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Nursing Care Plan Client s name: Abigail Lim Age: 22 years old ASSESSMENT: Subjective: - Wala akong ganang

kumain as verbalized by the patient. - ngayong month na to siguro 4kg ang nababawas sa timbang ko as verbalized by the patient. Objective: -weak -very thin DIAGNOSIS: -Imbalanceed nutrition: less than body requirement (lack of appetite) AEB weight loss PLANNING: -Nutrition meets metabolic demans -Client will demonstrate the nutrition meets metabolic demands AEB weight gain of 1 or more pound every week. INTERVENTION: -Obtain weight using same scale same time of the day, and same clothing, as much as possible. -Plan with the clients of what will she eat in a day per meal. -Give some appetizers. -Encourage her to eat healthy foods such as fruits, meat and vegetables. RATIONALE: -To provide knowledge on healthy foods for her to eat and for her gain weight. -To have healthy lifestyle. EVALUATION: -After 2 weeks of nursing intervention the client was able to gain weight and have energy.

Nursing Care Plan Name: Agu Soriano Age: 64 ASSESSMENT: Subjective: - nahihirapan ako huminga as verbalized by the client. Objective: -Difficulty in breathing -Increased respiratory rate (28 cpm) -Ineffective coughing method DIAGNOSIS: -Ineffective airway clearance related to inability to remove airway secretions secondary to pulmonary tuberculosis as manifested by difficulty in breathing and increased respiratory rate (28 cpm) PLANNING: -After series of nursing interventions the client should stabilize the respiratory rate to normal range as well as the respiratory rhythm INTERVENTIONS: -Position the head midline with flexion -Monitor Vital Signs including respiratory rhythm and note for any respiratory distress -Encourage deep breathing and coughing exercise -Advise client to avoid cold places. -Advise client to increase oral fluid intake RATIONALE: -To open or maintain airway in at rest or compromised individuals -To obtain baseline vital signs for future comparison as well as to assess any digns and symptoms distress -To allow lung expansion to compensate for the decreased O2 level in the lungs -Cold temperature irritates the mucus linings with in the upper respiratory tract -To help liquefy mucus secretions -mobilize mucus secretions -To get rid of any obstructing mucus secretions within the airway -To provide additional oxygen to the client -To kill bacteria, liquefy mucus secretions and expel mucus that blocks the airway. EVALUATION: -After series of nursing interventions goals partially met as evident of the clients gradual decrease in effort in breathing, and stabilization of respiratory rate to normal range

Nursing Care Plan Client s name: Sheenally Abejero Age: 15 years old ASSESSMENT: Subjective: - Hindi ako makatulog ng maayos kasi ang ingay ng mga kasama ko sa bahay nakakatulog na lang ako pag talagang antok na antok na ako as verbalized by the client. -4-5hrs of sleep - Minsan sa umaga na nga ako natutulog sa sobrang antok ko tapos pag gabi talgang gising na lang ako as verbalized by the client. Objective: -Weak DIAGNOSIS: -Disturbed sleep pattern r/t inadequate stimulation, poor sleep hygiene, and substance use as evidenced by the
client

PLANNING: - Client will identify personal habits that disrupt sleep pattern and strategies to improve quality of sleep as
measured by verbalization of at least two contributing factors and strategies -Client will express commitment to avoid daytime napping as a method of alleviating boredom for one week as measured by a verbalization of the client. -Client will describe alternate activities to avoid daytime napping as a result of boredom measured by verbalization of at least three alternate activities. -Client will engage in daily activities that she finds interesting and feasible in lieu of daytime napping as measured by observation and self report of daily participation -Client will regularly fall asleep without difficulty as measured by client verbalization of ease of falling asleep consistently

INTERVENTION: -Advice the client to sleep in time. -Put headset every time her roommates are noisy. -drink milk or chocolate drink before sleeping. RATIONALE: -To have good sleep. -To have 8hrs of sleep. -For the client to sleep easily. EVALUATION: -After series of interventions after one week surely the client s goals are met.

Nursing Care Plan Name: Angelica Orita Age: 31 ASSESSMENT: -Skin breakout -black heads and white heads appears on her face -oily face but dry DIAGNOSIS: -Impaired Skin integrity Altered epidermis and/or dermis: Invasion of body structures, destruction of skin layers (dermis), and disruption of skin surface (epidermis). PLANNING: -The client will know the right food that she will take. -The client will learn more about hygiene
INTERVENTIONS: -Monitor site of skin impairment at least once a day for color changes, redness, swelling, warmth, pain, or other signs of infection.  Individualize plan according to client's skin condition, needs, and preferences. Avoid harsh cleansing agents, hot water, extreme friction or force, or cleansing too frequently . Do not position client on site of skin impairment. If consistent with overall client management goals, turn and position client at least every 2 hours  Evaluate for use of specialty mattresses, beds  Select a topical treatment that will maintain a moist wound-healing environment and that is balanced with the need to absorb exudates  Avoid massaging around the site of skin impairment

and over bony prominences.

Assess client's nutritional status


RATIONALE:

Systematic inspection can identify impending problems early.  A validated risk-assessment tool such as the Norton or Braden scale should be used to identify clients at risk for immobilityrelated skin breakdown. Transfer client with care to protect against the adverse effects of external mechanical forces such as pressure, friction, and shear.

To reduce shear and friction, and use lift devices, pillows, foam wedges, and pressure-reducing devices in the bed.

- Massage may lead to deep-tissue trauma Inadequate nutritional intake places individuals at risk for skin breakdown and compromises healing EVALUATION: -That the clients skin breakdown will be lessen with in 2weeks.

Nursing Care Plan Client s name: Ronald Lim Age: 42 years old
ASSESMENT: Subjective: bakit kaya madalas ako mahio as verbalized by the patient. Objective: -request for information -agitated behavior -Inaccurate follow through of instruments. DIAGNOSIS: -Risk for prone behavior related to lack of knowledge about the disease PLANNING: -After 8 hours of nursing interventions, the patient will verbalize understanding of the disease process and treatment regimen. INTERVENTION: -Define and state the limits of desired BP. Explain hypertention ans its effect on the heart, blood vessels, kidney and brain. -Assist the patient in identifying modifiable risk factors like diet high in sodium, saturated fats and cholesterol. -Reinforce the importance of adhering to treatment regimen and keeping follow up appointments. -suggest frequent position changes, leg exercises when lying down. -Held patient indentify sources of sodium intake. -Encourage patient to decrease or eliminate caffeine like tea, coffee, cola and chocolates. -Stress importance of accomplishing daily rest periods. EVALUATION: -After 8 hours o nursing interventions, the patient was able to verbalize understanding of the disease process and treatment regimen.

Nursing Care Plan Client s name: Kristine Allen Age: 21 years old
ASSESSMENT: Subjective: - madalas akong dumumi ngayon kaysa kahapon as verbalized by the client. Objective: -Increased peristalsis. -Frequent watery stools. -Abnormal pain. DIAGNOSIS -Diarrhea related to presence of toxins. PLANNING -After 4 hours of nursing interventions, the patient will report reduction on frequency of stools. INTERVENTION: -Promote best rest. -Provide bedside commode. -Identify foods and fluid that precipitate diarrhea. -Restart oral fluid intake gradually. Offer clear liquids hourly, and avoid cold fluids. -Encourage at eat foods like banana and apple. -Avoid foods that are oily, spicy and caffeine. -Administer anti-diarrheals as prescribed by the physician. EVALUATION: -After 4 hours of nursing interventions, the patient was able to report reduction in frequency of stools.

Nursing Care Plan Client s name: Rein Macabangon Age: 19 years old
ASSESSMENT: Subjective: Hindi ako makatulog dahil sa ubo ko as verbalized by the patient. Objective: -Fatigue -Dyspnea DIAGNOSIS: Activity intolerance to exhaustion associated with interruption in usual sleep pattern because of discomfort, excessive coughing and dyspnea. PLANNING: -After 4 hours of nursing interventions, the patient will demonstrate a measurable increase in tolerance in activity with absence od dyspnea and excessive fatigue. INTERVENTION: -Evaluate patient s response to activity. -Ask the client to elevate and encourage frequent position changes, deep breathing and effective coughing. -Encourage adequate rest balanced with moderate activity. Promote adequate nutrition intake. -Force fluids to at least 3000 ml per day and often warm, rather than cold fluids. -Administer medications as prescribe: mucolytics and experctorants. EVALUATION: -After 4 hours of nursing interventions, the patient was able to demonstrate a measureable increase in tolerance in activity with absence of dyspnea and excessive fatigue.