PHINMA - Cagayan de Oro College

College of Allied Health Sciences – BS Nursing

NURSING CARE PLAN

ACTUAL PROBLEM
NAME OF STUDENT: SECTION: DATE:
NAME OF PATIENT: ATTENDING PHYSICIAN: C.I.: HOSPITAL/ROOM:

ASSESSMENT DIAGNOSIS PLANING INTERVENTION EVALUATION

Subjective: Short Term: Independent : Short Term:

At the end of 2 hrs, the
Impaired  Monitor and record BP. At the end of 2 hours,
Patient report feeling tired patient will attain lower
cardiovascular Rationale: It's important to the patient was able to attain
after working at her eatery blood pressure than get an accurate blood
function related to lower blood pressure than
130/90 pressure reading so that you 130/90.
reports of high blood
have a clearer picture of
pressure as evidenced your risk for heart disease
by blood pressure and stroke.
result as 130/90  Provide calm, restful
surroundings, and minimize
environmental activity and
noise.
Rationale: Reducing stress
with a quiet
environment increases
relaxation and decreases
anxiety, even on a stressful
 day.
 Encourage verbalization of
feelings and concerns.
Rationale: This
approach creates a
supportive environment and
sends a message of caring.

Dependent:

 Monitor response to
medications to control
blood pressure.
Rationale: Blood pressure
monitoring would perform
better as a means of
detecting nonadherence
where the effects of the
regimen were large and
worse where they were
small.

Interdependent:
 Long Term:
Objective:
At the end of 1 week;
Vital signs:
BP: 130/90 • the patient’s long-term
Skin: Burn on right hand.
needs will be given
Laboratory: Myoma
• available resources,
.
specific referrals will be
made.
 Refer the patient to a Long Term:
cardiologist to provide
further treatment.
At the end of 1 week;
Rationale: A cardiologist is a
physician who's an expert in
• the patient’s long-term
the care of your heart and needs were given
blood vessels. They can
treat or help you prevent a • available resources, specific
number of cardiovascular referrals were made.
problems.

89

NAME OF STUDENTS:
NAME OF PATIENT:
ASSESSMENT
Subjective:
“Naa koy paso-paso sa right
hand tungod sa pagluto sa
sud-an sa karenderya”
PHINMA - Cagayan de Oro College
College of Allied Health Sciences – BS Nursing
NURSING CARE PLAN
RISK
SECTION: DATE:
ATTENDING PHYSICIAN: C.I.: HOSPITAL/ROOM:
DIAGNOSIS PLANING INTERVENTION EVALUATION
Short Term Independent Short Term:
Risk for occupational  Identify employment/job specifics (e.g.,
At the end of the day, the
injury as evidenced of works with dangerous tools/machinery,
patient will be able to At the end of the day,
clients verbalizes “Naa electricity, explosives, hazardous
understand and verbalize the patient was able to
koy paso-paso sa chemicals, first responders, healthcare
injury prevention in the understand and
right hand tungod sa worker, computer data entry, works
workplace. verbalize injury
pagluto sa sud-an sa alone or above ground).
prevention in the
karenderya” Rationale: Aids in identifying risks and
workplace.
individual safety needs.
 Clarify client's awareness of
occupational safety and health
administration (OSHA) standards
applicable to client.
Rationale: Lack of awareness can limit
client's ability to make best decisions to
promote personal safety.
 Instruct in safety techniques/procedures
specific to the client's situation (e.g.
 wear appropriate protective personal
equipment)
Rationale: To prevent any injuries in the
body
Objective Dependent:
Vital signs:  Determine factors related to individual
BP: 130/90 situation and extent of risk for
Skin: Burn on right hand. injury/illness
Rationale: Influences scope and intensity
Laboratory: Myoma
of interventions to manage threats to
safety, which are dynamic and constants
in every life and situation.
 Review pertinent job-related safety
regulations with client.
Rationale: Provides information
necessary for client to make informed
decisions.
 Determine client's perception of
individual safety and view of hazards in
workplace including exposure to
violence.
Rationale: Lack of knowledge of safety
needs or appreciation of significance of
individual hazards increases risk of injury.
Lack of focus on specific problems can
result in no change or may even result in
increased injuries.
Interdependent:
Long Term:
At the end of 1 week, the
patient will be able to
develop a plan for long-
term monitoring of health
risks and evaluation of
risk reduction strategies.
 Refer to trainer or physical therapist for Long Term:
for regular exercise program, including
At the end of 1 week,
focus on core strength/stability and
the patient was able to
flexibility,. Rationale: Research suggests
decreased core strength contributes to develop a plan for long-
injuries of back extremities. term monitoring of
health risks and
evaluation of risk
reduction strategies.
 PHINMA - Cagayan de Oro College
College of Allied Health Sciences – BS Nursing

NURSING CARE PLAN

HEALTH PROMOTION/WELLNESS
NAME OF STUDENT: SECTION: DATE:
NAME OF PATIENT: ATTENDING PHYSICIAN: C.I.: HOSPITAL/ROOM:

ASSESSMENT DIAGNOSIS PLANING INTERVENTION EVALUATION

Subjective: Short Term: Independent Short Term:

.Patient verbalizes willingness
to manage her time to take a
rest and avoid working too
much
Readiness for  Encourage the patient to take her stress
At the end of 2 hours, the At the end of 2 hours,
enhanced health self- reliever medicines as prescribed.
patient will be able to the patient was able to
management to have Rationale: Encouraging patient to take
understand the health understand the health
time to take rest. her stress reliever medicine as
self-management. self-management
prescribed by the physician will help her
reduce the effects of stress in her body
 Encourage the client's participation in
relaxation exercises such as deep
breathing, progressive muscle
relaxation, guided imagery, meditation
and so forth.
Rationale: By active participation,
patient can comply fully and can
meditate if possible stress attacks would
 happend. It can also help the patient to
prevent stress that might occur.
Objective: Dependent:
Vital signs:  Patient will seek her physiotherapist
BP: 130/90 twice a week.
Skin: Burn on right hand.
Laboratory: Myoma
Rationale: seeking health companion
will help the patient reduce her stress
plus it can also guide her to proper
knowledge of stress coping.
 Patient will follow her daily medication
routine as prescribed
Rationale: Taking up prescribed
medicine on time and on the right route
medications will help our body to cure
or reduce the pain or stress.
Interdependent:
Long Term: Long Term:

At the end of 1 week, the At the end of 1 week,

patient will be able to the patient was able to
demonstrate self- demonstrate self-
management to attain management to attain
desired outcomes. desired outcomes.