NURSING CARE PLAN

ASSESMENT NURSING NURSING NURSING INTERVENTION RATIONALE ACTUAL

DIAGNOSIS GOAL EVALUATION

S = “wala ako Self-Care Deficit in At the end of the 1. Access client’s ability to  Use of observation of Week 1 :
gana sa sarili ko” bathing/hygiene 2 week related bath-self through direct function provides Goal was met.
related to learning observation(in usual complementary Patient was able
O = received decreased or lack experience, bathing setting assessment data for to perform self-
patient sitting on of motivation. patient will be only)nothing specific goal and intervention care activities
the bench alone. able to perform deficits and their causes. planning. with minimal
 Dirty personal hygiene 2. Plan activities to prevent  Energy conservation supervision or
clothes within level of fatigue during bathing. increases activity assistance.
noted own ability. 3. Instruct patient to select tolerance and promote
 Dirty hair bath time when he or self-care. Week 2 :
and skin she is rested and  Hurrying may result in Goal was met.
noted unhurried. accidents and the Patient was able
 With long 4. Encourage energy required for to do self-care
nails independence, but these activities may be activities without
 Unpleasan intervene when patient substantial. someone
t odor cannot perform.  An appropriate level of prompting or
5. Use consistent routines assistive care can telling him to do
and allow adequate time prevent injury with so.
for patient to complete activities without
tasks. causing frustration.
6. Provide privacy during  This helps patient
bathing/dressing as organize and carry out
appropriate. self-care skills.
7. Encourage use of  The need for privacy is
clothing one size larger. fundamental for most
patients.
 This ensures easier
dressing and comfort.
 NURSING CARE PLAN

ASSESMENT NURSING NURSING NURSING RATIONALE ACTUAL

DIAGNOSIS GOAL INTERVENTION EVALUATION

Subjective : Disturbed sleep Short Term:  Observe and obtain  To determine usual Short Term :
“putol-putol ang pattern r/t Within 1 hour of feedback from sleep pattern and After 1h of
tulog ko” as environmental adequate nursing client regarding provide comparative adequate nursing
verbalize by the factors such as intervention/ usual bedtime, baseline. intervention the
patient. giving of teaching the rituals and number  Provides opportunity patient was able to
medication, vital patient will be able of hours of sleep. to address verbalized
signs, monitoring to verbalize  Determine clients misconception/unreal understanding of
Objective : noise and understanding of expectation of istic expectation. sleep disturbance
 Irritable lightning. sleep disturbance. adequate sleep  This contains -Goal met.
 Lethargic  Recommend ingredients that
 Dark circles Long Term : limiting of decreases the ability Long term :
under eyes Within the shift of caffeine/alcohol to fall asleep. After the shift of
 Hypo adequate nursing use and eating of  To compensate the adequate nursing
responsiven intervention the chocolate prior to lack of sleep. intervention the
ess patient will be able sleep. patient wasn’t able
 Less than 6 to report  Advise patient to to improve sleeping
½ hours of improvement in take a nap. pattern.
sleep sleep/rest pattern -Goal not met.
and increase sense
of well-being and
feeling rested.
 NURSING CARE PLAN

ASSESMENT NURSING NURSING GOAL NURSING RATIONALE ACTUAL

DIAGNOSIS INTERVENTION EVALUATION

SUBJECTIVE : Fatigue related to After 8hrs of nursing INDIPENDENT :  Help in  After 8hrs of
“nanghihina ako, altered body interventions, the  Have patient developing a plan interventions,
pakiramdam ko lagi chemistry, side patient will report rate fatigue, for managing the patient
akong pagod” as effects of pain improved sense of using a numeric fatigue. was able to
verbalized by the and other energy. scale, if  Frequent rest report
patient medications, possible, the periods or naps improved
chemotherapy time of the day are needed to sense of
OBJECTIVES : when it is most restore or energy.
 Disinterest in severe. conserve energy.
the  Plan care to Planning will
surrounding. allow rest allow patient to
 Lethargy periods. be active during
 V/S taken as Schedule times when
follows : activities for energy level is
periods when higher, which may
T - 37.3 patient has restore feeling of
P - 90 most energy. well being and a
R - 22  Assist patient sense of control.
BP - 120/0 with self-care  Weakness may
needs. Keep make activities of
bed in low daily living and
position and ambulation
assist with difficult, further
ambulation. assistance is
needed.
 NURSING CARE PLAN

ASSESMENT NURSING NURSING GOAL NURSING RATIONALE ACTUAL

DIAGNOSIS INTERVENTION EVALUATION

SUBJECTIVE : Anxiety related to Within 8hrs of  Monitor vital  To identify physical  After 8hrs of
“hindi ko alam kung threat to/or nursing signs (e.g. rapid responses intervention
makakatrabaho pa change in health intervention the or irregular pulse, associated with both s, the
ako kaagad status. patient will appear rapid breathing) medical and patient
pagkagaling ko eh..” relaxed and the  Use presence environmental appeared
as verbalized by the level of anxiety will touch, conditions. relaxed and
patient reduced to a verbalization or  Being supportive the level of
manageable level. clarification of and approachable anxiety will
ADJECTIVES : needs, concerns, encourages reduced to
T - 37.3 unknowns and communication manageable
P - 90 questions.  If defence are not level.
R - 22  Accept clients threatened, the
BP - 120/0 defence’s, do not client may feel safe
confront and enough to look at
argue and the behaviour.
debate.  Talking or otherwise
 Allow and expressing feeling
reinforce clients reduces anxiety
personal  To educate the
reactions toward patient regarding
the thresten to the disease to
well being. reduce anxiety.
 Explain
everything
necessary
regarding the
disease.