JH CERILLES STATE COLLEGE

in consortium with
Western Mindanao State University
West Capitol Road, Balangasan District, Pagadian City

PATIENT INITIALS : P.L DATE :

STUDENT NURSE : Group 3 Student Nurse AREA of ROTATION : Out-Patient Department
YEAR LEVEL and BATCH : II - Merakia CLINICAL INSTRUCTOR : Alfred Zomar B. Bongolan MN
NURSING CARE PLAN
ASSESSMENT DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATION
Subjective cue: Impaired skin The Patient will a. Assess sensation a. Decreased sensation
integrity related to be able to display of affected area may put the patient at risk The Patient was able
physical improvement in b. Note skin color, for developing pressure to:
immobilization as skin integrity as texture and turgor ulcer and skin infection a. display
Objective cue: c. Palpate skin
evidence by reports of evidence by: b. Proper skin timely healing of
lesion for size, shape,
Blood Pressure:100/70 itching, pain and a. heal skin assessment and skin lesions
numbness of affected lesions consistency, texture, documentation facilitates b. increased
mmHg area b. increase temperature and prevention of the sensation
sensation hydration breakdown of skin c. absence of
Weight: 60 kg c. absence of breakdown which is the redness
redness body’s first line of defense
against pathogens.
Changes of skin lesion for
size, shape, consistency,
texture, temperature and
hydration may indicate
vascular or neurologic
problems such as peripheral
neuropathy
 JH CERILLES STATE COLLEGE
in consortium with
Western Mindanao State University
West Capitol Road, Balangasan District, Pagadian City

PATIENT INITIALS : P.L DATE :

STUDENT NURSE : Group 3 Student Nurse AREA of ROTATION : Out-Patient Department
YEAR LEVEL and BATCH : II - Merakia CLINICAL INSTRUCTOR : Alfred Zomar B. Bongolan MN
NURSING CARE PLAN
ASSESSMENT DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATION
The Patient will be a. Identify The Patient was able
Disturbed sleep able to: presence of factors a. Sleep to:
Subjective cue: pattern related to a. report improve known to interfere with problems can arise a. report improve sleep
sleep, including current from internal and
interruption sleep b. report increase sense
illness external factors and
b. report increase b. Perform of well-being and
may require
Objective cue: sense of well-being monitoring and care assessment over time feeling rest
and feeling rest activities without to differentiate c. identify individually
Blood Pressure:100/70 c. identify waking client whenever specific cause appropriate
individually possible b. Allows for interventions to
mmHg appropriate Provide bedtime care longer periods of promote sleep
interventions to such as straightening uninterrupted sleep,
Weight: 60.3 kg bed sheets, changing especially during
promote sleep
damp linens or gown, night
c. To promote
back massage
physical comfort
 JH CERILLES STATE COLLEGE
in consortium with
Western Mindanao State University
West Capitol Road, Balangasan District, Pagadian City

PATIENT INITIALS : P.L DATE :

STUDENT NURSE : Group 3 Student Nurse AREA of ROTATION : Out-Patient Department
YEAR LEVEL and BATCH : II - Merakia CLINICAL INSTRUCTOR : Alfred Zomar B. Bongolan MN
NURSING CARE PLAN
ASSESSMENT DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATION

Impaired social The Patient will be a. Determine a. Affects ability The Patient was able
Subjective cue: interaction related to able to: patient’s use of coping to be involved in social to:
skills and defense situations
therapeutic isolation a. verbalize a. verbalize awareness
mechanisms b. Enhances
as evidence by awareness of factors comfort with new of factors causing
b. Role plays
Objective cue: discomfort in social causing impaired changes and discusses behavior impaired social
interaction social interaction impact c. Encourages interaction
Blood Pressure:120/70 b. express desire for c. Provide positive continuation of desired b. express desire for
positive changes in reinforcement for behaviors and efforts positive changes in
mmHg social behaviors and improvement in social for changes social behaviors and
interpersonal behaviors and interpersonal
Weight: 63 kg interactions
relationship relationship
HR: 61bpm c. give positive c. give positive
reinforcement for reinforcement for
changes that are changes that are
achieved achieved