condom) signs.
about STI importance of STI
vaginal, oral, or
screening. screening in
anal sex with
someone who has detecting early
an STI. (2) during infections, what
genital touching. It tests will be done,
is possible to get and how they will
some STIs, such as be done
syphilis and  To detect presence
herpes, without of infection and
having sex; and (3) identify the needed
treatment
through sexual  Encourage as  May improve
contact between much general feelings of
women who have physical well-being
sex only with other  Perform STI
activity as testing as
women. possible. ordered.
 Explain
preventive
 To increase
 measures for knowledge about
STI and practices that can
encourage prevent STI,
applying it. especially if the
patient is negative
in STI testing

CASE SCENARIO #3
Mrs. Uy is an employee of Chua Garments Factory. She is assigned in
the production area where majority of the workers are there. She is the
breadwinner in the family because her husband died early. She is an
industrious worker and sometimes she don’t rest during the break time
just to finish the task assigned to her. Nurse Dina observed during her
rounds that Mrs. Uy do not use her mask again. The nurse keeps on
Health Care Deficit: History of pneumonia and tuberculosis
Health Threat: Inadequate rest and noncompliance to a medical instruction
Foreseeable Crisis: Death of husband

NURSING CARE PLAN

Cues Nursing Background Goals Nursing Intervention Rationale Evaluation
 Diagnosis Knowledge

Long Short Term Ideal Actual

Term
Objective data: Noncomplianc A patient is After 4 hours of  Assess the  To know the After 4 hours of
e as evidenced considered non- nursing factors that etiology of nursing interventions,
 History of by failure to compliant when interventions, the the client noncompliance and the goals were met as
pneumonia and follow a they desire to client will: thinks allows for an evidenced by:
tuberculosis medical comply but cannot interfere with individualized plan
 Does not follow  form a  a verbal
instruction due to certain compliance.
repeatedly the verbal contract of the
repeatedly factors preventing  Assess  To determine the
instruction to contract with client with the
them to do so. In understandin extent of
use mask the nurse nurse that she
this case, the g about her knowledge of the
that she will will use the
etiology of condition. client about her
use the mask mask as
noncompliance is condition and
as instructed instructed and
unknown, given instructions
and  verbalization of
however, it is  To determine the
evidenced by the  verbalize the the benefits of
willingness of the
failure in following benefits of  Assess adhering to the
client in complying
repeatedly the adhering to viewpoint use of mask
with the medical
instruction to use the use of and interest instructions
mask, which is a mask in complying
significant with the
instruction for medical
 To promote
patients with instructions.
compliance in
pneumonia and/or medical
tuberculosis. instructions
  Create a
verbal
contract that
the client will  To encourage
use the mask compliance and
as needed know its
and follow significance to the
other medical health of the client,
 Educate the instructions. family, and other
client and people
family
members on
the benefits
of adhering
to the use of
mask