DMC COLLEGE FOUNDATION, INC.

Sta. Filomena, Dipolog City

Second Semester 2023-2024
Name: Alice S. Jammang Subject: NCM 102-lec
Course: BSN -1 weekend program Date: 03/18/2023

Nursing Care PlanPatient Initials:

Case scenario
1. A 23-year-old male is admitted to your unit for. The patient is pleasant. He has a history of Diabetes Type 2, hypertension, and high cholesterol. The patient had
a cholecystectomy last year and appendectomy at the age of 11. The patient is 5"8, weighs 295 lb., and has a BMI of 44.8. He has trouble walking and requires a
wheelchair to get around. During the history-taking, you have the patient list down what a typical daily meal is for him, and according to what the patient eats daily
his caloric intake exceeds over 6,000 calories.

ASSESSMENT NURSING DX/: PLANNING INTERVENTION RATIONALE EVALUATION

Subjective data:
The patient verbalizes:
"nahihirapan akong gumalaw
lalong lalo na kapag maglakad
dahil sa aking condition at
madali akong mapagod" as
[verbalized by the patient
Objective data:
> Limited range of motion
> Slowed movement
> Reluctance to attempt
movement
> Trouble walking and
requires wheelchair to get
around
Impaired physical mobility After 8 hours of rendering INDEPENDENT: After 8° of renderend
related to musculo- nursing intervention, the 1.. Assist with activity/progressive 1• Until healing occurs, activity is nursing care, the goals
skeletal impairment as patient will be able to: ambulation. limited and advanced slowly was met as evidenced by:
according to individual tolerance.
evidence by limited range
> Increase strength to
of motion, slowed individual tolerance. and 2. Encourage and facilitate early 2. The longer the patient
> Move within range of
movements and reluctance function of affected body ambulation and other ADLs when remains immobile the greater motion
to attempt movement part possible. Assist with each initial the level of debilitation that will
change: dangling, sitting chair, Occur
• Move within range of ambulation.
motion
3. Provide patient with ample time to 3. To promote optimal level of
perform mobility related task. function.
DEPENDENT: DEPENDENT1.To relieve mild or
1. Administer analgesic medication: moderate pain.
Ketorolac
IVTT × 4 doses g 8 hours as
prescribed by the physician
 DMC COLLEGE FOUNDATION, INC.
Sta. Filomena, Dipolog City
Second Semester 2023-2024

Name: Alice S. Jammang Subject: NCM 102-lec

Course: BSN -1 weekend program Date: 03/18/2023
Nursing Care Plan

2. A 70-year-old man was taken to the hospital by his daughter who stated that his father was weak, vomited four times, and has pain in his belly. She also said that
his appetite is poor and he is very anxious. On assessment of the client, he is lethargic, states his pain is a 9 on a scale of 1-10. He vomited three times with 100 ml
of greenish fluid, and passed approximately 150 ml of urine in the urinal. His Temperature is 102°C, pulse 80, respiration 22, and blood pressure 140/80.

ASSESSMENT NURSING DX: PLANNING INTERVENTION RATIONALE Evaluation

Subjective: anxiety related to After 2-4 hrs of nursing 1.determine precipitants of 1.Obtaining insight allows the After 2-4 hrs of nursing
The daughter stated changes/threats of intervention the patient anxiety that may indicate patient to reevaluate the intervention the goal
that his father was health status as will: interventions. threat or identify new ways to was met by:
deal with it.
weak, vomited four evidenced by fever,
The patient identified
times and had pain in tachypnea and >Identify and verbalize
2.Allow patients to talk about 2.Talking about anxiety and verbalized anxiety
his belly. She also abdominal pain. anxiety precipitants, anxious feelings and examine producing situations and anxious precipitants, conflicts,
stated that his appetite conflicts, and threats. anxiety-provoking situations feelings can help the patient and threats.
is poor and he is very if they are identifiable. perceive the situation
anxious. his pain is a 9 >demonstrates improve realistically and recognize The patient was able to
on a scale of 1-10. concentration and factors leading to the anxious demonstrate improved
accuracy of thoughts.. feelings. concentration and
Objectives: accuracy of thoughts.
3.Teach the patient and the 3.The patient and the family
Vital signs:
family about the health needs to understand what to
Temp: 38.2C
problems, therapeutic expect from the disease or
HR: 80 bpm interventions, prevention of problem to allow them to better
RR: 22 cpm complications, and adaptation understand the rationale for
BP: 140/80 in lifestyle that are required. needed therapeutic
interventions.