URDANETA CITY UNIVERSITY

COLLEGE OF NURSING

NURSING CARE PLAN

MONTH/YEAR OF EXPOSURE: JUNE 24-JULY 5,2019
AFFILIATING AGENCY/AREA: MANILA AFFILIATION-PHILIPPINE ORTHOPEDIC CENTER
ASSESSMENT NURSING PLANNING INTERVENTION RATIONALE EVALUATION
DIAGNOSIS

Subjective Data: Risk for malnutrition Short Term Goal: Independent: Short Term Goal:
related to surgery as  After 8hours of
“walang ganang kumain manifested by decrease  After 8hours of  Explain the benefits  To gain nursing
ang anak ko” as weight nursing of eating a necessary participation in intervention, the
verbalized by the mother intervention diet current diet patients appetite
Scientific explanation patient will able  promote pleasant required has improved as
Objective Data: to regain and relaxing  To enhance food evidence by
Surgery → post trauma considerable environment intake weight gain
 Decrease food ↓ appetite for food
and fluid intake Poor environment  minimize unpleasant  To prevent Long term Goal:
 Intake of multi- ↓ Long Term Goal: odors negative effect  After a week of
vitamins Loss of appetite on appetite nursing
 Loss of weight ↓  Patient will  Provide  Attention to the intervention ,
 Lack of interest Risk for malnutrion gradually gain companionship social the patient
in food weight after a during mealtime perspective of regain normal
week of eating is weight as
Vital signs: continued important evidence by
appetite  Consider six small  To lessen the weight gain
BP: 90/60mmHg nutrient-dense meals feeling of from 28kg to
PR: 89/min fullness 30kg
RR: 21/bmp
T: 36’
 URDANETA CITY UNIVERSITY
COLLEGE OF NURSING

ASSESSMENT NURSING PLANNING INTERVENTION RATIONALE EVALUATION

DIAGNOSIS

Medical Diagnosis:  Promote adequate  To lessen

timely intake of fluid dehydration
 Pin tract
infection at Dependent:
Left elbow  Administer  To supplement
Multivitamins lack of
supplement as vitamins
ordered by the
physician

Collaborative:  For the diet

 Consult with necessary for
dietician for the patient
further
assessment and
recommendations
to support
nutritional needs

Prepared by: Submitted to:

Alexandra T. Manzano Mr. Rodney E. Salagubang, PTRP., RN., MAN.

Name of Student Clinical Instructor
BSN III June 24 to July 5, 2019