Name: Franzi Alyanna A.

Mugar
Clinical Instructor: Sir Edward R. Occeño, RN,
NURSING CARE PLAN Section & Group: BSN3F Group 3
 Assessment Cues Nursing Diagnosis (Rationale) Desired Nursing Intervention Justification Evaluation
Pathophysiologic / Schematic Outcome
Diagram
-The patient verbalized- Activity intolerance After 8 hours of After 8 hours of
“Ndi ko mayo ka giyo, related to physical Predisposing Precipitating nursing nursing intervention,
gapangluya ko” weakness Factors: Factors: intervention, the the patient will be
-36 year old -Immobility patient will be able able to:
-The patient verbalized of Definition: - Diagnosed: -Sedentary to:
unusual discomfort when Independent:
Insufficient Leptospirosis lifestyle
doing ADLs physiological or 1.Participate in
-Deconditioned Encourage activity The patient might tolerate it
psychological energy to state 1. Participate in progressively. (Sitting up in bed much better if activities are activities of daily
-Patient verbalizes
endure or complete -Lack of activities of Sitting on the side of the bed increased slowly. It provides living (ROM as
abdominal pain
required or desired motivation; daily living and dangle legs Standing up more time for the body to tolerated)
daily activities. anxiety (ROM as with assistance Marching in adjust. Goal met.
Objective:
-Severe stress tolerated) place Sitting in the chair for
 Patient face: grimace
Source/Reference: -Imposed activity meals Walking a few steps with
 Patient nauseous
rest in between and the
 Patient Doenges, M.E., restriction
opportunity to sit down)
Moorhouse, M.F., and
Abnormal Findings: Murr, A.C. (2019). Infected animal discharge urine
 Latest Vital Signs: Nurse’s pocket guide ↓ 2.Report an increased
BP - 90/60 mmHg; 15th Edition. Contaminant water/soil (Environment) 2. Report an Perform range of motion (ROM) tolerance to perform
PR - 81bpm; Philadelphia, ↓ increased as tolerated. ROM exercises increase activities and report
RR - 24 cpm; Pennsylvania: F.A. tolerance to circulation and help prevent onset of pain during
Bacteria enters the body through
Temp – 36.5 contractures.
Davis Company.NANDA broken skin or mucous membranes perform exercises right away.
O2 sat – 95% Encourage the patient to
↓ activities and Goal met.
report onset of perform active ROM exercises. Regular exercise maintains
Bacteria multiplies in blood
muscle strength, flexibility, and
↓ pain during
joint and tendon alignment.
Strengths: Development of antibodies exercises right
Over time, repeated exercises
1. Strong faith in God ↓ away. help increase tolerance, which
2. Supportive family Organism disappears from blood but is vital to perform ADLs.
remains in organs: brain, liver lung, Coordinate rest periods before 3.To achieve an
3. Optimistic heart, and kidneys straining activities such as Rest periods allow the patient increased conditioned
↓ eating, bathing, and to conserve energy. It allows for physical state.
Organism gains access to the kidney, it ambulating. heart rate and breathing to Goal met.
Weaknesses:
migrates to interstitium, renal tubules, 3. To achieve an normalize.
1. Lack of knowledge
increased If the patient is on bed, rest or
2. Financial and tubular lumen
unable to sit up, place the Upright positioning helps
difficulties ↓ conditioned
patient in an upright position prevent the deconditioning of
Interstitial nephritis and tubular necrosis physical state. several times per day. the heart and lungs. Lying for a
3. Time management ↓ prolonged period may
Renal failure develops due to tubular contribute to decreased cardiac
damage output, increased resting heart
↓ rate, and orthostatic
Liver involvement is seen as hypotension.
Centrlloubular Necrosis with
Monitor skin integrity several