MISSION

VISION MABINI COLLEGES provides quality instruction,

MABINI COLLEGES shall cultivate a research and extension services as its monumental
CULTURE
EDUCATION
of EXCELLENCE in MABINI COLLEGES, INC. contribution to national and global growth and
development.

Daet, Camarines, Norte into:

Specifically, it transforms students

1. God-fearing
College of Nursing and Midwifery 2. Nation-loving
3. Law-abiding
4. Earth-caring
5. Productive, and
6. Locally and Globally competitive
persons

NURSING CARE PLAN

Chronic Pain
ASSESSMENT DIAGNOSIS PLANNING INTERVENTION EVALUATION

Subjective: Chronic pain related to After 4hrs of nursing  Note reports of pain, After 4 hours of nursing
“Laging sumasakit yung tyan ko chemical burn of gastric intervention, Patient will including location, duration interventions, the patient was
ditto sa may kaliwang parte” As mucosa, oral cavity and verbalize relief of pain and will and intensity. (scale 0-10). able to verbalize relief of pain
verbalize by the patient. physical response such as flex demonstrate relaxed body Pain is not always and demonstrate relaxed body
muscle spasm in the stomach posture and be able to sleep or present, should be posture and be able to sleep
Objective: wall. rest properly. compared with patient’s and rest properly.
previous pain symptom.
 Abdominal Guarding
 Review factors that
 Pain scale of 7/10 aggravate pain.Helpful in
 Fatigue body posture establishing diagnosis
 Vital signs and treatment needs.
BP: 90/60  Note non verbal pain
Temp: 35.5ºC cues.Non- verbal cues
PR: 62 may be both physiological
RR:27 and may be use in
conjunction with verbal
cues to evaluate extent
and severity of the
problem.
 Identify and limit foods that
cause discomfort.Food has
an acid neutralizing effect
and dilutes the gastric
contents.Client may
receive nothing by mouth

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 MISSION
VISION MABINI COLLEGES provides quality instruction,
MABINI COLLEGES shall cultivate a research and extension services as its monumental
CULTURE
EDUCATION
of EXCELLENCE in MABINI COLLEGES, INC. contribution to national and global growth and
development.

Daet, Camarines, Norte into:

Specifically, it transforms students

1. God-fearing
College of Nursing and Midwifery 2. Nation-loving
3. Law-abiding
4. Earth-caring
5. Productive, and
6. Locally and Globally competitive
persons

initially.
 Provide frequent oral care
and comfort measures
including back rub and
position change.
 Use regular than skim milk if
milk is allowed.Fat regular
milk may drecreases
gastric secretions. The
calcium and protein
content especially in skim
milk increases secretions.
 Administer medication as
indicated such as
analgesic.Helps relieve
acute or severe pain.

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 MISSION
VISION MABINI COLLEGES provides quality instruction,
MABINI COLLEGES shall cultivate a research and extension services as its monumental
CULTURE
EDUCATION
of EXCELLENCE in MABINI COLLEGES, INC. contribution to national and global growth and
development.

Daet, Camarines, Norte into:

Specifically, it transforms students

1. God-fearing
College of Nursing and Midwifery 2. Nation-loving
3. Law-abiding
4. Earth-caring
5. Productive, and
6. Locally and Globally competitive
persons

NURSING CARE PLAN

Knowledge Deficit
ASSESSMENT DIAGNOSIS PLANNING INTERVENTION EVALUATION

Subjective: Knowledge deficient r/t limited After 3 hours of nursing  Provide clear, thorough, and Patient recognizes need for
“Lagi po ako pabalik balik ng information resource interventions, the patient will understandable medications, and understands
hospital pero di ko pa po alam recognizes need for explanations and treatments and exhibits ability
diagnosis ko” as verbalize by medications, and understands demonstrations.Patients to deal with health situation and
the patient. treatments. are better able to ask remain in control of life.
questions when they have
Objective: basic information about
what to expect.
 Pale looking
 Explore reactions and
 Complete Bed rest feelings about
 Difficulty of moving changes.Assessment
 Vital signs assists the nurse in
BP: 90/60 understanding how the
Temp: 35.5ºC learner may respond to
PR: 62 the information and
RR:27 possibly how successful
the patient may be with
the expected changes.
 Provide an atmosphere of
respect, openness, trust,
and
collaboration.Conveying
respect is especially
important when providing

Page | 41
 MISSION
VISION MABINI COLLEGES provides quality instruction,
MABINI COLLEGES shall cultivate a research and extension services as its monumental
CULTURE
EDUCATION
of EXCELLENCE in MABINI COLLEGES, INC. contribution to national and global growth and
development.

Daet, Camarines, Norte into:

Specifically, it transforms students

1. God-fearing
College of Nursing and Midwifery 2. Nation-loving
3. Law-abiding
4. Earth-caring
5. Productive, and
6. Locally and Globally competitive
persons

education to patients with

different values and
beliefs about health and
illness.
 Encourage questions.
Questions facilitate open
communication between
patient and health care
professionals and allow
verification of
understanding of given
information.

Page | 42
 MISSION
VISION MABINI COLLEGES provides quality instruction,
MABINI COLLEGES shall cultivate a research and extension services as its monumental
CULTURE
EDUCATION
of EXCELLENCE in MABINI COLLEGES, INC. contribution to national and global growth and
development.

Daet, Camarines, Norte into:

Specifically, it transforms students

1. God-fearing
College of Nursing and Midwifery 2. Nation-loving
3. Law-abiding
4. Earth-caring
5. Productive, and
6. Locally and Globally competitive
persons

NURSING CARE PLAN

Activity Intolerance
ASSESSMENT DIAGNOSIS PLANNING INTERVENTION EVALUATION

Subjective: Activity intolerance related to After 8 hours of nursing  Assess patient’s ability to Patient reveals an increase in
“Madali ako manghina lalo na imbalance between oxygen interventions the patient will: perform normal task or activity tolerance,
andito ako sa hospital” as supply (delivery) and demand. activities of daily demonstrating a reduction in
verbalized by the patient. Report an increase in activity living.Influences choice of physiological signs of
tolerance including activities of interventions or needed intolerance and laboratory
Objective: daily living. assistance. values within normal range.
 Note changes in balance/
 Fatigue Demonstrate a decrease in gait disturbance, muscle
 Greater need for sleep and physiological signs of weakness.May indicate
rest. intolerance. neurological changes
 Vital signs associated with vitamin
BP: 90/60 B12 deficiency, affecting
Temp: 35.5ºC Display laboratory values within
patient safety or risk of
PR: 62 acceptable range.
injury.
RR: 27  Recommend quiet
atmosphere, bed rest if
indicated. Enhances rest
to lower body’s oxygen
requirements, and
reduces strain on the
heart and lungs.
 Elevate the head of the bed
as tolerated.Enhances

Page | 43
 MISSION
VISION MABINI COLLEGES provides quality instruction,
MABINI COLLEGES shall cultivate a research and extension services as its monumental
CULTURE
EDUCATION
of EXCELLENCE in MABINI COLLEGES, INC. contribution to national and global growth and
development.

Daet, Camarines, Norte into:

Specifically, it transforms students

1. God-fearing
College of Nursing and Midwifery 2. Nation-loving
3. Law-abiding
4. Earth-caring
5. Productive, and
6. Locally and Globally competitive
persons

lung expansion to
maximize oxygenation for
cellular uptake.
 Provide or recommend
assistance with activities or
ambulation as necessary,
allowing patient to do as
much as possible.Although
help may be necessary,
self-esteem is enhanced
when patient does some
things for self
 Plan activity progression
with patient, including
activities that the patient
views essential. Increase
levels of activities as
tolerated. Promotes
gradual return to normal
activity level and
improved muscle tone or
stamina without undue
fatigue.
 Identify or implement
energy saving technique
like sitting while doing a
task.Encourages patient
to do as much as
possible, while
conserving limited energy
and preventing fatigue.

Page | 44
 MISSION
VISION MABINI COLLEGES provides quality instruction,
MABINI COLLEGES shall cultivate a research and extension services as its monumental
CULTURE
EDUCATION
of EXCELLENCE in MABINI COLLEGES, INC. contribution to national and global growth and
development.

Daet, Camarines, Norte into:

Specifically, it transforms students

1. God-fearing
College of Nursing and Midwifery 2. Nation-loving
3. Law-abiding
4. Earth-caring
5. Productive, and
6. Locally and Globally competitive
persons

NURSING CARE PLAN

Impaired Comfort
ASSESSMENT DIAGNOSIS PLANNING INTERVENTION EVALUATION

Subjective: Impaired comfort related to After 8 hours of nursing  Determine how the client is After 8 hours of nursing
“Laging sumasakit yung tyan ko abdominal pain as manifested interventions the patient will managing pain and pain interventions the patient has
ditto sa may kaliwang parte” As by patient’s abdominal start to verbalize sense of components. Lack of started to verbalize sense of
verbalize by the patient. guarding, facial grimace, comfort or contentment. control may be related to comfort or contentment.
fatigue body posture. other issues or emotions
Objective: such as fear, loneliness,
anxiety, noxious stimuli,
 Abdominal Guarding or anger.
 Pain scale of 7/10  Work with the client to
 Facial grimace prevent pain and other
 Fatigue body posture discomforts. To have a
 Vital signs collaborative problem
BP: 90/60 solving skills.
Temp: 35.5ºC  Review medications or
PR: 62 treatment regimen. To
RR:27 determine possible
changes or options to
reduce side effects.
 Maintain open and flexible
visitation with client’s
desired persons. Close
relationship with family
may increase comfort

Page | 45
 MISSION
VISION MABINI COLLEGES provides quality instruction,
MABINI COLLEGES shall cultivate a research and extension services as its monumental
CULTURE
EDUCATION
of EXCELLENCE in MABINI COLLEGES, INC. contribution to national and global growth and
development.

Daet, Camarines, Norte into:

Specifically, it transforms students

1. God-fearing
College of Nursing and Midwifery 2. Nation-loving
3. Law-abiding
4. Earth-caring
5. Productive, and
6. Locally and Globally competitive
persons

emotionally.
 Promote overall health
measures. This promotes
wellness for the client’s
condition.
 Administer medications as
prescribed.

Page | 46
 MISSION
VISION MABINI COLLEGES provides quality instruction,
MABINI COLLEGES shall cultivate a research and extension services as its monumental
CULTURE
EDUCATION
of EXCELLENCE in MABINI COLLEGES, INC. contribution to national and global growth and
development.

Daet, Camarines, Norte into:

Specifically, it transforms students

1. God-fearing
College of Nursing and Midwifery 2. Nation-loving
3. Law-abiding
4. Earth-caring
5. Productive, and
6. Locally and Globally competitive
persons

NURSING CARE PLAN

Fatigue
ASSESSMENT DIAGNOSIS PLANNING INTERVENTION EVALUATION

Subjective: Fatigue related to decrease of By discharge, the client will feel  Ascertain client’s belief By discharge, the clientwas
“Bago pa ako maospital, oxygen transport in body less fatigue and be able to about what is causing the able to will feel less fatigue and
mabilis na talaga ako tissues secondary to decrease report improved sense of fatigue. Client has an idea be able to report improved
mapagod. Hanggang ngayon, in blood RBC as manifested by energy. about his current health sense of energy.
medyo nanghihina pa din ako” nausea, easy fatigability, pale situation.
verbalized by the patient. appearance, and low  Regularly monitor vital
hemoglobin and hematocrit signs, including oxygen
 Patient stated that he feels count based on laboratory saturation. To evaluate
nauseated tests. fluid status and
 Easily fatigued cardiopulmonary
response to regimen.
Objective:
 Note daily energy patterns,
 Pale or instruct the watcher to
 Disinterest in surroundings observe daily energy
 Vital signs patterns of the client. This
BP: 90/60 is helpful in determining
Temp: 35.5ºC patter/timing of activity.
PR: 62  Avoid or limit exposure to
RR:27 temperature and humidity
extremes. Can negatively
 Hematology test shows Hgb impact energy level.
count of 88 and Hct of 0.26  Provide supplemental
oxygen, as indicated.
Anemia or hypoxia

Page | 47
 MISSION
VISION MABINI COLLEGES provides quality instruction,
MABINI COLLEGES shall cultivate a research and extension services as its monumental
CULTURE
EDUCATION
of EXCELLENCE in MABINI COLLEGES, INC. contribution to national and global growth and
development.

Daet, Camarines, Norte into:

Specifically, it transforms students

1. God-fearing
College of Nursing and Midwifery 2. Nation-loving
3. Law-abiding
4. Earth-caring
5. Productive, and
6. Locally and Globally competitive
persons

reduces oxygen available

for cellular uptake and
contributes to fatigue.
 Encourage intake of foods
rich in iron.
 Administer medications as
prescribed by the physician.

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