REPUBLIC of the PHILIPPINES

City of Makati
UNIVERSITY OF MAKATI
COLLEGE OF ALLIED HEALTH STUDIES
J. P. Rizal Extension, West Rembo, Makati City 1215
Telephone No. : (+632) – 881 – 1571
_____________________________________________________________________________________
CENTER OF NURSING

NURSING CARE PLAN

NAME OF STUDENT:__________________________ YEAR/GROUP:_________ CONCEPT:_________ AREA:______ DATE:___________

Assessment Nursing Inference Planning Intervention Rationale Evaluation

Diagnosis
Subjective Constipation r/t Change in bowel - Determine fluid - to evaluate Long term
Cues gastrointestinal pattern; bright red Long Term intake client’s Objective
malfunction as blood with stool; Objective hydration After 8
“hindi siya hours of
evidence by presence of soft status
makadumi After 8 hours nursing
bloated paste-like stool in
pag hindi of nursing
stomach rectum; distended - sedentary intervention,
siya intervention, - note energy and the client
abdomen; dark, black, lifestyle may
binibigyan the client will activity levels was able to
or tarry stool; affect
ng gamut be able to and exercise regain
increased abdominal elimination
pampadumi” regain patterns pattern normal
pressure; percussed
as normal pattern of
abdominal dullness;
verbalized pattern of - provides a bowel
pain with defecation;
by the bowel baseline for functioning
bowel sounds; - note color, odor,
mother functioning comparison, Short term
palpable abdominal conconsistency,
mass; abdominal promotes objective
Objective amount and
Cues tenderness with or Short Term recognition
Objective
frequency of After 4
without palpable of changes
After 4 hours stool hours of
muscle resistance;
nausea and/or of nursing - to improve nursing
vomiting; oozing liquid intervention organ intervention
- encourage or the nurse
stool the nurse will function
support
be able to
treatment of including the was able to
assess bowel assess
underlying current
current
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 REPUBLIC of the PHILIPPINES
City of Makati
UNIVERSITY OF MAKATI
COLLEGE OF ALLIED HEALTH STUDIES
J. P. Rizal Extension, West Rembo, Makati City 1215
Telephone No. : (+632) – 881 – 1571
_____________________________________________________________________________________
CENTER OF NURSING
Reference: pattern of medical causes - To best treat pattern of
http://nursing- elimination where acute elimination
concept.blogspot.com/ appropriate situation.
- Refer to primary
care provider for
medical
therapies
(suppositories,
saline or - To
hyperosmolar determine if
laxatives etc.) drugs
contributing
- Discuss client’s to
current constipation
medication can be
regimen with discontinued
physician or changed.

39
 REPUBLIC of the PHILIPPINES
City of Makati
UNIVERSITY OF MAKATI
COLLEGE OF ALLIED HEALTH STUDIES
J. P. Rizal Extension, West Rembo, Makati City 1215
Telephone No. : (+632) – 881 – 1571
_____________________________________________________________________________________
CENTER OF NURSING
Assessment Nursing Inference Planning Intervention Rationale Evaluation
Diagnosis
Subjective Imbalanced - Determine - To all Long term
Cues nutrition: Less Than Body Long Term client’s ability to factors that Objective
less than Requirements in Objective chew, swallow, can affect After 8
“hindi siya women exhibit a hours of
body and taste food. ingestion
Magana higher incidence After 8 hours nursing
requirements Evaluate teeth and/or
kumain kung regarding voluntary of nursing intervention,
as gums and poor digestion of
kalian nya restriction of food intervention, the client
evidenced oral health and nutrients.
lang gusting intake secondary to the client will was able to
by weight note denture.
kumain dun anorexia, bulimia, and be able to be regain
lang siya free from -
self-constructed fad - Assess drug That may be normal
kakain” as dieting. A pregnant signs of
interactions, affecting pattern of
verbalized by woman who has malnutrition appetite, bowel
disease effects,
the mother eating problems may and weight food intake functioning
allergies use of
also have problems gain or Short term
Objective latexatives,
Cues like fetal dieuretics absorptions objective
growth restriction. Short Term
Lack of Older patients who Objective - Assess weight - To establish After 4
interest in have cognitive After 4 hours measure or baseline hours of
food impairments and of nursing calculate body parameters nursing
encounter financial intervention fat intervention
limitations have higher the client will the nurse
weight : 7.5
chances of eating be able to - Note age, body - Helps was able to
kg
problems. This have interest build, strength determine assess
includes negligence, in eating activity and rest nutritional current
physical limitations, level and so needs pattern of
deterioration of their forth. elimination
senses, reduction of
gastric secretion, poor - Evaluate total - To reveal
digestion, and social daily food intake possible
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 REPUBLIC of the PHILIPPINES
City of Makati
UNIVERSITY OF MAKATI
COLLEGE OF ALLIED HEALTH STUDIES
J. P. Rizal Extension, West Rembo, Makati City 1215
Telephone No. : (+632) – 881 – 1571
_____________________________________________________________________________________
CENTER OF NURSING
isolation and boredom cause of
that cause lack of malnutrition
interest in eating. and
Reference: changes
nurseslabs.com that could
be made in
client’s
intake

- Consult with - For long

dietitian or term need
nutritional
support team as
necessary

41
 REPUBLIC of the PHILIPPINES
City of Makati
UNIVERSITY OF MAKATI
COLLEGE OF ALLIED HEALTH STUDIES
J. P. Rizal Extension, West Rembo, Makati City 1215
Telephone No. : (+632) – 881 – 1571
_____________________________________________________________________________________
CENTER OF NURSING
Assessment Nursing Inference Planning Intervention Rationale Evaluation
Diagnosis
Subjective Disturbed 1. Identify presence 1. Sleep problems Long term
Cues sleep Health care Long Term
of factors known to can arise from Objective
pattern as interventions as Objective
interfere with sleep, internal and external After of 24
evidence by stimulus including current factors, and may hours of
After 24 hours nursing
Objective interrupted illness and require assessment
of nursing intervention
Cues sleep hospitalization. over time to
intervention the client
differentiate specific
> Sympathetic nervous the client will causes. reported
system report improvement
restlessness
improvement in quality
2. Assess sleep 2. These factors can
in quality sleeping
>difficulty pattern disturbances reduce client’s ability
sleeping pattern
falling or that are associated to rest and sleep at a
Norepinephrine pattern. Short term objective
remaining with the environment. time when more rest
sleep Short Term is needed.
Objective 3. Observe and 3.To determine After of 8 hours
>lack of After of 8 obtain feedbacks usual sleeping of nursing
interest in hours of regarding on the pattern and to intervention the
activities Hypothalamus ad nursing usual sleeping compare if there are client was able
cerebral cortex intervention pattern, bedtime any improvements to have good
the client’s routine and the usual on the sleeping quality of sleep
will be able to number of hours of pattern of the
have good sleep and rest. patient.
serotonin and GABA quality of
sleep. 4. Do as much care 4. To avoid
as possible without disturbances during
waking up the client sleep, and also to
and do as much care maximize the sleep
send nerve impulse and rest of the client.

42
 REPUBLIC of the PHILIPPINES
City of Makati
UNIVERSITY OF MAKATI
COLLEGE OF ALLIED HEALTH STUDIES
J. P. Rizal Extension, West Rembo, Makati City 1215
Telephone No. : (+632) – 881 – 1571
_____________________________________________________________________________________
CENTER OF NURSING
as possible while the
client is still awake.
activates reticular
activating system 5. Explain 5. For the
(RAS) necessity patient to
of disturbances for have an
monitoring Vital understanding
Signs and care when of the
REN&NREM hospitalized. importance of
care being
done to her
and to
minimize the
Disturbed sleeping complaints.
pattern

Reference:

Kozier & Erbs.

Fundamentals of
Nursing 8th edition
Volume II, pp.1163-
1171
Reference:

43
 REPUBLIC of the PHILIPPINES
City of Makati
UNIVERSITY OF MAKATI
COLLEGE OF ALLIED HEALTH STUDIES
J. P. Rizal Extension, West Rembo, Makati City 1215
Telephone No. : (+632) – 881 – 1571
_____________________________________________________________________________________
CENTER OF NURSING
Assessment Nursing Inference Planning Intervention Rationale Evaluation
Diagnosis
Subjective Risk for Decrease in fluid 1. assess patients 1. patient who Long term
Cues electrolyte intake Long Term fluid status demonstrate fluid Objective
imbalance Objective volume alterations After of 24
are likely to have hours of
During nursing
Objective Increase in sodium electrolyte
confinement intervention
Cues alterations as well.
the client and the client
healthcare reported
Lack of Loss of water 2. Monitor patient for 2. many cardiac,
team will be improvement
interest in physical sign of neurological and
able to in quality
food electrolyte imbalance musculoskeletal
prevent fluid sleeping
Isotonic fluid deficit in symptoms are
electrolyte pattern
Decreased ECF compartment indicative of
imbalance Short term objective
skin turgor specific electrolyte
Short Term abnormalities
Pale Dehydration Objective 3. educate patent and After of 8 hours
conjunctiva family regarding risk 3. Early of nursing
After nursing for electrolyte identification and intervention the
Body Hypovolemia intervention disturbances intervention may client was able
weakness the client will associated with their prevent life to have good
be able to particular medical threatening quality of sleep
Dry lips Generalized body show condition and possible complications of
weakness, improvement intervention if electrolyte
in hydration symptoms occur imbalance.
status

Electrolyte
imbalance

44