NURSING CARE PLAN
ASSESSMENT
Subjective:
"Grabe, sobra na nga ang
ipinayat k, hindi naman ako
ganito kapayat dati.
”as verbalized by the patient.
Objective:
 Reported food
intake less than
recommended
dietary allowance
 Perceived inability
to ingest food
 Aversion to eating
 Poor muscle tone
NURSING PLANNING
DIAGNOSIS
Long term:
“Imbalance nutrition: After 1 week of nursing
less than body intervention the client will be
requirement related to able to take sufficient nutrients
inadequate intake of to maintain optimum cellular
nutrition.” and metabolic function.
Short term:
 After 2 hrs of nursing
intervention, the client
will be able to discuss
the agreeable daily
caloric intake goal.
 Improve eating habits
IMPLEMENTATION EVALUATION
Long term:
Observe eating behavior After 1 week of nursing
intervention the client had been
able to take sufficient nutrients
to maintain optimum cellular an
Recommend to have metabolic function.
his/her favorite meal
Short term:
Discuss a mutually
After 2 hrs of nursing
agreeable daily caloric
intake goal intervention, the client will be
able to:
Discuss ways to restore  Discuss the agreeable
physiological homeostasis: daily caloric intake goal.
electrolyte and fluid  Improve eating habits
replacement.
Monitor V/S and fluid &
electrolyte balance
 ASSESSMENT NURSING PLANNING IMPLEMENTATION EVALUATION
DIAGNOSIS

Short Term Goals /

Subjective: “Ineffective Airway Outcomes: Assess airway for patency by After 8hrs of nursing
"Ang hirap pong huminga”as Clearance related to Patients lungs sounds will asking the patient to state his intervention, the patient’s O2
verbalized by the patient. tracheo-bronchial be clear to auscultate name. saturation will back to normal;
obstruction.” Patient will be free of 90-100%
Objective: dyspnea Inspect the mouth, neck and
 Blood in the mouth position of trachea for potential
noted Long Term Goal: obstruction.
 Flaring nostrils Patient will maintain a
 Confuse patent airway Auscultate lungs for presence of
 Lethargic Patient will demonstrate normal or adventitious lung
correct coughing and deep sounds.
 Wheezing sound
breathing techniques
 Use of accessory
muscle while Assess respiratory quality, rate,
breathing depth, effort and pattern.
 O2 Sat: 87 % Assess for mental status changes.
 ASSESSMENT NURSING PLANNING IMPLEMENTATION EVALUATION
DIAGNOSIS

Subjective: “Anxiety related to Within 8 hours of Monitor vital signs(e.g., rapid or irregular The patient shall have
“Hindi ko alam kung change in health status nursing pulse, rapid breathing) demonstrated
makakapagtrabaho na ako and situational crisis.” interventions the participation in his
kaagad pagkagaling ko eh" patient will appear Use presence, touch, reduced to a manageable recommended treatment
as verbalized by the patient. relaxed and the level verbalization or demeanour to remind program.
level of anxiety client and to encourage expressions or
Objective: will reduced to a clarification of needs, concerns, unknowns
-Vital signs, manageable level ‘and questions
BP130/90
Temp.36.2c Accept client's defences, do not confront, and
CR- 64 argue and debate
RR-20
-restlessness Allow and reinforce clients personal reaction
-difficulty in sleeping towards the threatens to wellbeing
-fatigue
 Explain everything necessary regarding the
disease

To identify physical responses associated

with both medical and emotional conditions