NURSING CARE PLAN

NAME OF PATIENT:
CARE PLAN PREPARED BY:
ASSESSMENT DIAGNOSIS OUTCOMES/GOALS INTERVENTIONS RATIONALE EVALUATION

Subjective: Risk for fall r/t dizziness At the end of 8-hour 1. Monitored V/S q2 1. helps nurses identify - Goal was met
“Naa gihapon lipong- nursing shift, pt will hours when a patient has an - Pt was able to
lipong” verbalize understanding of elevated heart rate or verbalize
condition and safety issues blood pressure, which understanding
Objective: as evidenced by being able could indicate of condition
(+) Dizziness to recognize potential risk dehydration or shock; and safety
(+) Body Malaise factors rapid breathing, which issues by
(+) Nausea and vomiting could indicate recognizing
(+) Claudication respiratory distress; or potential risk
2. Encouraged changing low blood pressure, factors
V/S: of positions as which could indicate
BP: 130/90 mmHg tolerated shock.
PR: 101 bpm
RR: 23 cpm 3. Instructed to raise bed 2. To promote comfort
O2 Sat: 94% rails
Temp: 37.2 ℃
4. Instructed to avoid
abrupt changing of 3. To prevent potential
positions injuries or risks of
accidents

4. Helps keep blood

5. Instructed to apply
extra pillow on back
or nape for comfort
flowing. This helps the
skin stay healthy and
prevents bedsores.
Turning a patient is a
good time to check the
skin for redness and
sores.

6. Educated pt’s family 5. To promote comfort and

to avoid walking keep upper body
without supervision elevated

7. Encouraged to 6. To prevent accidents

 verbalize concerns

7. Verbalization of actual
or perceived threats can
help reduce anxiety and
open doors for ongoing
communication.

ASSESSMENT DIAGNOSIS OUTCOMES/GOALS INTERVENTIONS RATIONALE EVALUATION

Subjective: Ineffective health At the end of 8-hour 1. Develop realistic 1. Patients may be - Goal was met
“Mas ganahan pako muuli maintenance r/t difficulty nursing shift, pt will goals unwilling to change - Pt was able to
kesa mupundo diari kay with decision-making due demonstrate lifestyle their lifestyles but demonstrate
dako nami ug gasto” to dependency on partner as changes that promote developing small goals lifestyle
evidenced by inability to effective health that can be met such as changes that
Objective: take responsibility for maintenance cutting back on desserts promote
(+) Dizziness health actions or walking twice a week effective health
(+) Body Malaise can be a compromise. maintenance

V/S: 2. Educate pt and family 2. If the patient displays

BP: 130/90 mmHg about medication difficulty adhering to
PR: 101 bpm management their medication
RR: 23 cpm schedules schedule, help them
O2 Sat: 94% develop reminders such
Temp: 37.2 ℃ as alarms, pill boxes,
signage, etc., that
supports adherence.

3. Refer to community 3. The patient may require

support programs. home health support,
social worker assistance,
or even skilled nursing
services in order to meet
their health and safety
requirements.

4. Educate pt about 4. Stress can be a major

appropriate ways to factor in managing
manage stress such as health maintenance
watching television, behaviors. If the patient
household chores, is burdened by other
and exercising as roles such as caregiving,
tolerated parenting, or career
responsibilities, their
health may not be a
priority.

5. Assist the patient to 5. Self-management

 develop confidence in education improves
managing the health physiological outcomes,
condition effective healthcare use,
and enhanced coping
techniques.

Direction:
List and rank 5 identified priority nursing diagnoses.

Problem Etiology (Related Factors) Signs and Symptoms

(Diagnostic Label – NANDA) (Defining Characteristics)
1. Ineffective health maintenance difficulty with decision-making due to dependency on inability to take responsibility for health actions
partner
2. Risk for fall dizziness
3. Knowledge deficit lack of interest to learn poor adherence and irritability regarding teaching follow-
up
4. Fatigue Sepsis and pain medications lack of motivation and body malaise
5. Decreased activity tolerance prolonged bed rest and inconsistent sleeping hours body malaise, claudication and dizziness