Republic of the Philippines

CATANDUANES STATE UNIVERSITY

Virac, Catanduanes

COLLEGE OF HEALTH SCIENCES

JOHN L. TACORDA JR
BSN1B
COLLEGE OF HEALTH SCIENCES
NURSING DEPARTMENT

CASE ANALYSIS (NURSING CARE PLAN)

NCM 103 FUNDAMENTALS OF NURSING

1. You are an Out-Patient Department (OPD) Nurse working at a nearby healthcare

facility. Mrs. Rosales, 54 years old, arrived at your healthcare facility with complaint of
dizziness and nape pain for 3 days prior to her consultation. Upon checking her vital
signs, you noted that her blood pressure showed 140/100 mmHg. Past health history
revealed- noncompliant client for 2 years, maintenance medication of Losartan 50 mg
tablet OD, with family history of cardiovascular disease and diabetes. She further added
that she only takes her maintenance medications when she experiences severe
dizziness. As a student nurse, you are aware of the different nursing responsibilities to
this client. Please formulate relevant nursing care plan to this client.
Republic of the Philippines
CATANDUANES STATE UNIVERSITY
Virac, Catanduanes

NURSING CARE PLAN

Assessment Nursing Diagnosis Planning Nursing Intervention Rationale Evaluation

Chief complaint:  Ineffective self-health Short-term goal:  Assess patient's  Assessment helps identify Goal: Mrs. Rosales will be
Dizziness and nape management related to knowledge and knowledge gaps and compliant with her medication
pain for the past 3 noncompliance with  Within the next 24 understanding of misconceptions that can be regimen to manage hypertension
days. medication regimen as hours, the patient will be hypertension and addressed through patient and prevent further complications.
manifested by the patient able to verbalize medication regimen. education. (Ackley, B. J., &
Subjective data: only taking Losartan understanding of the (Ackley, B. J., & Ladwig, Ladwig, G. B., 2018, p. 582) Outcome criteria:
during severe dizziness importance of taking G. B., 2018, p. 582)  Patient education is a
 Noncompliant with episodes and medication regularly as  Provide patient crucial intervention to  Mrs. Rosales takes her
medication for 2 noncompliance with prescribed. education on the improve patient medication as prescribed every
years medication for 2 years. importance of understanding and day.
 Family history of Long-term goal: medication adherence adherence to medication  Mrs. Rosales reports
cardiovascular and potential regimen. (Ackley, B. J., & experiencing fewer episodes of
disease and  Within the next 2 weeks, consequences of Ladwig, G. B., 2018, p. 582) dizziness and nape pain.
diabetes the patient will be able noncompliance.  Identifying potential barriers  Mrs. Rosales' blood pressure is
 Only takes to demonstrate (Ackley, B. J., & Ladwig, and providing strategies consistently below 140/90
maintenance compliance with her G. B., 2018, p. 582) can help the patient mmHg.
medication of medication regimen, as  Identify potential overcome challenges to  Expectations for goals being
Losartan 50mg evidenced by taking her barriers to medication medication adherence. met:
when she Losartan 50mg tablet adherence and provide (Ackley, B. J., & Ladwig, G.  If Mrs. Rosales takes her
experiences daily as prescribed. strategies to overcome B., 2018, p. 582) medication as prescribed every
severe dizziness. these barriers. (Ackley, day, reports fewer episodes of
B. J., & Ladwig, G. B., dizziness and nape pain, and
Objective data: 2018, p. 582) her blood pressure is
 Acute pain related to Short-term goal:  Assess patient's pain  Assessment of pain consistently below 140/90
 Blood pressure: nape pain as manifested intensity and intensity and characteristics mmHg, the goal will be met.
140/100 mmHg by the patient's complaint  Within the next 8 hours, characteristics. (Ackley, helps identify the most
 Age: 54 years old of discomfort in the nape the patient will report a B. J., & Ladwig, G. B., appropriate pain  If Mrs. Rosales takes her
area. decrease in pain 2018, p. 708) management strategies. medication irregularly,
intensity from 8/10 to  Administer pain (Ackley, B. J., & Ladwig, G. continues to report frequent
4/10 on a pain scale. medications as B., 2018, p. 708) episodes of dizziness and nape
prescribed. (Ackley, B.  Pain medications can help pain, and her blood pressure
Long-term goal: J., & Ladwig, G. B., alleviate pain and remains at or above 140/90
2018, p. 711) discomfort. (Ackley, B. J., & mmHg, the goal will be partially
 Within the next 2 days,  Provide non- Ladwig, G. B., 2018, p. 711) met or unmet.
the patient will report no pharmacological pain  Non-pharmacological pain
Republic of the Philippines
CATANDUANES STATE UNIVERSITY
Virac, Catanduanes
 Risk for cardiovascular
disease related to family
history of the disease.  Within the next 24
 Within the next 6
 Risk for stroke related to
uncontrolled hypertension
as manifested by a blood  Within the next 24
pressure reading of
140/100 mmHg.
pain or discomfort in the relief measures such as
nape area. cold or heat therapy.
(Ackley, B. J., & Ladwig,
G. B., 2018, p. 712)
Short-term goal:  Assess patient's
understanding of
cardiovascular disease
hours, the patient will be and its risk factors.
able to verbalize (Ackley, B. J., & Ladwig,
understanding of the G. B., 2018, p. 63)
importance of lifestyle  Provide patient
modifications and education on modifiable
regular follow-up visits risk factors such as
to prevent the smoking, sedentary
development of lifestyle, and unhealthy
cardiovascular disease. diet. (Ackley, B. J., &
Ladwig, G. B., 2018, p.
Long-term goal: 63)
 Encourage patient to
engage in regular
months, the patient will exercise and maintain a
demonstrate a decrease healthy diet. (Ackley, B.
in modifiable risk factors J., & Ladwig, G. B.,
such as smoking, 2018, p. 63)
sedentary lifestyle, and
unhealthy diet.
Short-term goal:  Monitor blood pressure
regularly: Assess blood
pressure at least once
hours, the patient's every shift, or as
blood pressure will be ordered by the
reduced to less than physician. (Doenges et
130/80 mmHg through al., 2021, p. 503)
medication management  Administer
and lifestyle antihypertensive
modifications. medications as
prescribed:
Long-term goal:
relief measures can also
help manage pain and
improve patient comfort.
(Ackley, B. J., & Ladwig, G.
B., 2018, p. 712)
 Assessment helps identify
knowledge gaps and
misconceptions that can be
addressed through patient
education. (Ackley, B. J., &
Ladwig, G. B., 2018, p. 63)
 Patient education is a
crucial intervention to help
the patient identify and
modify modifiable risk
 Early identification of
changes in blood pressure
can aid in prompt
intervention to prevent a
stroke. (Doenges et al.,
2021, p. 503)
 Medications such as
angiotensin-converting
enzyme inhibitors, calcium
channel blockers, and beta-
blockers can lower blood
pressure and reduce the
Plan for continuation or
revision:
If the goal is met, the plan of care
will be continued as prescribed,
with regular monitoring of blood
pressure and medication
compliance. A follow-up
appointment will be scheduled in
one month to assess progress and
adjust the plan of care if
necessary.
If the goal is partially met or
unmet, the plan of care will be
revised to address the barriers to
medication compliance and blood
pressure control. The patient and
family will be re-educated on the
importance of medication
adherence and lifestyle
modifications to manage
hypertension. A referral to a
hypertension specialist may be
considered. A follow-up
appointment will be scheduled in
two weeks to reassess progress
and adjust the plan of care as
needed.
Rationale for revisions:
According to the American Heart
Association (AHA), noncompliance
with medication regimens is a
common cause of uncontrolled
hypertension and subsequent
complications. Lack of
understanding about the
importance of medication
adherence and lifestyle
Republic of the Philippines
CATANDUANES STATE UNIVERSITY
Virac, Catanduanes

risk of stroke. (Doenges et modifications can contribute to

 Within the next 6 al., 2021, p. 502) noncompliance. Therefore, re-
months, the patient will education and referral to
have well-controlled specialists may be necessary to
blood pressure with a address these barriers and
reading consistently promote adherence to medication
below 130/80 mmHg. regimens.
 Risk for noncompliance Short-term goal:  Develop a medication  Work with the patient to
with medication regimen schedule with the develop a medication New evaluation date/time:
related to lack of  Within the next 24 patient schedule that is easy to If the goal is met, a follow-up
knowledge about hours, the patient will be  Reinforce the follow and fits into their appointment will be scheduled in
hypertension able to verbalize importance of daily routine. (Doenges et one month. If the goal is partially
management. understanding of the medication adherence al., 2021, p. 504) met or unmet, a follow-up
importance of  Remind the patient about appointment will be scheduled in
adherence to medication the potential consequences two weeks
regimen. of noncompliance and
encourage them to ask
Long-term goal: questions if they have
concerns about their
 Within the next 2 weeks, medications. (Doenges et
the patient will al., 2021, p. 504)
demonstrate compliance
with her medication
regimen, as evidenced
by taking her Losartan
50mg tablet daily as
prescribed.
 Risk for falls related to Short-term goal:  Implement fall  Implement interventions to
dizziness as manifested prevention measures reduce the patient's risk for
by the patient's complaint  Within the next 12  Encourage the use of falls, such as using a bed
of dizziness. hours, the patient will be assistive devices alarm or chair alarm,
able to identify factors providing nonskid footwear,
that trigger dizziness and ensuring that the
episodes. patient's environment is free
of tripping hazards.
Long-term goal: (Doenges et al., 2021, p.
557)
 Within the next 2 weeks,  Encourage the patient to
the patient will be able use assistive devices, such
 Republic of the Philippines
CATANDUANES STATE UNIVERSITY
Virac, Catanduanes

to demonstrate as a walker or cane, to

improved balance and
coordination, as
evidenced by no further
reports of falls or near-
falls.
 Readiness for enhanced Short-term goal:  Provide education about
knowledge related to
hypertension  Within the next 24
management. hours, the patient will be  Use visual aids
able to verbalize
understanding of
hypertension, its
causes, and its
management.
Long-term goal:
 Within the next 2 weeks,
the patient will be able
to demonstrate
knowledge of the
benefits of lifestyle
modifications and
medication adherence to
effectively manage
hypertension.
improve their balance and
reduce the risk of falls.
(Doenges et al., 2021, p.
557)
 Use simple language to
hypertension explain the causes, risk
management: factors, and potential
consequences of
hypertension. (Doenges et
al., 2021, p. 504)
 Use visual aids, such as
pictures, diagrams, or
videos, to enhance the
patient's understanding of
hypertension management.
(Doenges et al., 2021, p.
505)

Bibliography:
Republic of the Philippines
CATANDUANES STATE UNIVERSITY
Virac, Catanduanes

 Ackley, B. J., & Ladwig, G. B. (2020). Nursing diagnosis handbook: An evidence-based guide to planning care. Elsevier Health Sciences.

 American Nurses Association. (2015). Nursing scope and standards of practice. American Nurses Association.

 Doenges, M. E., Moorhouse, M. F., & Murr, A. C. (2016). Nursing care plans: Guidelines for individualizing client care across the life span. FA Davis.

 Gulanick, M., & Myers, J. L. (2020). Nursing care plans: Diagnoses, interventions, and outcomes. Elsevier Health Sciences.

 National Institute of Diabetes and Digestive and Kidney Diseases. (2018). Managing diabetes. Retrieved from https://www.niddk.nih.gov/health-information/diabetes/overview/managing-
diabetes

 World Health Organization. (2022). Cardiovascular diseases (CVDs). Retrieved from https://www.who.int/news-room/fact-sheets/detail/cardiovascular-diseases-(cvds)