NURSING CARE PLAN

Name of Student: RUIZ, LEXENICA ASHLEY B.

Name of Patient: Civil Status: STUDENT
Diagnosis or Clinical Impression: Age: 20 Sex: FEMALE
Date: NOVEMBER 01, 2023

ASSESSMENT/ NURSING BACKGROUND GOAL AND NURSING EVALUATION

CUES DIAGNOSIS KNOWLEDGE OBJECTIVES INTERVENTONS AND
RATIONALE
SUBJECTIVE DATA Sleep pattern Sleep pattern NOC: NIC:
As stated by the disturbance related disturbance is a time-  Sleep  Sleep
client, "I can't sleep to anxiety and limited awakenings enhancement
because I'm worried stress. due to external  Environmental
about my exams next factors. North management:
week." American Nursing comfort
tension associated to Diagnosis Association
exams making it (NANDA)
difficult to sleep and GOAL:
worrying constantly. After the nursing
She also complained interventions, the
about being dizzy and client will be able to
feeling tired all the sleep more than 4
time. hours without any
disruptions.
OBJECTIVE DATA
-pale conjunctivae OBJECTIVES: INTERVENTIONS: EVALUATION:
- dark circles around After the nursing During the health care, After the evaluation,
the eye interventions, the the nurse will: the client was able
client will be able to: to:
a) Identify i Review client’s Apply the identified
individually usual bedtime individually
appropriate rituals, routines, appropriate
interventions and sleep interventions to
to promote environment promote sleep
sleep needs. This
provides
information on
client’s
management of
the situation
and identifies
areas that
might be
modified when
the need arises.
ii Address sleep
management
techniques that
may be useful
during stressful
conditions or
lifestyle
changes. This
helps induce
sleep
iii Encourage usual
bedtime
routines such as
washing face
and hands and
 brushing teeth
to facilitate
transition from
wakefulness to
sleep
iv Problem-solve
immediate
needs. Short-
term solutions
may be needed
until client
adjusts to
situation or
crisis is
resolved, with
resulting return
to more usual
sleep pattern.
v Provide
pamphlet with
information
about sleep-
enhancement
techniques
 NURSING CARE PLAN

Name of Student: RUIZ, LEXENICA ASHLEY B.

Name of Patient: Civil Status:
Diagnosis or Clinical Impression: Chronic iron deficiency Age: 35 Sex: FEMALE
anemia
Date: NOVEMBER 01, 2023

ASSESSMENT/ NURSING BACKGROUND GOAL AND NURSING EVALUATION

CUES DIAGNOSIS KNOWLEDGE OBJECTIVES INTERVENTONS AND
RATIONALE
SUBJECTIVE DATA Activity intolerance Activity intolerance is NOC: NIC:
-complaints of related to impaired an insufficient - Endurance - Energy
difficulty in breathing
oxygen transport physiological or - Activity management
and dizziness when and decreased psychological energy Tolerance
doing an activity hemoglobin level, to endure or complete
as evidenced by required or desired
difficulty in daily activities. North
breathing and American Nursing
OBJECTIVE DATA inability to maintain Diagnosis Association
-hemoglobin level of usual level of (NANDA)
9.1 g/dL physical activity
-pale secondary to
-weak chronic iron GOAL:
deficiency anemia After the nursing
interventions, the
client will be able to
report an increase in
activity tolerance,
including ADLs.
OBJECTIVES: INTERVENTIONS: EVALUATION:
After the nursing During the health care, After the evaluation,
interventions, the the nurse will: the client was able
client will be able to: to:

a. Determine a. Assess client’s Determine the need

the need of ability to of assistance when
assistance perform normal doing ADL’s
tasks and ADLs,
noting reports
of weakness,
fatigue, and
difficulty
accomplishing
tasks. This
influences the
choice of
interventions
and assistance.

b. Be aware of B1) Monitor Became more aware

the health patient’s oxygen of one’s health
status when response, pulse status especially
performing rate, cardiac when performing
ADL’s rhythm, and certain ADL’s
respiratory rate
to self- care or
nursing
activities. To
establishes
parameters for
 the patient’s
normal
Measurements.

B2) Suggest
client change
position slowly;
monitor for
dizziness.

C1) Assist client

c. Participate in to prioritize Participate in
planning for ADLs and planning activities
doing ADL’s desired that may facilitate in
activities. successfully doing
Alternate rest ADL’s
periods with
activity periods.

C2) Provide or
recommend
assistance with
activities as
necessary,
allowing client
to be an active
participant as
much as
possible.

C3) Plan activity

 progression
with client,
including
activities that
client views as
essential.
Increase activity
levels, as
tolerated. If
necessary,
adjust activities
to prevent
overexertion.

d. express D1) Advise and Understand more

understandin educate the about the need of
g about his or patient to eat taking in vitamins
her condition foods rich in and nutrition that is
and possible iron, folic acid, essential for her
causative and vitamin B12 health.
factors. which are
needed to
promote RBC
formation.
 NURSING CARE PLAN

Name of Student: RUIZ, LEXENICA ASHLEY B.

Name of Patient: Civil Status:
Diagnosis or Clinical Impression: Chronic iron deficiency Age: 35 Sex: FEMALE
anemia
Date: NOVEMBER 01, 2023

ASSESSMENT/ NURSING BACKGROUND GOAL AND NURSING EVALUATION

CUES DIAGNOSIS KNOWLEDGE OBJECTIVES INTERVENTONS AND
RATIONALE
SUBJECTIVE DATA
-complaints of
difficulty in breathing
and dizziness when
doing an activity
-complaints of being
tired

OBJECTIVE DATA
-hemoglobin level of
9.1 g/dL
-pale
-weak