CAPITOL UNIVERSITY

COLLEGE OF NURSING
Cagayan De Oro City

Name of Student:Lorenzana,Jennifer B. Date of Assignment: May 16, 2022

Name of Patient: pangilinan, pacifica P. Ward: Room: 414

NURSING CARE PLAN

ASSESSMENT NURSING GOALS NURSING INTERVENTIONS AND EVALUATION

DATA DIAGNOS AND RATIONALE
(Subjective IS OBJECTIV
& Objective (Problem and ES
Cues) Etiology)
Subjective: : Acute pain related to After 8 hrs. Of nursing  Encourage client to promoted oral After the nursing
Ma’am naa koy Aphthous ulcer, left intervention, the patient hygiene intervention, the
luas “ as tongue will be able to minimal (R: This to reduce the infection ) goal is met, the
verbalized by the mouth sore infection patient will
patient  Administer gargle as prescribed by the verbalized comfort
physician as evidenced by
Objective: After 2 days of nursing (R: to minimize the infection and reduce the minimal mouth
Pain scale: 7/10 intervention,the patient discomfort) sore pain
V/S: will able to totally heal
BP: 130/80 the mouth sore.  Instruct the client and the family to avoid
Temp: 35.4 acidic food and fruits)
PR: 96 (R: to avoid the irritation of the infection)
RR: 22
SPO2: 99
 CAPITOL UNIVERSITY
COLLEGE OF NURSING
Cagayan De Oro City

Name of Student:Lorenzana,Jennifer B. Date of Assignment: May 16, 2022

Name of Patient: pangilinan, pacifica P. Ward: Room: 414

NURSING CARE PLAN

ASSESSMENT NURSING GOALS NURSING INTERVENTIONS AND EVALUATION

DATA DIAGNOS AND RATIONALE
(Subjective IS OBJECTIV
& Objective (Problem and ES
Cues) Etiology)
Subjective::” Impaired verbal After 8 hours of nursing  Note results of neurological tests After the nursing
ma’am galisod ko communication intervention the patient (R: to assess and delineate underlying intervention, the
ug estorya” as will participate in conditions affecting verbal communication) goal is met, the
verbalized by the therapeutic patient was able to
patient communication in  Keep communication simple,speaking in improved speak
which need can be short sentences,using appropriate but still with
Objective: expressed words slurred speech
slurred speech ( R: to avoid any misinterpretation of the due to CVD Infarct
GSC 15 word)
After 2 days of nursing
intervention the patient  Determine age and developmental
will be able to express consideration
thoughts and feelings in ( R:older client does not or not able to
coherent, logical, goal- speak, verbalizes difficulty, or has difficulty
directed mbanner hearing or comprehending language or
concept)
 CAPITOL UNIVERSITY
COLLEGE OF NURSING
Cagayan De Oro City

Name of Student:Lorenzana,Jennifer B. Date of Assignment: May 16, 2022

Name of Patient: pangilinan, pacifica P. Ward: Room: 414

NURSING CARE PLAN

ASSESSMENT NURSING GOALS NURSING INTERVENTIONS AND EVALUATION

DATA DIAGNOS AND RATIONALE
(Subjective IS OBJECTIV
& Objective (Problem and ES
Cues) Etiology)
Subjective: Risk for unstable After 8 hours of  Assess blood glucose levels before After the nursing
“ ga binhod usahay blood glucose level nursing intervention the meals and at bedtime. intervention, the goal
akong tiil” patient will identify (R: Random blood glucose test results is met, the patient
factors that may lead to should be between 140 to 180 mg/dL. Non- glucose level will
Objective: unstable blood glucose intensive care patients should be reduce to 91mg/dl
Glucose insulin: levels maintained at pre-meal levels <140 mg/dL.) from 103mg/dl
103mg/dl  Instruct patient to follow an DM diet
After 2 days of nursing @1700kcal 25kcal/kg divided into 3
intervention the patient meals with 2 snack CHO as doctors
verbalize plan in order
modifying identified risk ( to remain glucose level into normal range)
factors to prevent shift
in glucose level
 CAPITOL UNIVERSITY
COLLEGE OF NURSING
Cagayan De Oro City

Name of Student:Lorenzana,Jennifer B. Date of Assignment: May 16, 2022

Name of Patient: pangilinan, pacifica P. Ward: Room: 414

DISCHARGE PLAN:
Goals:

The patient

Medication:
The patient has to continue the medication given
Explain to the patient and guardian the right time and dosage of the medication

Treatment/ therapy:
Insist physical therapy for improving strength and walking
Should undergo speech therapy to improve talking

Health teaching/hygiene:
Instruct the patient how to have a healthy lifestyle, right food to eat and food to avoid
Instruct the family member how to prepare DM diet @1700kcal, 25kcal/kg divided into 3 meals with 2 snack

Out-patient follow up/Consultation:

Advise the patient and patient’s guardian to follow up checkup as physician’s ordered

Diet:
Instruct the patient and guardian to prepare low sodium and low fat food
Advise the patient to eat nutritious food

Spiritualy:
 CAPITOL UNIVERSITY
COLLEGE OF NURSING
Cagayan De Oro City

Name of Student:Lorenzana,Jennifer B. Date of Assignment: May 16, 2022

Name of Patient: pangilinan, pacifica P. Ward: Room: 414

Encourage the patient to pray daily and ask god’s for continuous healing