DON MARIANO MARCOS MEMORIAL STATE UNIVERSITY

South La Union Campus

College of Community Health and Allied Medical Sciences
Agoo, La Union
Tel. 072.682.06.63/cchams@dmmmsu.edu.ph
NURSING DEPARTMENT

NURSING CARE PLAN

ASSESSMENT EXPLANATION OF OBJECTIVE INTERVENTIONS RATIONALE EVALUATION
THE PROBLEM
Subjective: Anemia occurs when there After 7 days of nursing Document the patient’s Weight loss can be  Demonstrate
“nahihilo ako ma’am, tapos aren’t enough healthy red intervention the patient will progressive weight
weight. Weight the measured accurately
nang hihina po ako” blood cells to carry oxygen be able to: gain toward goal
to your body’s organs. As a Increase body weight 20% patient daily in the with a patient’s actual  Demonstrate
Objective: result, it’s common to feel or more under ideal. mornings. weight rather than by behavior, lifestyle
 Weakness cold and symptoms of estimate. The patient’s changes to regain
 Chest pain tiredness or weakness. There and/or maintain
weight is also an ideal
 Cold hands and feet are many different types of appropriate weight
anemia, but the most tool in the assessment
 Dizziness
common type is iron- of a person’s nutritional
V/S taken as follows: deficiency anemia. You can requirements.
 BP: 180/120 begin to ease symptoms of
 TEMP: 36.7 this type of anemia by Assess what the patient Patients with dysphagia
adding iron to your diet. can safely eat and drink.
 O2: 97 may be able to tolerate
 PR: 97
thickened liquids and
 RR: 19
pureed food. Assessing
NURSING DIAGNOSIS: what the patient can
Imbalance nutrition less tolerate will help
than body requirements support nutrition and
arrange food choices to
Weigh the patient become available.
 DON MARIANO MARCOS MEMORIAL STATE UNIVERSITY
South La Union Campus
College of Community Health and Allied Medical Sciences
Agoo, La Union
Tel. 072.682.06.63/cchams@dmmmsu.edu.ph
NURSING DEPARTMENT

regularly and document The patient’s weight will

readings. help in the evaluation of
the patient’s progress.

NURSING CARE PLAN

ASSESSMENT EXPLANATION OF THE OBJECTIVE INTERVENTIONS RATIONALE EVALUATION
PROBLEM
 DON MARIANO MARCOS MEMORIAL STATE UNIVERSITY
South La Union Campus
College of Community Health and Allied Medical Sciences
Agoo, La Union
Tel. 072.682.06.63/cchams@dmmmsu.edu.ph
NURSING DEPARTMENT

SUBJECTIVE: Obstructive uropathy is a
Namamanas ako at hindrance to normal urinary
nanghihina katawan ko” flow that can be caused by a
variety of structural and
OBJECTIVE: functional etiologies. This is
a common and potentially
 Generalize edema serious condition that affects
 Patient reports of people across all ages and
fatigue, weakness, walks of life. To avoid the
and malaise morbidity and mortality
 V/S taken as follows associated with this
 BP: 130/90 condition, it must be
 TEMP: 36.7 promptly diagnosed and
 O2: 99% treated. This activity reviews
 PR: 107
 RR: 22
the evaluation and
management of patients with
NURSING DIAGNOSIS: obstructive uropathy. It
FLUID VOLUME EXCESS represents a common
R/T COMPROMISED presentation affecting
REGULATORY multiple medical specialties
MECHANISM (RENAL and highlights the role of the
FAILURE) interprofessional team in
early identification and
improved care for patients
with this condition.
After 8 hours of nursing
intervention the patient will
display appropriate urinary
output with specific
gravity/laboratory studies
near normal; v/s within
patient’s normal range; and
absence of edema
 Record accurate Goal met patient has
intake and output  Accurate I&O is displayed appropriate
 Weight daily at same necessary for urinary output with specific
time of the day, on determining renal gravity/laboratory studies
same scale, with function and fluid near normal; stable weight;
same equipment and replacement needs V/S within the patient’s
clothing and reducing risk of normal range; absence of
 Assess skin dace, fluid overload edema
dependent areas for  Daily body weight is
edema best monitor of fluid
 Plan oral fluid status
replacement within  Edema occurs
multiple restrictions primarily in
dependent tissues of
the body
 Helps avoid periods
without fluid
minimizes boredom
of limited choices