NURSING CARE PLAN

Name of Patient: ___Patient P__________________________ Age: __32_____ Civil Status: ________M__Sex: _____F____Religion: _____________________
Address: ________________________________________Informant: ______________________ Relationship: _________________________________________
Chief Complaint: ________________________________ _________ Medical Diagnosis: ___________________________________________________________
Date PROBLE ASSESSME NURSING PLANNING IMPLEMENTATION
M LIST NT (cues & DIAGNOSI (Objectives- EVALUATION
(According evidences/ S long & short Rationale/ Justifications
to priority) Objective & term) (Nursing Theories of Care,
Nursing Interventions Reference
Maslow’s subjective) Developmental stage, s
Hierarchy tasks, Principles, EBP,
of Needs Standards of Nursing
Practice)

Psychosoci Subjective: Risk for Long Term: Independent: N Goal Met. After 7
al needs “I don’t Post-Trauma A days of rendering
want to go Syndrome After 7 days of  Establish rapport. N nursing intervention,
 To gain patient’s trust.
through that caused by nursing  Observe for and D the patient was able
 To note the factors
again” as the non- intervention, the elicit information A to demonstrate ability
that aggravate possible
patient conductivity patient will be about physical or to deal with
sever anxiety.
verbalize. of able to psychological injury. 15TH emotional reactions
Environment demonstrate Edition in an individually
Sept. to needs and ability to deal Doenges appropriate manner
 Listen for  To prevent rumination
28, Objective: insufficient with emotional et. al, 2019 and verbalize the
medical Comments of guilt, about lack of absence of severe
2022 reactions in an humiliation, shame, Pages 676-
support individually responsible that leads 684 anxiety, or reduced
or taking on to anxiety and PTSD. anxiety, or fear.
appropriate responsibility.
manner and
report absence
of severe  Provide safe, and
clean environment.  To promote trust and
anxiety, or safety of the client.
reduced anxiety
or fear.

Dependent:

 Administer
medication such as  To prevent
antidepressants as sleeplessness of the
necessary and as the client.
doctor ordered.

Collaborative:

 Provide daily therapy

or therapeutic  Assess the condition
conversation. of the mental state of
the client and help
alleviate severe
factors.