ILOILO DOCTORS’ COLLEGE

COLLEGE OF NURSING
West Avenue, Molo, Iloilo City

NURSING CARE PLAN

Defining Characteristic Nursing Outcome Nursing Intervention Rationale Evaluation
Diagnosis Identification
Subjective: Long term: Independent: Goals are met as
evidenced by:
Risk for Self- After 1 month of
Directed Violence nursing intervention
“Indi ko na gusto mabuhi  Provide safety.
related to the patient will be able ⮚ To prevent patient
pa” as verbalized by the Patient’s suicidal
depressive to: from self-harm.
patient ideation has
symptoms and
 Start working diminished, and she
suicidal ideation.
on constructive has not engaged in
plans for the ⮚ To build trust, create any self-harm
future.  Establish a behaviors.
an open
 Demonstrate therapeutic communication, and
alternative relationship with encourage the
ways of the patient.
Rationale: patient to participate
dealing with
actively in her care.
Objective: Vulnerable to depression and
behaviors in which stress.
an individual
demonstrates that ⮚ Learn alternative
⮚ exhibits a Short term:
he or she can be  Encourage the ways of dealing with
depressed mood physically, patient to express overwhelming
After 2-3 weeks of
emotionally, feelings (anger, emotions and gain a
⮚ has suicidal nursing intervention
and/or sexually sadness, guilt). sense of control over
the patient will be able
harmful to self.
to:
 ILOILO DOCTORS’ COLLEGE
COLLEGE OF NURSING
West Avenue, Molo, Iloilo City

ideation  Avoid his/her life.

inflicting harm
to self.
 State that she
⮚ To remove any
wants to live.
 Lessen her potential means of
depression.  Remove potential self-harm from the
means for self- patient’s
harm. environment, such as
sharp objects, ropes,
belts, or any harmful
substances.

⮚ Helps the patient

address underlying
psychological issues
and develop coping
skills to manage
depression.
 Encourage
participation in
psychotherapy.
⮚ To promote her
recovery and prevent
relapse.
 ILOILO DOCTORS’ COLLEGE
COLLEGE OF NURSING
West Avenue, Molo, Iloilo City

 Provide
education on
self-care and
coping skills.

 Increases the levels

Dependent:
of serotonin in the
Administer brain, which helps to
antidepressant drug as improve the mood
ordered: and other symptoms
of depression.

 Fluoxetine 20
mgs daily

Defining Characteristic Nursing Outcome Nursing Intervention Rationale Evaluation

Diagnosis Identification
Subjective: Long term: Independent: Goals are met as
evidenced by:
After 2-3 weeks of
nursing intervention, Patient was able to
“Pabay-e lang da ya ang Self- care deficit  Introduce self To build trust of the
the patient will be able establish an
 ILOILO DOCTORS’ COLLEGE
COLLEGE OF NURSING
West Avenue, Molo, Iloilo City

akon nga chura” as related to loss of to: and intention client to the nurse adequate balance of
verbalized by the patient. interest in ADLs during the first rest and sleep,
 Demonstrate
phase of groom and dress
progress in the
interaction appropriately with
maintenance of
help from nursing
adequate
staff and/ or family,
hygiene and be
 Initiate dressing Clients with depression may identified alternative
appropriately
and grooming have the most energy and action to perform
groomed and
tasks in the feel best in the morning and activities in daily
dressed
morning may have greater success at living, demonstrates
 Perform ADLs
Objective: Rationale: that time progress in the
within their
maintenance of
Patients with own level of
adequate hygiene
major depression ability
- Matted hair  Encourage and A patient with depression and be appropriately
may experience a  Verbalize
- Clothing is soiled coach has a slower, clouded groomed and
self-care deficit proper
and wrinkled thought process and dressed, performed
due to symptoms hygienic
- Lack of energy difficulty concentrating. ADLs within their
such as fatigue, practices
They may need step-by-step own level of ability,
decreased verbalize proper
guidance to complete even
motivation, and hygienic practices
Short term: simple tasks
loss of interest in
activities of daily After 4-7 days of
living. They may nursing intervention, Setting a specific
struggle with basic the patient will be able  Provide a routine sleep/wake schedule and
self-care tasks to: and schedule routine for eating,
such as hygiene.
 Established an grooming, and dressing can
adequate help motivate the patient.
 ILOILO DOCTORS’ COLLEGE
COLLEGE OF NURSING
West Avenue, Molo, Iloilo City

balance of rest
and sleep
 Groom and
dress Patients can become
appropriately  Encourage dependent on caregivers and
with help from participation in support staff and should be
nursing staff care encouraged to carry out as
and/ or family much of their self- care as
 Identify possible.
alternative
action to
perform Patients may need to shift
activities in  Suggest easier their wardrobes to pullover
daily living clothing options sweaters and shirts, pants
 with elastic waistbands, and
shoes with Velcro in order
to dress themselves.

The patient may need

 Evaluate tools for adaptive tools for hair
grooming brushing, shaving, and
applying makeup. Feeling
confident in one’s
appearance is important to
maintaining hygiene.
ILOILO DOCTORS’ COLLEGE
COLLEGE OF NURSING
West Avenue, Molo, Iloilo City

To determine the patient

 Assess patient
capability to perform ADLs
overall condition

 Give health Emphasizing this health

teaching about teaching help to remind the
the importance of client and the family why it
the following: is necessary.

Toothbrushing
Handwashing
Combing
Nail cutting
Take a bath

Dependent:
Administer medication
as ordered:
 ILOILO DOCTORS’ COLLEGE
COLLEGE OF NURSING
West Avenue, Molo, Iloilo City

 Amitryptyline  It works by
100 mgs at bed increasing levels of
time and 50 mgs serotonin in your
at 9 am brain which can
improve mood.

 Fluoxetine 20
mgs once a day
 Indicated for
both acute and
maintenance
treatment of major
depressive disorder.
It works
by increasing the
levels of serotonin in
the brain..

Defining Characteristic Nursing Outcome Nursing Intervention Rationale Evaluation

Diagnosis Identification
Subjective: Long term: Independent: Goals are met as
evidenced by:
After 2-3 months of
nursing intervention, Patient was able to
“Ginatamad ako Activity  Increase Physical Physical activity can reduce
the patient will be able establish an
maghulag bisan mag kaon intolerance related Activity: depression symptoms,
 ILOILO DOCTORS’ COLLEGE
COLLEGE OF NURSING
West Avenue, Molo, Iloilo City

nalang” as verbalized by to depression to: Encouraging increase energy levels and adequate balance of
the patient increasing improve overall health. rest and sleep,
 Reach a state
physical activity groom and dress
of emotional
level can help appropriately with
stability,
reduce help from nursing
improved
depression staff and/ or family,
mood, and
symptoms and identified alternative
increased
improve activity action to perform
physical
tolerance. activities in daily
activity over a
living, demonstrates
period of time.
Objective:  Reduce Stress: Stress can worsen progress in the
Rationale: Short term: Encouraging the depression symptoms and maintenance of
Depression can patient to reduce activity tolerance. adequate hygiene
After 1-2 weeks of practice stress and be appropriately
 Lack of motivation cause physical nursing intervention,
 Lack of energy symptoms such as reduction groomed and
the patient will be able techniques such dressed, performed
 Severe depression pain, which can to:
based on Beck make physical as deep breathing ADLs within their
Depression activity difficult.  gradually and progressive own level of ability,
Inventory Finally, depression increase the muscle relaxation verbalize proper
 Lack of sleep can lead to poor amount of can help reduce hygienic practices
 Loss of Appetite concentration and physical depression and
activity improve activity
difficulty focusing,
which can make it tolerance.
difficult to
complete
activities.  Improve Sleep
Hygiene: Poor sleep can worsen
ILOILO DOCTORS’ COLLEGE
COLLEGE OF NURSING
West Avenue, Molo, Iloilo City

Encouraging the depression symptoms and

patient to reduce activity tolerance
improve their
sleep hygiene by
establishing a
regular sleep
schedule and
avoiding caffeine
and alcohol can
help reduce
depression and
improve activity
tolerance.

 Promote Proper nutrition can

Nutrition: improve overall health and
Encouraging the reduce depression
patient to symptoms.
maintain a
healthy, balanced
ILOILO DOCTORS’ COLLEGE
COLLEGE OF NURSING
West Avenue, Molo, Iloilo City

diet can help

reduce
depression
symptoms and
improve activity
tolerance.

It can provide valuable

 Monitor insight into the patient's
Neurologic vital physiological state and alert
signs and vital caregivers to any changes or
signs. abnormalities.

 Provide a calm It promotes relaxation and

environment can help reduce anxiety.

Dependent:
Administer medication
as ordered:
 It works by
increasing levels of
 Fluoxetine 20
ILOILO DOCTORS’ COLLEGE
COLLEGE OF NURSING
West Avenue, Molo, Iloilo City

mgs once a day serotonin in the

brain, which helps to
improve mood,
reduce anxiety, and
increase energy
levels.