WESLEYAN

AN AUTONOMOUS METHODIST UNIVERSITY

COLLEGE OF NURSING AND ALLIED MEDICAL SCIENCES

NURSING CARE PLAN
NAME OF CLIENT: DIAGNOSIS: ______________________
AGE: 21 years old
ASSESSMENT NURSING Nursing Goal Nursing Intervention RATIONALE EVALUATION
DIAGNOSIS

Subjective Data: Imbalanced Short Term Goal: Independent Nursing Short Term
Method: Interview Action: Goal:
Nutrition: less than
After 8 hours of  Establish rapport  To acquire the
body requirements patient’s trust, build a
“Ayoko kumain ng nursing After 8 hours
related to emotional nurse-client
gulay at sinuskua intervention, the relationship to be able of nursing
ko lang kapag stress as
patient will to assess the client intervention
pinipilit akong manifested by with comfor
establish adequate the patient was
kumain” as stress loss
verbalized by the nutritional eating  To help clients begin able to
patient patterns.  Identifying emotions to recognize emotions establish
and developing such as anxiety or adequate
Ineffective coping strategies.  guilt by asking them
nutritional
Objective Data: coping related to Long Term Goal: to describe how they
are feeling and
eating
Method: IPAPEA inability to meet
After 2 months to allowing adequate patterns.
basic needs.
4 months of time for response.
Disturbed body nursing
 Assess the patient’s  Negative statements
intervention, the
image related to perception of change about the affected
patient will regain in the structure of body part may
being excessively her normal weight. her body daily. indicate limited ability
underweight. to integrate change Long Term
Vital Signs:
 Monitor lab values Goal:
 WESLEYAN
AN AUTONOMOUS METHODIST UNIVERSITY

COLLEGE OF NURSING AND ALLIED MEDICAL SCIENCES

 BP: including serum
100/70mmhg albumin, transferrin,  A variety of lab test After 2-4
CBC, electrolytes may be used to months of
 HR: 49bpm monitor the patient’s
that indicate nursing
 RR: 12 nutritional status.
wellbeing or intervention
 Temp: 35.9’C Including protein
deterioration once depletion and the patient
now malnutrition. regained her
normal weight.

 Assess attitudes and

beliefs toward eating  Many factors
food contribute to
determining factor for
food consumed by the
patient
 Measure weight and
height of patient
 Vitamins are used to
daily
meet necessary
dietary requirements.
They are utilized in
metabolic pathways. 
 Make selective menu
available, and allow
 Patient who gains
patient to control
choices as much as confidence in self and
possible. feels in control of the
environment is more
likely to eat preferred
foods.
 WESLEYAN
AN AUTONOMOUS METHODIST UNIVERSITY

COLLEGE OF NURSING AND ALLIED MEDICAL SCIENCES

 Provide nutritional
therapy within a
hospital treatment  Cure of the
program as underlying problem
indicated when the cannot happen
condition is life-
without improved
threatening.
nutritional status.
Hospitalization
provides a controlled
environment in which
food intake, vomiting
and elimination,
medications, and
activities can be
monitored.
Dependent Nursing
Action:

 Administer selective
serotonin reuptake
inhibitors  SSRIs reduce binge-
(SSRIs): fluoxetine purge cycles and may
(Prozac) as also be helpful in
prescribed by the treating anorexia.
physician
 WESLEYAN
AN AUTONOMOUS METHODIST UNIVERSITY

COLLEGE OF NURSING AND ALLIED MEDICAL SCIENCES

Collaborative Nursing
Action:

 Refer to Dietitians
and Nutritionists

 To prescribe dietary
treatments for people
suffering from eating
disorders and Provide
basic advice on
nutrition, eating
plans and motivations
for eating well

Name of Student Roger Bryan Aguilar____________________________________

_____________________________________
Year/Block #___BSN 3-1______________ Name of Instructor