Estonilo, Michelangelo S.

BSN 2 - J
CHAPTER 3
Activity E
1. Some hospitals have taken an active role to include cultural sensitivity in the care of
patients and their families. Research the hospitals in your area to identify those who
have telephone service agreements to assist families with language interpretation.
 Elguira General Hospital
 Pangasinan Doctors Hospital
 Pangasinan Provincial Hospital
 Virgen Milagrosa Medical Center
2. Collaborate with your classmates to create a mock nursing care plan for patients of
this ethnic orientation who may be experiencing problems attending appointments or
making the appointment on time.
Assessment Diagnosis Planning Intervention Evaluation

Subjective: Risk for partial Short term Independent: Goal met:

“Naninikip ang collapse of the goal: 1. Assess Short term
dibdib ko lung as After 8 hours of respiratory goal:
palagi kaya evidenced by nursing function, noting After 8 hours of
nahihirapan an altered interventions, fast or shallow nursing
akong breathing the patient will: breathing or interventions,
huminga.,” as pattern and 1. The patient “air hunger” the patient was
verbalized by tightening of will be able to reports, along able to attain a
the patient. the chest. establish a with changes normal
normal and in vital signs.  breathing
Objective: effective pattern and
- Altered breathing 2. Maintain has been
breathing pattern. pressure cleared of
pattern 2. Patient’s dressing to the cyanosis. In
- Bluish-purple respiratory rate incision site of addition, no
hue on the skin will remain chest tube and signs of
(Cyanosis) within assess for any oxygen
-V/S taken as established patency related shortage
follow: limits. fluctuations symptoms
Temperature: 3. As the and properly were noted.
39.5 °C patient's secure tube at
RR: breathing all times.
32 bpm rhythm returns Long term
PR: to normal, his 3. Assessed goal:
155 bpm skin color will chest tube for After 3 days of
 BP: return to the draining nursing
90/60 mmHg normal as well. fluids. interventions,
O2 Sat: 90% the patient was
Long term Dependent: able to
goal: 1. Observe and completely
After 3 days of monitor the eliminate
nursing lungs through shortness of
intervention, x-rays for breath and
the patient will several weeks. showed no
be able to: indicators of
1. Will report 2. Check cyanosis or
absence/ patient’s other oxygen
decrease in appearance, shortage
shortness of capillary refill symptoms
breath. not more than through
2. The patient 2 seconds to administered
will show no assess for medication as
signs of perfusion and prescribed by
impending blood pressure the physician.
cyanosis and
other oxygen
shortage
related
symptoms.

Activity F
Select a patient you are caring for in the clinical setting and create a nursing care plan
for him or her, including an assessment of the family and the community. State the
nursing diagnosis found in making your assessment and provide the appropriate
nursing orders.
Assessment Diagnosis Planning Intervention Evaluation

Subjective: Situational low self- Short term Independent: Goal Met:

“Nahihiya na esteemed related to goal: 1. Assess Short term
rin ako annoying/debilitating After 2 weeks specific goal:
lumabas ng symptoms as of nursing stressors. After 2 weeks
bahay dahil evidenced by interventions, of nursing
sa kulay ng yellowish the patient will 2. Suggest intervention,
balat ko.” discoloration of the be able to patient wear the patient is
verbalized by skin and eyes. express his bright reds or able to
the patient. feelings blues and express his
“Ayaw na nya openly, blacks instead feelings
lumabas ng verbalize of yellows or openly,
bahay o minimized greens. verbalized
gumala feelings of minimized
kasama self-hate, 3. Provide feeling of
kaibigan nya shame and be privacy. self-hate,
dahil sa kulay able to shame and is
ng balat nya” demonstrate 4. Contract able to
verbalized by improved self- with patient demonstrate
his parents. esteem regarding time an improve
through more for listening. self-esteem
Objective: pride in by having
-Yellowish appearance. 5. Encourage more pride in
discoloration visits and appearance.
to the Long term interactions
patient’s skin goal: with people in Long term
and eyes. After similar goal:
-V/S Taken discharge, the situations. Upon
as follows: patient will (Discoloration discharge,
T: 38.9 °C verbalize of skin) the patient
PR: 88 bpm having an verbalized an
RR: 25 bpm overall Dependent: overall
BP:115/75 improved self- 1. Provide a improved
mmHg esteem, journal as self-esteem,
develop a ordered by the developed a
consistent, physician. consistent,
positive self- positive
image and image and
establish an established
inward sense an inward
of self-worth sense of self-
and worth and
confidence. confidence.