NURSING CARE PLAN
Identified Problem: Overweight
Nursing Diagnosis: Imbalanced Nutrition: More Than Body Requirements as evidenced by BMI > 25
CUES
Subjective:
“Ganahan man gud kaayo ko
mukaon ug mga tambok oy.
Mao man gud na sila ang lami.
Pero ga avoid naman ko ug
mga ing ana bag o lng. Pero
syempre, dli man pud ma dali2
ug ubos atong timbang.”
Objective:
 Height: 5’1” ft
 Weight: 68 kg
 BMI: 28.3
OBJECTIVES INTERVENTIONS RATIONALE EVALUATION
Short term: Independent: Independent: Short term:
After 4 hours of nursing care 1. Assess the effects or complications of 1. Medical complications Goal Met
and health teaching, the being overweight. include cardiovascular and
patient will be able to: respiratory dysfunction, After 4 hours of nursing care and
 Claim ownership for sleep-disordered breathing, health teaching, the patient was
current eating higher incidence of be able to:
patterns. diabetes mellitus, and  Claim ownership for
 State related factors aggravation of current eating patterns.
contributing to weight musculoskeletal disorders.  State related factors
gain. Social complications and contributing to weight
 Verbalize measures poor self-esteem may also gain.
necessary to attain result from obesity.  Verbalize measures
beginning weight 2. Assess dietary intake through 24-hour necessary to attain
reduction. recall or questions regarding usual intake 2. Data may not be fully beginning weight
 Identify behaviors that of food groups. accurate. Permits appraisal reduction.
remain under his or of patient’s knowledge  Identify behaviors that
her control. about diet also. remain under his or her
 Organize relevant 3. Know patient’s knowledge of a nutritious control.
activities requiring diet and need for supplements. 3. This information is helpful  Organize relevant
energy expenditure in developing an activities requiring energy
into daily life. individualized teaching plan expenditure into daily life.
 Design dietary based on patient’s current  Design dietary
modifications to meet state. modifications to meet
individual long-term 4. Determine the patient’s readiness to individual long-term goal
goal of weight control, initiate a weight loss regimen by asking 4. More specific directions of weight control, using
using principles of questions such as the following: regarding weight loss can principles of variety,
variety, balance, and be addressed if the patient balance, and moderation.
How do you feel about starting a weight is in the preparation or
moderation.  Express willingness to
loss program? action stages.
 Express willingness to incorporate the weight
Are you ready to choose a time to start
incorporate the weight reduction plan into her
changing your eating habits?
reduction plan into her daily life.
daily life.
5. Observe for situations that indicate a
nutritional intake of more than body 5. Such observations help
Long term:
requirements. gain a clear picture of the
Long term:
patient’s dietary habits.
Goal Met
6. Conduct a nutritional assessment to
After a week of nursing care
include: 6. Environmental factors
and health teaching, the After a week of nursing care and
Daily food intake – type and amount of greatly contribute to obesity
patient will be able to: health teaching, the patient was
Patient P/ Room 123No. | 1
 Demonstrate food than genetics or biological be able to:
appropriate selection Approximate caloric intake vulnerability. Assessment  Demonstrate appropriate
of meals or menu Activity at time of eating of current eating patterns selection of meals or
planning toward the Feelings at time of eating provides a baseline for menu planning toward the
goal of weight Location of meals change. Assessment goal of weight reduction.
reduction. Meals skipped methods may include 24-  Perform relevant activities
 Perform relevant Snacking patterns hour recall and foods requiring energy
activities requiring Social/familial considerations eaten, food diaries/records, expenditure into daily life
energy expenditure or food frequency recording such as yoga and Zumba.
into daily life such as 7. Determine patient’s motivation to lose using typical food groups.  Use sound scientific
yoga and Zumba. weight, whether for appearance or health sources to evaluate need
 Use sound scientific benefits. 7. Successful change is more for nutritional
sources to evaluate likely to occur if patient has supplements.
need for nutritional formulated plans for dealing  Fulfill desired weight loss
supplements. 8. Determine the patient’s ability to plan a with any barriers. in a reasonable period (1
 Fulfill desired weight menu and make appropriate food to 2 pounds per week).
loss in a reasonable selections. 8. This information provides
period (1 to 2 pounds the starting point for the
per week). educational sessions.
Teaching content the
patient already knows
wastes valuable time and
9. Evaluate the patient’s ability to hinders critical learning.
accurately identify appropriate food
portions. 9. Serving sizes must be
understood to limit intake
according to a planned diet.
10. Set appropriate short-term and long-term
goals. 10. Improvement in nutritional
status may take a long
time. Patient may lose
interest in the whole
process without short-term
11. Negotiate with the patient regarding the goals.
aspects of his or her diet that will need to
be modified. 11. Give and take with the
patient will lead to culturally
12. Suggest patient to keep a diary of food harmonious care.
intake and circumstances surrounding its
consumption (methods of preparation, 12. Self-monitoring helps the
duration of meal, social situation, overall patient assess adherence
mood, activities accompanying to self-determined
consumption). performance criteria and
progress toward desired
goals.

Patient P/ Room 123No. | 2

13. Advise patient to measure food regularly.
13. Measuring food alerts
patient to normal portion
sizes. Estimating amounts
can be extremely
inaccurate.
14. Encourage water intake.
14. Water helps in the
elimination of byproducts of
fat breakdown and helps
prevent ketosis.
15. Review patient’s current exercise level.
With patient and primary healthcare 15. Exercise is vital for
provider, design a long-term exercise increased energy
program. expenditure, for
maintenance of lean body
mass, and as component of
a total change in lifestyle.
16. Weigh patient twice a week under the
same conditions. 16. It is important to most
patients and their progress
to have an actual reward
that the scale shows.
Monitoring twice a week
keeps the patient on the
program by not allowing
him or her to eat out of
control for a couple of days
and then fast to lose
17. Educate patient about adequate weight.
nutritional intake. A total plan permits
occasional treats. 17. Permanent lifestyle
changes must occur for
weight loss to be long
lasting. Excluding all treats
is not sustainable. During
energy restriction, a patient
should consume 72 to 80 g
of high biological value
protein per day to lessen
risk of ventricular
18. Allow and encourage patient to adopt an arrhythmias.
exercise routine that involves 45 minutes
of exercise five times per week. 18. Moderately intense physical
activity for 30 to 45 minutes

Patient P/ Room 123No. | 3

 5 to 7 days/week can
expend the 1500 to 2000
calories/week that appear
to be necessary to maintain
19. Guide the patient regarding changes that weight loss.
will make a major impact on health.
19. Even modest weight loss
contributes to diabetes and
20. Teach stress reduction methods as hypertension control.
alternatives to eating.
20. The patient needs to
substitute healthy for
unhealthy behaviors.

NURSING CARE PLAN

Identified Problem: Risk for Decreased Cardiac Output
Nursing Diagnosis: Risk for decreased cardiac output related to increased vascular resistance secondary to hypertension

CUES OBJECTIVES INTERVENTIONS RATIONALE EVALUATION

Subjective: Short term: Independent: Independent: Short term:

“Usahay malipong ko dayon
mabantayan nako na gapula
akong mata. Magpa-BP dayon
ko sa akong anak dayn taas
man jud dayn. Mga 140/90.”
Objective:
 Patient has history of
high blood pressure.
 Patient takes Neobloc
(Metoprolol) as her
After 2 hours of nursing care, 1. Monitor and record BP. Measure in both
the patient will be able to:
 State related factors
contributing to high
blood pressure.
 Verbalize measures
necessary to maintain
normal BP levels.
 Design dietary
modifications to
control blood
pressure.
1. Comparison of pressures
arms and thighs three times, 3–5 min provides a more complete
apart while patient is at rest, then sitting, picture of vascular
then standing for initial evaluation. Use involvement or scope of
correct cuff size and accurate technique. problem. Severe
hypertension is classified in
the adult as a diastolic
pressure elevation to 110
mmHg; progressive
diastolic readings above
120 mmHg are considered
first accelerated, then
malignant (very severe).
Systolic hypertension also
Goal Met
After 2 hours of providing care,
the patient was able to:
 State related factors
contributing to high blood
pressure.
 Verbalize measures
necessary to maintain
normal BP levels.
 Design dietary
modifications to control
blood pressure.
Patient P/ Room 123No. | 4
 maintenance
medication. Add more. Long term:
Ask mader tom
 Last BP remembered After 12 hours of providing
was around ??? care and health teaching, the
 Current BP taken at patient will be able to:
6:30 pm is 120/80.  Perform normal day
routine without
experiencing
dizziness.
 Exercise intake of
balanced meals, with
avoidance of fatty
foods.
 Participate in activities
that will prevent rise in
BP level (such as
stress management
activities, rest plans)
is an established risk factor
for cerebrovascular disease
and ischemic heart Long term:
disease, when diastolic
pressure is elevated.
Goal Met
2. Provide calm, restful surroundings, 2. Helps lessen sympathetic
minimize environmental activity and stimulation; promotes After 12 hours of providing care
noise. relaxation. and health teaching, the patient
was able to:
3. Provide comfort measures (back and 3. Decreases discomfort and  Perform normal day
neck massage, elevation of head). may reduce sympathetic routine without
stimulation. experiencing dizziness.
 Exercise intake of
4. Instruct in relaxation techniques, guided 4. Can reduce stressful balanced meals, with
imagery, distractions. stimuli, produce calming avoidance of fatty foods.
effect, thereby reducing BP.  Participate in activities
that will prevent rise in BP
5. Monitor response to medications to 5. Response to drug therapy level (such as stress
control blood pressure. (usually consisting of management activities,
several drugs, including rest plans)
diuretics, angiotensin-
converting enzyme [ACE]
inhibitors, vascular smooth
muscle relaxants, beta- and
calcium channel blockers)
is dependent on both the
individual as well as the
synergistic effects of the
drugs. Because of side
effects, drug interactions,
and patient’s motivation for
taking antihypertensive
medication, it is important
to use the smallest number
and lowest dosage of
medications.
6. Implement dietary sodium, fat, and 6. These restrictions can help
cholesterol restrictions as indicated. manage fluid retention and,
with associated
hypertensive response,
decrease myocardial
workload.
Patient P/ Room 123No. | 5
 NURSING CARE PLAN
Identified Problem: Risk for Fatigue
Nursing Diagnosis: Risk for fatigue related to inadequate sleeping hours

CUES OBJECTIVES INTERVENTIONS RATIONALE EVALUATION

Patient P/ Room 123No. | 6

Subjective:
“Akong anak tig-tulugan ni siya
mga kadlawon na. Dagko na
gud kay ni siyag eyebags dayon
makita nimo sa iyang lihok na
murag luya siya kay tungod lagi
kulang ug tulog pirme.”
Objective:
 Pale skin color
 Lack of energy
 Irritability
 Problems with
concentration
Short term:
After 2 hours of care and
health teaching, the patient will
be able to:
 Identify cause and
health risks of fatigue.
 Acknowledge action
towards current
sleeping pattern.
 Organize and develop
a schedule for
activities and rest
periods.
Long term:
After 8 hours of care and
health teaching, the patient will
be able to:
 Follow organized
schedule of daily
activities and rest.
 Report improved
sense of energy.
After a week of care and
health teaching, the patient will
be able to:
 Develop habits that
promote effective
rest/sleep patterns.
Independent: Independent:
1. Assess the patient’s ability to perform 1. Fatigue can restrict the
ADLs, instrumental activities of daily patient’s ability to
living (IADLs), and demands of daily participate in self-care and
living (DDLs). do his or her role
responsibilities in the family
and society, such as
working outside the home.
2. Aid the patient with developing a 2. A plan that balances
schedule for daily activity and rest. periods of activity with
Emphasize the importance of frequent periods of rest can help the
rest periods. patient complete desired
activities without adding to
levels of fatigue.
3. Assist the patient with setting priorities 3. Setting priorities is one sort
for preferred activities and role of an energy conservation
responsibilities. method that permits the
patient to utilize available
energy to complete
important activities.
Attaining desired goals can
develop the patient’s mood
and sense of emotional
health.
4. Restrict environmental stimuli, especially 4. Vivid lighting, noise,
during planned times for rest and sleep. visitors, numerous
distractions, and litter in the
patient’s physical
surroundings can limit
relaxation, disturb rest or
sleep, and contribute to
fatigue.
5. Promote sufficient nutritional intake. 5. The patient will need
properly balanced intake of
fats, carbohydrates,
proteins, vitamins, and
minerals to provide energy
resources.
6. Encourage an exercise conditioning 6. Fatigue caused by
Short term:
Goal Met
After 2 hours of care and health
teaching, the patient was able to:
 Identify cause and health
risks of fatigue.
 Acknowledge action
towards current sleeping
pattern.
 Organize and develop a
schedule for activities and
rest periods.
Long term:
Goal Met
After 8 hours of care and health
teaching, the patient will be able
to:
 Follow organized
schedule of daily
activities and rest.
 Report improved sense of
energy.
Goal Met
After a week of care and health
teaching, the patient will be able
to:
 Develop habits that
promote effective
rest/sleep patterns.
Patient P/ Room 123No. | 7
 program as appropriate. deconditioning and
prolonged bed rest can be
reduced through improved
functional capacity using
aerobic and muscle-
strengthening exercise.

7. Provide comfort such as judicious touch 7. These may reduce nervous

or massage, and cool showers. energy that lead to
relaxation.

8. Educate the patient and family about 8. Organization and

task organization methods and time management of time can
organization methods. assist the patient save
energy and avoid fatigue.

9. Make the patient aware about the signs
and symptoms of overexertion with
activity.
9. Changes in heart rate,
oxygen saturation, and
respiratory rate will reflect
the patient’s tolerance for
activity.

10. Aid the patient develop habits to promote 10. Promoting relaxation before
effective rest/sleep patterns. sleep and providing for
several hours of
uninterrupted sleep can
contribute to energy
restoration.

References:

https://nurseslabs.com/6-hypertension-htn-nursing-care-plans/

https://nurseslabs.com/imbalanced-nutrition-more-body-requirements/

https://nurseslabs.com/category/nursing-notes/

Patient P/ Room 123No. | 8