VISION

Republic of the Philippines MISSION

A premier university in CAVITE STATE UNIVERSITY Cavite State University shall provide
historic Cavite recognized Don Severino Delas Alas excellent, equitable and relevant
for excellence in the Campus educational opportunities in the arts,
development of morally science and technology through quality
upright and globally
Indang, Cavite instruction and relevant research and
competitive individuals. development activities. It shall produce
College of Nursing professional, skilled and morally upright
individuals for global competitiveness.

NURSING CARE PLAN

Name of Patient (initials): R.A.C. Date: 11-29-22

Age/Sex: M Diagnosis: Ineffective airway clearance related to loss ciliary
action, increased amount of secretion and increased airway
resistance as evidenced by dyspnea

NURSING
ASSESSMENT NURSING DIAGNOSIS PLANNING RATIONALE EVALUATION
INTERVENTION
Subjective Data: Ineffective airway After 5 hours of effective 1. Auscultate lungs 1. Abnormal breath After 5 hours of effective
“may ubo, sipon at hirap clearance related to loss nursing intervention the for presence of sounds can be nursing intervention the
huminga” ciliary action, increased client will be able to; normal or heard as fluid and goal was met the client
amount of secretion and 1. maintain clear, adventitious mucus able to;
increased airway open airways as breath sounds accumulate. This 1. maintain clear,
resistance as evidenced evidence by may indicate open airways as
by dyspnea. normal breath ineffective airway evidence by
sounds, normal clearance. normal breath
rate and depth of 2. Teach the patient 2. The most sounds, normal
respirations, and the proper ways of convenient way to rate and depth of
Objective Data: ability to coughing and remove most respirations, and
effectively cough breathing. (e.g., secretions is ability to
V/S: T - 36.6 up secretions after take a deep coughing. So it is effectively cough
PR – 161 treatments and breath, hold for 2 necessary to up secretions after
deep breaths. seconds, and assist the patient treatments and
(+) dyspnea 2. demonstrate cough two or three during this activity. deep breaths.
increased air times in Deep breathing, 2. demonstrate
exchange. succession). on the other hand, increased air
promotes exchange.
oxygenation
before controlled
coughing.
3. Encourage patient 3. Fluids help
to increase fluid minimize mucosal
 intake to 3 liters drying and
per day within the maximize ciliary
limits of cardiac action to move
reserve and renal secretions.
function.
4. Give medications 4. A variety of
as prescribed, medications are
such as prepared to
antibiotics, manage specific
mucolytic agents, problems. Most
bronchodilators, e promote clearance
xpectorants, of airway
noting secretions and
effectiveness and may reduce
side effects. airway resistance.

5. Instruct patient 5. Hydration

guardian about the facilitates easy
need for adequate elimination of
fluid intake even secretions.
after hospital
discharge.

Submitted by: Aeron Waleed A. Palileo Submitted to: Ederlyn P. Destura RN, MAN
Year/Section/Group: BSN 4A-2/Group 2 Date:
Name of Patient (initials): M.C, Date: 11-29-22
Age/Sex: F Diagnosis: Acute pain related to acidic irritation of gastric
mucosa as evidenced by the client’s verbal report and
alteration of vital signs.
NURSING
ASSESSMENT NURSING DIAGNOSIS PLANNING RATIONALE EVALUATION
INTERVENTION
Subjective Data: Acute pain related to After the end of shift, 1. Perform a 1. The patient Goal was met as
“masakit ang tiyan ko” as acidic irritation of gastric the client will be able to; comprehensive experiencing pain evidenced by the client
verbalized by the client mucosa as evidenced by 1. decrease her pain assessment of is the most reliable pain score from 4 to 0.
the client’s verbal report scale from 4 to 0. pain. Determine source of
and alteration of vital the location, information about
signs. characteristics, their pain. Their
onset, duration, self-report on pain
frequency, quality, is the gold
and severity of standard in pain
Objective Data: pain via assessment as
assessment. they can describe
V/S: T – 36.1 the location,
PR – 90 intensity, and
R – 15 duration. Thus,
BP – 100/70 assessment of
O2 – 97 pain by conducting
Pain scale – 4/10 an interview helps
(+) grimace the nurse in
planning optimal
pain management
strategies.

2. Using charts or
2. Assess the drawings of the
location of the body can help the
pain by asking to patient, and the
point to the site nurse determines
that is specific pain
discomforting. locations.

3. It is preferable to
3. Provide measures provide an
to relieve pain analgesic before
before it becomes the onset of pain
severe. or before it
 becomes severe
when a larger
dose may be
required. An
example would be
preemptive
analgesia, which
is administering
analgesics
before surgery to
decrease or
relieve pain after
surgery. The
preemptive
approach is also
useful before
painful procedures
like wound
dressing changes,
physical
therapy, postural
drainage, etc.
4. Acknowledge and
accept the client’s 4. Nurses have the
pain. duty to ask their
clients about their
pain and believe
their reports of
pain. Challenging
or undermining
their pain reports
results in an
unhealthy therape
utic
relationship that
may hinder pain
management and
deteriorate
5. Provide
rapport.
nonpharmacologic
pain management.
5. Nonpharmacologic
methods in pain
management may
 include physical,
cognitive-
behavioral
6. Provide
strategies, and
pharmacologic
lifestyle pain
pain management
management.
as ordered.
6. Pain management
using
pharmacologic
methods involves
using opioids
(narcotics),
nonopioids
(NSAIDs), and
coanalgesic drugs.

Submitted by: Aeron Waleed A. Palileo Submitted to: Ederlyn P. Destura RN, MAN
Year/Section/Group: BSN 4A-2/Group 2 Date:

Name of Patient (initials): M.C,

Age/Sex: F
 Diagnosis: Deficient knowledge related to lack of information
Date: 11-29-22 or recall as evidenced by verbalization of the problem.

NURSING
ASSESSMENT NURSING DIAGNOSIS PLANNING RATIONALE EVALUATION
INTERVENTION
Subjective Data: Deficient knowledge After 3 hours of 1. Define and state 1. Provides the basis After 3 hours of
related to lack of effective nursing the limits of for understanding effective nursing
“nahihilo ako” as information or recall as intervention, the client will desired BP. elevations of BP intervention, goal was met
verbalized by the client evidenced by be able to; Explain and clarifies the client able to;
verbalization of the 1. Patient will hypertension and frequently used 1. verbalize
problem. verbalize its effects on the medical understanding of
understanding of heart, blood terminology. disease process
disease process vessels, kidneys, Understanding and treatment
Objective Data: and treatment and brain. that high BP can regimen.
regimen. exist without 2. Patient BP returns
V/S: T – 36 2. Patient will symptoms is to within
PR – 57 maintain BP within central to enabling individually
R – 17 individually the patient to acceptable
BP – 180/100 acceptable continue parameters.
O2 – 95 parameters. treatment, even
when feeling well.
2. Assist patient in 2. These risk factors
identifying have been shown
modifiable risk to contribute to
factors (obesity; a hypertension and
diet high in cardiovascular
sodium, saturated and renal disease.
fats, and
cholesterol;
sedentary lifestyle;
smoking; alcohol
intake of more
than 2 oz per day
regularly; stressful
lifestyle).
3. Reinforce the 3. Lack of
importance of cooperation is a
adhering to common reason
treatment for the failure of
regimens and antihypertensive
keeping follow-up therapy.
appointments. Therefore,
 ongoing
evaluation for
patient
cooperation is
critical to
successful
treatment.
Compliance
usually improves
when the patient
understands the
causative factors
and
consequences of
inadequate
intervention and
health
maintenance.
4. Instruct and 4. Monitoring BP at
demonstrate the home is
technique of BP reassuring to
self-monitoring. patients because it
Evaluate patient’s provides visual
hearing, visual and positive
acuity, manual reinforcement for
dexterity, and following the
coordination. medical regimen
and promotes
early deleterious
changes.
5. Explain the 5. Excess saturated
rationale for the fats, cholesterol,
prescribed dietary sodium, alcohol,
regimen (usually a and calories have
diet low in sodium, been defined as
saturated fat, and nutritional risks in
cholesterol). hypertension. A
diet low in fat and
high in
polyunsaturated
fat reduces BP,
possibly through
prostaglandin
 balance in both
normotensive and
hypertensive
people.
6. Rise slowly from a 6. Measures reduce
lying to a standing the severity of
position, sitting for orthostatic
a few minutes hypotension
before standing. associated with
Sleep with the the use of
head slightly vasodilators and
elevated. diuretics.
7. Antihypertensives: 7. Because patients
Take prescribed often cannot feel
doses regularly; the difference the
avoid skipping, medication makes
altering, or making in blood pressure,
up doses; and do it is critical to
not discontinue understand the
without notifying medications’
the healthcare working and side
provider. Review effects. For
potential side example, abruptly
effects and/or drug discontinuing a
interactions; drug may cause
rebound
hypertension
leading to severe
complications, or
medication may
be altered to
reduce adverse
effects.

Submitted by: Aeron Waleed A. Palileo Submitted to: Ederlyn P. Destura RN, MAN
Year/Section/Group: BSN 4A-2/Group 2 Date:
 DRUG STUDY

Name of Patient (initials): ______________________ Age & Sex: _____________________

DRUG MECHANISM OF INDICATION CONTRAINDICATIONS EFFECTS NURSING

ACTION RESPONSIBILITIES
Generic Name: Iron is necessary for Ferrous sulfate is - Patient allergic to the Side Effects: Client education:
Ferrous Sulfate maintaining good health, used for the drug - Dark-colored - Take medication
especially in the prevention and - Patient with urine - between meals with
Brand Name: formation of red blood treatment of iron hemochromatosis - Constipation, orange juice or
Fersulfate Iron cells (RBC), which deficiency anemia in - Hemosiderosis diarrhea, nausea vitamin C supplement
transport oxygen adults and children. - Any that is not cause - Leg cramps - Increases iron
Classification: throughout the body. A by iron deficiency absorption; decreases
Iron Supplements lack of iron means that Adverse Effects: metallic taste
the body is unable to - Fever - May take medication
Dosage: manufacture enough with food to decrease
- Shallow
350mg healthy red blood cells. gastrointestinal side
breathing,
effects
weakness, weak
Route: - Avoid taking
but fast
PO medication with
heartbeat
dietary fiber, eggs,
Frequency: - Pale or clammy milk, coffee, or tea
OD skin - Remain upright for at
- Severe or least 30 minutes after
Form: continuing administration
Tablet stomach
cramps, vomiting
(with or without
blood)
- Bloody diarrhea
- Bluish-colored
lips, hands, or
fingernails
- Chest pain
 DRUG STUDY

Name of Patient (initials): ______________________ Age & Sex: _____________________

DRUG MECHANISM OF INDICATION

ACTION
Generic Name: The mechanism of its Indicated to patients
Paracetamol analgesic effect has not with:
been fully determined but - Headache
Brand Name: may be associated with - Tension
Biogesic the inhibition of headache
prostaglandin synthesis - Migraine
Classification: in the CNS and to a - Backache
Analgesic lesser extent, through - Rheumatic
Anti-pyretic peripheral blockage of and muscle
pain-impulse generation. pain
Dosage: It produces antipyresis - Mild
500mg by inhibiting the arthritis/osteoa
hypothalamic heat- rthritis
Route: regulating centre. - Toothache
PO - Period pain
(dysmenorrhe
Frequency: a)
Q4 - Colds and flu
symptoms
Form: - Sore throat
Tablet - Sinus pain
- Post-operative
pain
- Fever (pyrexia
)