Nursing Care Plan

ASSESSMENT DIAGNOSIS PLANNING INTERVENTIONS RATIONALE EVALUATION

Subjective Cues Nursing Short Term: Independent:
“Hanap man ako Diagnosis:  After 8hrs of
panan aw “ as After 8hrs of establish rapport  To develop trust nursing
verbalized by the pt. Decreased nursing and affinity intervention, the
cardiac intervention, towards the pt. pt. has no
output the pt. will have elevation in
related to no elevation in  Monitor v/s  Serves as baseline blood pressure
vascular blood pressure every 2 hrs. data and any and will
resistance as and will changes may maintain blood
evidenced by maintain blood prompt attention pressure w/n
Objective Cues: increased bp; pressure w/n  Provide quite  Helps reduce acceptable limits
 Lethargic 150/90 and acceptable environment and anxiety and to (120/80- 130/90)
 Restlessness blurry vision. limits (120/80- provide make pt. more
 Tachycardia 130/90) comfortable comfortable
 Decreased clothing
cardiac 
output  Monitor ECG for decrease in
 Vital signs dysrhythmias cardiac output Long Term:
taken as ff; conduction may result in
 T: 37.6 Long Term: defects and for changes in cardiac After 3 days of
 PR: 83 heartache perfusion causing nursing
 RR: 24 After 3 days of dysrhythmias intervention, the
 BP: 150/90 nursing  Decrease pt. will to
mmhg intervention, peripheral venous maintain
the pt. will be  Suggest frequent poling that maybe adequate
able to maintain position prolong sitting cardiac output
adequate  Cardiac stimulant and cardiac
cardiac output  Encourage pt to and may adverse index
and cardiac decrease intake cardiac
index of caffeine, cola functioning
and chocolates
 Peripheral
 Obseverve skin vasoconstriction
color, temp and may result to
CRT pale,cool clammy
skin.

 Decrease
 Instruct pt and SO hypertension
to restrict w
sodium intake  Hypertensive
 Auscultate heart often have s4
tones gallops

 To avoid
 Instruct pt and SO increasing bp
to restrict pt in
any strenuous
activities  For better cardiac
 Encourage pt eat function
vegetables and
fruits  Promotes
 Instruct pt. and knowledge and
SO for compliance.
contraindication
and adverse
effect of drugs

Dependent:
  Administer  To promote
medicines as wellness and
prescribed by normalize bp
the physician
(such as
diuretics, CCB )

Nursing Care Plan

 ASSESSMENT DIAGNOSIS PLANNING INTERVENTIONS RATIONALE EVALUATION
Subjective Cues Nursing Short Term: Independent:
Diagnosis:  Short Term:
“makalimot nako” After 8hrs of establish rapport  To develop
as verbalized by the Ineffective nursing trust and After 8hrs of
pt. tissue intervention, the affinity nursing
perfusion pt. will be able to towards the intervention, the
(cerebral)  to maintain  Monitor v/s pt. pt. able to
related to normal bp every 3hrs  to maintain
interruption 120/80-  Serves as normal bp
of blood flow 130/90 baseline data 120/80-
Objective Cues: secondary to  remember and any 130/90
 Lethargic ischemic 1-2 changes may  remember
 Restlessness stroke as important prompt 1-2
 Tachycardia evidenced by events in  Maintain bed rest attention important
 Decreased memory loss his life and provide quite  Helps reduce events in
cardiac environment and anxiety and to his life
output provide make pt. more
 Increased bp comfortable comfortable
 Vital signs clothing
taken as ff;
 T: 37.6 Long Term:  Assess baseline
 PR: 83 function such as  Sudden Long Term:
 RR: 24 After 3 days of ability to swallow changes in
 BP: 150/90 nursing speak and move patients’ After 3 days of
mmhg intervention, the symptoms can nursing
pt. will be able to signify a new intervention, the
demonstrate no strow or pt. able to
further worsening demonstrate no
deterioration. condition further
 Prepare and deterioration.
administer  Supplemental
oxygen oxygenation
supplementation may be
as needed required to
prevent
cerebral
vasodilation

 Encourage pt to
express  To determine
him/herself ability in
expressing self

 Encourage pt to  Helps maintain

eat foods rich in healthy nerve
vit. b12 cells and
improve
memory

 Instruct pt. and

SO for  To gain
contraindication knowledge
and adverse and
effect of drugs compliance
Dependent:
 Administer
medicines as
prescribed by the  Help recover
physician (such damage brain
citicoline) cells
 Administer
medicine such as 
hypertensive to normalize
drugs the bp
 Nursing Care Plan
ASSESSMENT DIAGNOSIS PLANNING INTERVENTIONS RATIONALE EVALUATION
Subjective Cues Nursing Short Term: Independent: 
“kapoy permi “ as Diagnosis:  To develop Short Term:
verbalized by the After 8hrs of nursing establish trust and
pt. Imbalanced intervention, the pt rapport affinity After 8hrs of nursing
nutrition: will be able to towards the intervention, the pt
more than  identify pt. able to
body inappropriate  identify
requirement behaviors  Monitor v/s  Serves as inappropriate
s related to and every 2 hrs. baseline behaviors and
sedentary consequence data and any consequence
Objective Cues: lifestyle as s associated changes may s associated
 Lethargic evidenced by with prompt with
 Restlessnes more over overeating or attention overeating or
s optimum weight gain  Provide quite  Helps reduce weight gain
 BMI;31 body weight  demonstrate environment anxiety and  demonstrate
 Obese a change in and provide to make pt. a change in
 Vital signs eating comfortable more eating
taken as ff; patterns and clothing comfortable patterns and
 T: 37.6 involvement  Identifies involvement
 PR: 83 in individual  Review some in individual
 RR: 24 exercise individual choices of exercise
 BP: 150/90 program cause for intervention program
mmhg obesity  Provides
 Carry out and opportunity
Long Term: review daily to focus on Long Term:
 food diary realistic
After 2 weeks of amount of After 2 weeks of
nursing intervention, food nursing intervention,
the pt will be able to ingested the pt able to display
display weight loss (2-  Helps weight loss (2-3
3 kg)with optimal  Explore and identify kg)with optimal
maintenance of discuss when pt is maintenance of
health. emotions and eating to health.
events satisfy an
associated emotional
with eating rather than
physiological
hunger
 A plan
 Formulate developed
eating plan an agreed to
with the pt. by pt is more
likely to be
successful
 To gain
knowledge
 Emphasize about fad
the diets
importance 
of avoiding denying self
fad diets by excluding
 Discuss need desired
to give self- foods can be
permission to sabotage
include weight loss
desired or
 craved food
items  Motivation is
 Identify more easily
realistic sustained by
increment meeting stair
goals for step goals
weekly
weight loss  To burn fats
 Teach pt and loss
basic to weight easily
moderate
exercises

 Weigh  To
periodically determine
as the progress
individually of the
indicated and weight
obtain
appropriate
body
measuremen
t  Commitmen
 Determine t on the pat f
current the pt
activity levels enables the
and plan setting of
progressive more
exercise realistic
program goals and
 Reassess adherence
 calorie to plan
requirement  To control
as day intake of
 Discuss calories
restriction of  Water
sat intake retention
and diuretic may be the
drugs prob
 Encourage pt because of
to eat only at increased
a table fluid intake
 Encourage pt and fat
to eat metabolism
vegetables  To promote
and fruits balance diet

Dependent:
 Medications
as prescribed
by the  Used with
physician caution and
such as supervision
 Appetite at the
suppressant beginning of
drugs a weight loss
program to
 support pt
during stress
behavioral
and lifestyle
changes
 Obese have
large fuel
reserves but
lack of
vitamins and
 Vitamin and nutrients.
mineral
supplements

Collaborative
 Consult with
dietitian to
determine
 To calculate
caloric and
nutrient the food
requirement intake and to
for promote
individuals weight
weight loss reduction.