Adventist University of the Philippines

COLLEGE OF NURSING
Level III

NURSING CARE PLAN

STUDENT INFORMATION
Meibelle Dominique L. De Guzman Ellayza Rb D. Operaña
Student’s Name:___________________________________
Jhessica Meekhail Ventura TMC (The Medical City)
Affiliating Agency:_____________________________________

Clinical Instructor:__________________________________
Kristel Anne Rey Date of Actual Patient Care:_____________________________
March 14, 2023

GNU (General Nursing Unit)

Clinical Area/Blocking:_______________________________ Shift (Pls. tick mark): AM  PM ✓ NOC 

PATIENT INFORMATION

Name of Patient:___________________________________
Nestor A. Maranan Gender: ✓
Male  Female  Age________
28

Address:__________________________________________
PUROK 4 Timbao, Biñan Laguna ✓
Civil Status: Single  Married  Annulled 

_________________________________________________ Widowed  Divorced  Not Applicable 

Educational Attainment:_____________________________
College Graduate Date of Admission:___________________________________
March 9, 2023

Occupation:_______________________________________
Accountant Attending Physician:__________________________________
Dr. Samaniego, Dr. Dela Cruz & Dr. Lumanta

DOB (Difficulty of Breathing)

Chief Complaint:________________________________________________________________________________________
Acute Respiratory Failure 2nd to
Admitting Diagnosis/Impression:_______________________
Status Asthmaticus Acute Respiratory Failure 2nd to Status Asthmaticus
Final Diagnosis:______________________________________

HISTORY OF PRESENT ILLNESS

Mr. Maranan, Nestor a 28 year-old male, was admitted to the hospital on March 9, 2023 the patient
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presented to the emergency department with the chief complaint of DOB. He reported Difficulty of
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Breathing which He experience Chest tieghtness that cuases him to faint.Final Diagnosis with Acute
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Respiratory Failure 2nd to Status Asthmaticus.
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PAST MEDICAL HISTORY
Diagnosed with Asthma, Type 2 DM and Hypertension
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FAMILY MEDICAL HISTORY
Mr. Nestor Maranan have a history of Hypertension and Diabetic in their Family
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 PRINCIPLES/THEORIES OF GROWTH AND DEVELOPMENT
Task/Crisis According to Sigmund Freud (Psychosexual):
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The genital stage, which starts in puberty, is the last stage of Freud's psychosexual theory of personality development.
For Freud, the appropriate way for adults to express their sexual urges was by having heterosexual relations. Fixation
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and conflict may impede this, which could lead to the emergences of sexual perversions. For instance, fixation at the oral
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stage may result in a person gaining sexual pleasure primarily from kissing and oral sex, rather than sexual intercourse.
Discussion of Task/Crisis in Relation to the Patient’s Present Condition:
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In the Genital Stage the patient is capable of having a strong interest in the opposite sex. Patient is well balanced,
caring, and warm.
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Gans, S. and Cherry, K. (July 27 2023). Freud Development Theory

Book Reference:____________________________________________________________________________________________
https://www.simplypsychology.org/psychosexual.html
Task/Crisis According to Erik Erickson (Psychosocial):
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Intimacy versus isolation is the sixth stage which life centers on forming intimate, loving relationships with other people.
Erikson believed that it was vital to develop close, committed relationships with other people. Romantic and sexual
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relationships can be an important part of this stage of life, but intimacy is more about having close, loving relationships. It
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includes romantic partners, but it can also encompass close, enduring friendships with people outside of your family.
Discussion of Task/Crisis in Relation to the Patient’s Present Condition:
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During this period, the major conflict centers on forming intimate, loving relationships with other people. Success
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leads to strong relationships, while failure results in loneliness and isolation. Considering the patient’s condition, He
is in a strong bond with his family and friends which supports the claim that he is successful in this stage.
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Book Reference:____________________________________________________________________________________________
Morin A, and Cherry, K. (April 21, 2023). Erisksons Psychosocial Development Theory
https://www.simplypsychology.org/psychosexual.html

SIMPLE PATHOPHYSIOLOGY OF THE DISEASE PROCESS

Etiology:_______________________________ Predisposing Factor/s:____________________________________________

Trigger Factor

Airway Inflammation

Hypersecretion Airway Muscle Swelling Bronchial

of Mucus Contriction Membranes

Narrow Breathing Passages

Wheezing, Cough,
Shortness of Breath,
Tightness in Chest
 DIAGNOSTIC PROCEDURES
CHEST X-RAY
1. Procedure:_____________________________________________________________________________________________

NURSING RESPONSIBILITY with RATIONALE

BEFORE DURING AFTER

OBTAIN AN INFORMED CONSENT ASSESS THE PATIENT'S ABILITY

PROPERLY SIGNED
Rationale: Informed consent in used both to
inform patient about procedure and protect
physicians from litigation
PROVIDE COMFORT
TO HOLD BREATH
Rationale: Holding one’s breath after inhaling
Rationale: If the test is facilitated at the
enables the lungs and heart to be seen more
bedside, reposition the patient properly.
clearly in the x-ray.

REMOVE ALL METALLIC OBJECT PROVIDE APPROPRIATE CLOTHING

Rationale: Items such as jewelry, pins, buttons Rationale: Patients are instructed to remove
etc can hinder the visualization of the chest. clothing from the waist up and put on an X-ray
gown to wear during the procedure.
INSTRUCT PATIENT TO
COOPERATE DUIRNG PROCEDURE
Rationale: The patient is asked to remain still
because any movement will affect the clarity
of the image.

2. Procedure:______________________________________________________________________________________________

NURSING RESPONSIBILITY with RATIONALE

BEFORE DURING AFTER

3. Procedure:______________________________________________________________________________________________

NURSING RESPONSIBILITY with RATIONALE

BEFORE DURING AFTER

SPECIFIED/SPECIAL DIET (Indication, description, food specification): None

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75
Patient’s Actual Weight:_______ (kg) 63.3
Patient’s Age Appropriate Weight:_________ (kg)

Patient’s Actual Height:_______

5'6 (cm) Patient’s Age Appropriate Height:__________
5'6 (cm)

Patient’s BMI:________________
26.6 (kg/m2 ) Overweight
BMI Interpretation:_________________________
 HEALTH ASSESSMENT BASED ON GORDON’S
FUNCTIONAL HEALTH PATTERN
I. Health Maintenance-Perception Pattern
Before Hospitalization During Hospitalization
✓
Cigarette Smoking No  Yes  Cigarette Consumption : <pack/day  ✓
Cigarette Smoking No  Yes  Cigarette Consumption : <pack/day 

1-2 pack/day  >2 packs/day  1-2 pack/day  >2 packs/day 

QUIT :  Date/year QUIT:____________ QUIT :  Date/year QUIT:____________

Alcohol No  ✓ Yes  Type: Beer  Hard Liquor  Alcohol No ✓ Yes  Type: Beer  Hard Liquor 
Other  Specify:___________ Other  Specify:___________

Therapeutic Drugs No  ✓ Yes  Type of Drug:_______ Purpose:_______ Therapeutic Drugs No  ✓ Yes  Type of Drug:_______ Purpose:_______

Allergies Drugs  Food  Dyes  Others ✓ Specify:___________

Dust Allergies Drugs  Food  Dyes  Others ✓ Dust
Specify:___________

II. Nutritional- Metabolic Pattern

Before Hospitalization During Hospitalization
Regular DM Diet, Low
Special Diet No  ✓ Yes  Specify:___________________ Special Diet No  Yes ✓ Specify:___________________
Salt & Low Fat

Dietary Supplements/Vitamins No  ✓ Yes  Dietary Supplements/Vitamins No  Yes ✓

Appetite Normal  Increased 
✓ Decreased  Appetite Normal  Increased 
✓ Decreased 

Decreased taste sensation  Decreased taste sensation 

Nausea  Vomiting  Stomatitis  Weight loss/gain______lbs Nausea  Vomiting  Stomatitis  Weight loss/gain______lbs

Swallowing Normal  With Difficulty 

✓ With NGT  Swallowing Normal  With Difficulty 
✓ With NGT 
Dentures Upper(Partial:____ Full:___) Lower (Partial:____ Full:___) Dentures Upper(Partial:____ Full:___) Lower (Partial:____ Full:___)

III. Elimination Pattern

Before Hospitalization During Hospitalization

Bowel Habits Constipation  Diarrhea  Bowel Habits Constipation  Diarrhea 

No. of Bowel Movement ( BM)/day:_____ Date of last BM:_____________ No. of Bowel Movement ( BM)/day:_____ Date of last BM:_____________

With Ostomy  Appliance  Self Care  With Ostomy  Appliance  Self Care 

Frequency  Dysuria  Burning  Urgency  Frequency  Dysuria  Burning  Urgency 

Bladder Habits Hematuria  Dribbling  Nocturia  Bladder Habits Hematuria  Dribbling  Nocturia 

Incontinency yes  No  ✓ Daytime  Night time Occasional  Incontinency yes  No  ✓ Daytime  Night time Occasional 

Difficulty delaying voiding  Difficulty reaching toilet  Difficulty delaying voiding  Difficulty reaching toilet 

Catheterization Retention/Indwelling/Foley  Straight  Catheterization Retention/Indwelling/Foley  Straight 

Condom/weebag  Cystoclysis  Condom/weebag  Cystoclysis 

500 cc
Urine Output/Shift:_______cc/ml Light Yellow
Urine Color:____________ 500 cc
Urine Output/Shift:_______cc/ml Light Yellow
Urine Color:____________

IV. Activity and Exercises

Before Hospitalization
0 1 2 3 4
Self-Care Ability Assistance from Assistance from person Remarks
Independent Assistive Device others and equipment Dependent/Unable
Eating/Drinking
✓
Bathing
✓
Dressing/Grooming
✓
Toileting
✓
Bed Mobility
✓
Transferring
✓
Ambulating
✓
Stair Climbing
✓
Shopping
✓
Cooking
✓
Home Maintenance
✓
Assistive Devices: None ✓
 Crutches  Walker  Bedside Commode 

Cane  Splint/Brace  Wheelchair  Other  Specify:___________

During Hospitalization
0 1 2 3 4
Self-Care Ability Assistance from Assistance from person Remarks
Independent Assistive Device others and equipment Dependent/Unable
Eating/Drinking
✓
Bathing
✓
Dressing/Grooming
✓
Toileting
✓
Bed Mobility
✓
Transferring
✓
Ambulating
✓
Stair Climbing
✓
Shopping
✓
Cooking
✓
Home Maintenance
✓
Assistive Devices: ✓
None  Crutches  Walker  Bedside Commode 

Cane  Splint/Brace  Wheelchair  Other  Specify:___________

V. Sleep/Rest Pattern
Before Hospitalization During Hospitalization

Sleeping Habits: Regular  Irregular  With AM Nap  With PM Nap 

✓ Sleeping Habits: Regular  Irregular  With AM Nap  With PM Nap 
✓
Time of Sleep: _____Time
2 AM of Arising:6____Total
AM hours of sleep at night: _____
3 AM Time of Sleep: _____Time
2 AM of Arising: 6____Total
AM hours of sleep at night: _____
3 AM

Feeling rested after sleep  Feeling inadequately rested after sleep 

✓ Feeling rested after sleep  Feeling inadequately rested after sleep 
✓
Problems None  Early Walking  Insomia  Nightmares 
✓ Problems None  Early Walking  Insomia  Nightmares 
✓
VI. Cognitive—Perceptual Pattern
Before Hospitalization During Hospitalization
VI. Cognitive-Perceptual Pattern VI. Cognitive-Perceptual Pattern

Mental Alert 
✓ Oriented  Confused  Combative  Mental Alert  ✓ Oriented  Confused  Combative 
Unresponsive  Receptive Aphasia  Unresponsive  Receptive Aphasia 

Speech Normal  Slurred  Garbled

✓  Expressive Aphasia  Speech Normal  Slurred  Garbled
✓  Expressive Aphasia 
Tagalog
Spoken Language:_____________ Interpreter:________________ Tagalog
Spoken Language:_____________ Interpreter:________________

Level of Anxiety Mild  Moderate  Severe Panic  Level of Anxiety Mild  Moderate  Severe Panic 

Hearing Normal  ✓ Impaired  Right ( ) Left ( ) Hearing Normal  ✓ Impaired  Right ( ) Left ( )

Deaf  Right( ) Left ( ) Hearing Aid  Tinnitus  Deaf  Right( ) Left ( ) Hearing Aid  Tinnitus 

Vision Normal  Eye glasses  Contact Lenses  Vertigo 

✓ Vision Normal  Eye glasses  Contact Lenses  Vertigo 
✓
Impaired  Right( )Left( ) Blind  Right ( ) Left ( ) Impaired  Right( )Left( ) Blind  Right ( ) Left ( )

Discomfort/Pain None  ✓ Acute  Chronic  Description:_________ Discomfort/Pain None  ✓ Acute  Chronic  Description:_________

Pain Management: Pain Management:

________________________________________________________________ ________________________________________________________________

VII. Role - Relationship Pattern

Before Hospitalization During Hospitalization
VII. Role-Relationship Pattern VII. Role-Relationship Pattern

Marital Status Single  ✓ Married  Separated  Widow/Widower  Marital Status Single  ✓ Married  Separated  Widow/Widower 

Employment Employed  Unemployed

✓  Employment Employed  Unemployed
✓ 
Short-term/long-term disability  Accountant
Occupation:______________ Short-term/long-term disability  Occupation:______________
Accountant

Support System Spouse  Neighbors/Friends  None 

✓ Support System Spouse  Neighbors/Friends  None  ✓
Other  Specify:___________________ Other  Specify:____________________

Family concerns regarding hospitalization:____________________________ Family concerns regarding hospitalization:____________________________

VIII. Sexuality - Reproductive Pattern
Before Hospitalization During Hospitalization
VIII. Sexuality—Reproductive Pattern VIII. Sexuality—Reproductive Pattern
SUBJECTIVE (REPORTS) SUBJECTIVE (REPORTS)
NA
Sexually active:___________________ Use of condoms:____________ NA
Sexually active:___________________ Use of condoms:____________
Birth control method:____________________________________________ Birth control method:____________________________________________
Sexual concerns/difficulties:_______________________________________ Sexual concerns/difficulties:_______________________________________
Recent change in frequency/interest:________________________________ Recent change in frequency/interest:________________________________

Female: Subjective (Reports) Female: Subjective (Reports)

Age at menarche:_________________ Length of cycle:_____________ Age at menarche:_________________ Length of cycle:_____________
Duration:_____________ No. of pads used/day:_________________ Duration:_____________ No. of pads used/day:_________________
Last menstrual period:____________ Pregnant now:______________ Last menstrual period:____________ Pregnant now:______________
Bleeding between periods:________________________________________ Bleeding between periods:________________________________________
Menopause:____________________ Vaginal lubrication:__________ Menopause:____________________ Vaginal lubrication:__________
Surgeries:______________________________________________________ Surgeries:______________________________________________________
Hormonal therapy/calcium use:____________________________________ Hormonal therapy/calcium use:____________________________________
Practices breast self-examination:__________________________________ Practices breast self-examination:__________________________________
Last mammogram:__________________ Pap smear:_________________ Last mammogram:__________________ Pap smear:_________________

Objective (Exhibits) Objective (Exhibits)

Breast examination:_____________________________________________ Breast examination:_____________________________________________
Genital warts/lesions:_____________ Vaginal Discharge:_______________ Genital warts/lesions:_____________ Vaginal Discharge:_______________

Male: Subjective (Reports)-NA Male: Subjective (Reports) -NA

Penile discharge:_________________ Prostate disorder:___________ Penile discharge:_________________ Prostate disorder:___________
Circumcised:_____________________ Vasectomy:_________________ Circumcised:_____________________ Vasectomy:_________________
Practice self-examination: Breast:_________ Testicles:_________________ Practice self-examination: Breast:_________ Testicles:_________________

Objective (Exhibits)-NA Objective (Exhibits) -NA

Breast:___________ Penis:____________ Testicles:__________________ Breast:___________ Penis:____________ Testicles:__________________
Genital warts/lesions:_________________ Discharge:_________________ Genital warts/lesions:_________________ Discharge:_________________

IX. Coping - Stress Tolerance/ Self-Perception/Self-Concept

Before Hospitalization During Hospitalization

IX. Coping- Stress Tolerance/ Self-Perception /Self-Concept
Major concerns regarding hospitalization or illness (Financial, self-care):
_____________________________________________________________
_____________________________________________________________
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Major loss/crisis/change in past year/s: Yes  No ✓
Specify:______________________________________________________
Fear of Violence Yes  No ✓ Who/Specify:________________
Outlook on Future:________ (rate 1-poor to 10- very optimistic)
Describe:
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IX. Coping- Stress Tolerance/ Self-Perception /Self-Concept
Major concerns regarding hospitalization or illness (Financial, self-care):
_____________________________________________________________
_____________________________________________________________
_____________________________________________________________
Major loss/crisis/change in past year/s: Yes  No ✓
Specify:______________________________________________________
Fear of Violence Yes  No ✓ Who/Specify:________________
Outlook on Future:________ (rate 1-poor to 10- very optimistic)
Describe:
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X. Value — Belief Pattern

Religion: Born Again Religious Restrictions: NONE

Request Chaplain Visitation: Yes 

✓ No  Time:_____________

OTHER INFORMATION
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 Nursing Diagnosis and Goals and Objectives NI Rationale with Evaluation
Problem Nursing Interventions
Rationale References
NOC: NIC:
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Nursing Diagnosis:
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No.__:______________
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Cues Independent:
Goal/s:
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Subjective Data:
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Rationale:
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Objective/s:
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Cues
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Objective Data:
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Dependent:
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Reference:
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 Nursing Diagnosis and Goals and Objectives NI Rationale with Evaluation
Problem Nursing Interventions
Rationale References
NOC: NIC:
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Nursing Diagnosis:
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Cues Independent:
Goal/s:
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Subjective Data:
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Rationale:
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Objective/s:
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Cues
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Objective Data:
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Dependent:
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Reference:
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 Nursing Diagnosis and Goals and Objectives NI Rationale with Evaluation
Problem Nursing Interventions
Rationale References
NOC: NIC:
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Nursing Diagnosis:
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Cues Independent:
Goal/s:
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Subjective Data:
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Rationale:
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Objective/s:
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Cues
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Objective Data:
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Dependent:
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Reference:
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 Nursing Diagnosis and Goals and Objectives NI Rationale with Evaluation
Problem Nursing Interventions
Rationale References
NOC: NIC:
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Nursing Diagnosis:
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No.__:______________
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Cues Independent:
Goal/s:
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Subjective Data:
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Rationale:
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Objective/s:
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Cues
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Objective Data:
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Dependent:
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Reference:
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 DRUG STUDY
Drug to drug and drug to food Contraindications & Rationale with reference
Name of Drug & Dosage Drug Classification & Indication Nursing Responsibilities
Interaction Adverse Effects
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