NURSING CARE PLAN
NURSING OBJECTIVE OF NURSING INTERVENTION
DIAGNOSIS CARE
ASSESSMENT EVALUATION
S: “Pila na ka adlaw Impaired Physical After 8 hours of care, Established rapport Partially Met.
wala ko nakapasahero Mobility related to the patient will report Vital Signs taken and
After nursing
tungod ga luya akoang body weakness and decreased pain and Recorded
interventions, the
kalawasan ug sakit joint pain as improved comfort, Assessed pain level using a
patient verbalized
akoang tuhod inig evidenced by allowing for pain scale.
relief from pain and
akung ilakaw” as difficulty in increased ease in Administered due medications
expressed improved
verbalized by the performing activities performing ADLs. as prescribed to manage pain
comfort, but may still
patient. of daily living (ADLs) and discomfort.
experience some
and reported Repositioned the patient to
O: limitations in mobility.
discomfort during ensure comfort and promote
Facial movement. rest.
grimace Assessed the patient’s dietary
noted (pain intake and encouraged a
scale 8/10) NEEDS: balanced diet rich in nutrients.
Decreased in Monitored for signs and
PHYSIOLOGICAL
Range of symptoms of increased pain or
NEEDS
Motion discomfort to respond to any
Body changes in condition.
Malaise/Bod Educated patient and
y Weakness encouraged in Rage of Motion
(ROM) exercises as tolerated
to maintain joint flexibility and
reduce stiffness, and to
promote independence and
strength.
Attended to patient needs
promptly to reduce anxiety and
enhance comfort.
Provided care that addressed
physiological needs, focusing
on comfort and pain
management.
NURSING CARE PLAN
NURSING NURSING INTERVENTION
ASSESSMENT DIAGNOSIS OBJECTIVE OF EVALUATION
CARE
S: “Sakit kaayo akong Acute Pain related After 8 hours of Established rapport After 4 hours
tuhod.” As verbalized to joint inflammation nursing care the Vital signs taken and of nursing care
by the patient. as evidenced by the patient pain will be recorded the patient
patient’s verbal relieve and pain will Administered prescribed pain was
O: report/verbalized of reduce from 8/10 medicine relieved
Restlessnes pain at a level of Teach patient about range Pain scale
s noted 8/10 of motion exercises that he from 8/10 to
Facial can perform 2/10
grimace Encourage patient
noted (pain frequent changes of Goal Met
scale 8/10) position
Assess and monitor pain
NEEDS: level regularly
Encourage rest period
PHYSIOLOGICAL
between activities
NEEDS
Due meds given
Watched out for
unusualities
NURSING CARE PLAN
ASSESSMENT NURSING OBJECTIVE OF NURSING INTERVENTION EVALUATION
DIAGNOSIS CARE
S: '' Dili ko kaayo ka Disturbed Sleep Within 8 hours of Established rapport with the After 8 hours of
tarong ug tulog maam Pattern related to nursing interventions patient. implementing nursing
kay usahay ga sakit pain secondary to the patient will report a Assess patient’s pain levels interventions, the patient
akong tuhod taga knee discomfort as reduction in knee pain and sleep disturbances was reassessed for knee
kadlawon." as evidenced by the intensity to a level of 6 Motivate the patient to pain intensity and reported
verbalize by the patient's report of or below on a scale of document their sleep a pain level of 5 on a scale
patient difficulty sleeping 2/10. patterns, including duration of 2/10, indicating that the
and waking up due and disturbances objective of reducing pain
O: to knee pain during Educate the patient on how intensity to 6 or below was
Restless sleep early morning hours. engaging in regular met, demonstrating the
Signs of physical activity can help effectiveness of the
discomfort manage knee pain and interventions; therefore,
Awakenings at improve sleep further monitoring and
night Evaluate the patient's sleep continued pain
NEEDS: environment management strategies
Physiological Needs assess the patient’s will be essential to
emotional state for signs of maintain this improvement.
anxiety or depression that
may be impacting their
sleep quality and pain
perception
Encourage Limitations on
Daytime Napping
Explain the role of pain
management in improving
sleep quality
NURSING CARE PLAN
ASSESSMENT NURSING DIAGNOSIS OBJECTIVE OF NURSING RATIONALE EVALUATION
CARE INTERVENTION
S: Knowledge Deficient Within 8 hours of Established rapport Good rapport fosters Within 8 hours of
“"dili ko permi naga related to inadequate nursing with the patient. open, honest nursing
inom ug tambal understanding of interventions the Assess Patient’s communication, which interventions the
maam kay diabetes management patient will be Knowledge and helps healthcare patient verbalized
mahadlok ko na and importance of able to verbalize Misconceptions providers gather an understanding
basig ma apektuhan medication adherence an About Diabetes and accurate information, of the role of
akoang atay sa ka as evidenced by understanding of Its Treatment educate patients medication in
daghan nakog inconsistent medication the role of Provide Clear, effectively, and diabetes
tambal na gina intake and elevated medication in Simple Education address any management and
inom" as verbalized blood glucose levels. diabetes on the Mechanism misunderstandings. committed to a
by the patient.” management of Diabetes Identifying specific regular medication
and commit to a Medications knowledge gaps or schedule.
O: NEEDS: regular Explain the Long- misconceptions allows
Inconsistent Physiological Needs medication Term Benefits of for more personalized
medication schedule. Medication in education that
intake Preventing addresses the
high blood Diabetes patient’s particular
glucose Complications concerns and beliefs.
readings Discuss the
Importance of Explaining how the
Lifestyle Changes medications help
as a Complement manage blood glucose
to Medication. can clarify their role,
Encourage the reduce anxiety about
Patient to Ask taking them, and
Questions and
Voice Concerns improve adherence.
During Helping the patient
Appointments. understand how
Collaborate with medication adherence
the Patient to Set can prevent
Realistic, Short- complications like
Term Goals for neuropathy, vision
Medication loss, and kidney
Adherence. disease.
Educating the patient
that diet, exercise, and
stress management
enhance, medication
can encourage them
to see medications as
part of a complete
treatment plan.
Allowing the patient to
express concerns
fosters a collaborative
approach, improves
their understanding,
and builds trust in the
care plan.
Small, achievable
goals, such as taking
medications daily for
one week, can give
the patient a sense of
accomplishment and
reinforce adherence.
NURSING CARE PLAN
NURSING
ASSESSMENT DIAGNOSIS OBJECTIVE OF NURSING RATIONALE EVALUATION
CARE INTERVENTION
S: Risk for Within 8 hours of Established rapport with to create a calm and Within 8 hours
“Minsan makalimot ko unstable blood nursing the patient. safe environment to of nursing
og inom sakong glucose level intervention the Assessed and recorded ensure patient intervention
tambal, hantud wala related to patient will able patient vital signs. cooperation with health the patient
nako ga inom kay inadequate to acknowledge Patients IV flow rate care staff. was able to
nahadlok ko kay ingon adherence to factors that may monitored and Establishing baseline, acknowledge
daw nila maka sira og therapeutic lead to unstable regulated and ensured regular recording of vital factors that
atay ang tambal nako” regimen. glucose level, patient IV line patency. signs creates a baseline may lead to
As verbalized by the verbalize Ascertained the for each patient, which unstable
patient. understanding of patient’s and significant can be useful for glucose level,
NEEDS: body and energy other’s knowledge, comparison verbalize
O: Physiological needs, and. perception and To ensure the patient understanding
Temp: 36.6 C. Needs understanding of the receives the correct of body and
BP: 110/80 Mmhg . condition and amount of fluids and energy needs,
PR: 85 Bpm treatment. prevent complications and
RR: 21 Cpm Provided information on These factors influence
Spo2: 98% balancing food intake, a patient’s ability to
antidiabetic agents and manage hi condition
energy expenditure. and must be considered
Reviewed the patient’s when planning.
diet, especially this knowledge
carbohydrate intake. empowers patients to
Encouraged the patient manage their condition
to read labels and effectively. And remove
choose carbohydrates fear of taking
described as low
glycemic index and medications.
foods with adequate Glucose balance is
protein, high fiber and determined by the
low-fat content. amount of
carbohydrates
consumed.
These foods produce
and slower rise in blood
glucose and more
stable release of insulin.
