M.

Top Three Nursing Care Plan

ASSESSMENT NURSING PLANNING NURSING INTERVENTION RATIONALE EVALUATION

DIAGNOSIS
Subjective: Impaired Gas Short term: 1. Place patient with 1. A sitting position permits Short term:
“naninikip ang exchange related After 3hours of proper body alignment maximum lung excursion After 3hours of nursing
pakiramdam ko to ECG result of nursing for maximum breathing and chest expansion. interventions, the client was
nahihirapan ventricular rate interventions, pattern. 2. These measures allow able to maintain improve
akong huminga” of 167/min the client will 2. Teach patient about: patient to participate in ventilation and is more
as verbalized by be able maintaining health status relaxed in her position than
the patient demonstrate a pursed-lip breathing and improve ventilation. before.
more relaxed
body posture Long Term:
and improve abdominal breathing After 4 days of nursing
Objective ventilation interventions, the client
Long Term: performing relaxation reported an ECG result of
ECG Result of After 4 days of sinus tachycardia with
Sinus Tachycardia nursing techniques ventricular result of 107/min
with Ventricular interventions,
Rate of 167/min the client will performing relaxation
be able to
techniques
report a
decrease in
ventricular rate taking prescribed medications
via ECG result
scheduling activities to avoid
fatigue and provide for rest
periods

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 ASSESSMENT NURSING PLANNING NURSING INTERVENTION RATIONALE EVALUATION
DIAGNOSIS
Knowledge Short term: 1. Establish rapport 1. To gain the trust of the Short term:
Objective deficit regarding After 3hours of patient After 3 hours of nursing
condition and nursing 2. Evaluate 2. Determine amount/level interventions, the client was
 Refusal to treatment related interventions, desire/readiness of of information to provide able to know and understand
seek to absence of the client will at any given moment the disease and is eager to
medical compliance after be able to patient to learn learn more about her
advice after first bleed know and 3. Assess motivation and 3. Some patient are ready to condition.
first bleed episode understand the cope with the situation,
willingness of patient
episode disease and other patients are better
process of the to learn denying or delaying the Long Term:
treatment by need of information After 4 days of nursing
verbalizing and interventions, the client was
participating in able to initiate lifestyle
learning changes by maintaining her
process. diet and coping up with her
treatment regimen.
Long Term:
After 4 days of
nursing
interventions,
the client will
be able to
initiate
lifestyle
changes.

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 ASSESSMENT NURSING PLANNING NURSING INTERVENTION RATIONALE EVALUATION
DIAGNOSIS
Activity Short term: 1. Assess patient’s ability 1. Influences choices of Short term:
Objective intolerance After 3hours of to perform normal interventions or needed After 3 hours of nursing
 Lethargic related to low nursing tasks/daily activities assistance interventions, the client was
 CBC result Hgb of 112g/L interventions, 2. Note changes in 2. May indicate neurologic able to demonstrate reduction
of low Hgb and low the client will balance/gait, changes associated with in physiologic signs of
of 112g/L potassium level be able to disturbance, muscle vitamin b12 deficiency intolerance and was able to
 Potassium of 3.94mmol/L report an weakness affecting safety do daily activities with more
test result of increase in 3. Recommend quiet 3. Enhances rest to lower ease.
3.94mmol/L activity atmosphere, bed rest if body’s oxygen
intolerance indicated requirements Long Term:
including daily 4. Elevate head of the bed 4. Enhances lung expansion After 4 days of nursing
activities and as tolerated to maximize cellular interventions, the client
decrease 5. Provide or recommend respiration reported a CBC result of Hgb
physiological assistance in activities 5. Help is necessary but 123g/L and potassium level
signs to or ambulation as self-esteem is also of 4.14mmol/L.
intolerance. necessary, allowing enhanced when patient
patient to do as much does things for herself
Long Term: as possible
After 4 days of
nursing
interventions,
the client will
report an
improvement
in laboratory
results.

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