DAVAO DOCTORA COLLEGE

General Malvar St., Davao City Nursing Program

NURSING CARE PLAN

Name of Patient: ___ _____PATIENT X_______________ Date of Admission: ________ Room: _ _

Age: ______ Sex: __ Civil Status: __ Chief Complaint: __ ____
Religion: __N/A___ ________ Attending Physician: _________

GOALS/OBJECTIVES NURSING INTERVENTIONS

PROBLEM SCIENTIFIC BASIS CRITERIA RATIONALE EVALUATION

March 17, 2023 Nursing Diagnosis: Long term goal Independent Nursing Action Independent Nursing March 20, 2023
Self-care deficit After 3 days of an effective 1. Establish rapport Action
SUBJECTIVE DATA: related to decrease in nursing intervention and 1. You will gain the
“I need help getting muscle strength as medical intervention the 2. Assess the patient’s trust of your Long term goal
ready for the day.” as evidenced by Inability patient will able to; strength to accomplish patient and by that
verbalize by the patient. to perform self-care ADLs efficiently and you can easily 1. Patient will perform
tasks. 1. Patient will perform cautiously on a daily perform the ADLs within their own
OBJECTIVE DATA: ADLs within their basis using a proper nursing level of ability
Scientific Basis: own level of ability assessment tool, such interventions.
- The patient is Self-care deficit refers as the Functional 2. Patient will maintain
unable to reach to the patient that is 2. Patient will maintain Independence 2. The patient may independence with
the entire body limited in performing independence with Measures (FIM). only need help [specify ADL]
when washing. activities of daily living [specify ADL] with some self-
(ADLs). This can care measures.
include tasks related to 3. Establish short-term FIM measures 18 3. Caregiver will
feeding, bathing and 3. Caregiver will goals with the patient. self-care items demonstrate the
hygiene practices, as demonstrate the related to eating, ability to meet
well as getting dressed ability to meet bathing, grooming, patient’s personal
and completing
toileting. Self-care
deficits can also
expand to more 4. Patient will
complex tasks such as
making phone calls or
managing finances,
which are referred to as
Instrumental Activities
of Daily Living (IADLs).
REFERENCE:
Herdman, T.H. &
Kamitsuru, S. (Eds.).
(2014). NANDA
International Nursing
Diagnoses: Definitions
& Classification, 2015–
2017. Oxford: Wiley
Blackwell
patient’s personal 4. Guide the patient in dressing, toileting, needs
needs accepting the needed bladder and bowel
amount of dependence. management, 4. Patient will
transfer, demonstrate
demonstrate 5. Present positive ambulation, and appropriate use of
appropriate use of reinforcement for all stair climbing. adaptive equipment
adaptive equipment activities attempted; PARTIALLY MET
note partial 3. Helping the
achievements. patient with setting
realistic goals will
reduce frustration.
6. Render supervision for
each activity until the 4. Patient may
patient exhibits the skill require help in
effectively and is determining the
secured in independent safe limits of trying
care; reevaluate to be independent
regularly to be certain versus asking for
that the patient is assistance when
keeping the skill level necessary.
and remains safe in the
environment. 5. External
resources of
positive
reinforcement may
promote ongoing
efforts. Patients
often have
difficulty seeing
progress.
6. The patient’s
ability to perform
self-care
measures may
change often over
time and will need
to be assessed
regularly.
BBN/DTS/2020

JUSTIN ALZATE