NURSING CARE PROCESS

Name of Patient: Patient M Age: 81 Sex: Female Civil Status: Room/Bed No.
Medical /Surgical Diagnosis: Assessment date: Intervention date:
Prepared by: Darwin F. Andal Section/Grp No. : Section 1 CI/Supervisor: Prof. Toni Notario
Cues Nursing Analysis Goals and Implementation Rationale Evaluation
Diagnosis Objective

Subjective cues: Stem: SCIENTIFIC Long-term Goal:

 I am just Ineffective health ANALYSIS
afraid I maintenance After of one hour and 30
might Ineffective health minutes of nursing
stumble Related to maintenance is the intervention and health
down Ineffective choices in inability to identify, teaching the patient will
anytime daily living for manage, and/or seek adhere to appropriate
because I meeting health goals out help to maintain changes in nutritional
sometimes health (NANDA-I). pattern and behaviors,
loose AEB this is the State in including eating patterns,
balance. which a person food quantity/quality, and
 not taking experiences or is at exercise that will help to
 I am glad I any risk of experiencing normalize her laboratory
am not medication a disruption in health results.
taking any s because of lack of
medications  eating knowledge to Objectives:
and still able anything manage a condition
or basic health 1. After 30 mins of the The nurse will Having an active Was the patient will
to eat she wants
requirements discussion the patient will demonstrate and discuss lifestyle will help to able to list and
anything I  low able to list and
want hemoglobin Health maintenance 8 activities and exercises Reduce the risk of dying demonstrate 5 out of 8
is a very crucial demonstrate 5 out of 8 that will help the patient from coronary heart activities and exercises
Objective cues:  high activities and exercises to
Vital signs sodium process to a person to normalize her disease and of ✓ Met
because he/she needs attain normal laboratory laboratory and ask the developing high blood
 BP- 120/90.  high uric results with optimal
 PR- 81; acid to maintain a healthy patient to list and pressure, colon cancer, _Partially
body with proper maintenance of health. explain. and diabetes.
 RR-17  normal
 Temp- 36.5 blood sugar functioning at all (Center for Disease
_Unmet
times. It is a crucial Control and Prevention,
 BMI = 22.2  borderline 2. After 15 mins of
process because it 2000)
Laboratory results (near high) discussion
entails a lot of
 low cholesterol The client will able to
resources in Maintaining a nutrient-
hemoglobin  low demonstrate how to create Was the patient able to
maintaining one’s The nurse will dense diet is critically
 high sodium calcium, a 3 healthy meal plan that demonstrate how to
health. demonstrate the 5 ways important for older
 high uric potassium. will help to normalize her create a 3 healthy meal
to create a meal plan adults because of the
acid that will help to impact of food intake on plan
Carpenito-Moyet, L.
 normal normalize her health. Years of ✓ Met
J. (2013). Nursing
blood sugar research have
diagnosis:
 borderline demonstrated that diet

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 (near high) Application to quality has a huge effect _Partially
cholesterol clinical practice. on physical condition,
 low calcium, cognitive condition, _Unmet
potassium. bone health, eye health,
 Chest x-ray SITUATIONAL vascular function, and
is normal . ANALYSIS: the immune system.
 orange to ( Institute of Medicine
brown (US) Food Forum.,
In the case given the 2010)
cerumen in patient a 81 year old
both ears. woman shows that
 Urinalysis she has a lack of
reveals 9-10 3. after 30 minutes of Home blood pressure
knowledge to health teaching the patient The nurse will monitoring — one week
WBC. manage her or her caregiver will able demonstrate how to use per month — was
condition or basic Was the patient able to
to use devices sphygmomanometer and sufficient to guide
health requirements demonstrate how to
(sphygmomanometer and glucometer and the people to better blood
because she is not use
glucometer) that will help patient will do a return pressure control. While
taking any sphygmomanometer
her can help her to demonstration of using Regular blood sugar
medications and still and glucometer
monitor her vitals. sphygmomanometer and monitoring is the most
able to eat anything I glucometer important thing you can
want as result her ✓ Met
do to manage the risk of
laboratory results having type 1 or type 2
have several diabetes _Partially
deviations (Harvard Health
Publishing, 2018) _Unmet

Was the patient able to

4. After 15 mins. of
discussion the patient will
reflect and state 3 health
behaviors that is not
helpful for her health.
The nurse will discuss Having a healthy reflect and state 3
the 10 benefits of lifestyle is an important health behaviors that is
adhering to a healthy part of staying healthy not helpful for her
lifestyle and the patient as you age. It can help health.
will reflect if her health you maintain a healthy
behaviors is helpful or weight, stay energized, ✓ Met
not helpful for her and get the nutrients
health. you need. _Partially
(Butler, RD, LD, 2019)
_Unmet

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**FONT SHOULD BE TIMES NEW ROMAN, ARIAL or CALIBRI FONT SIZE 9 OR LARGER ***