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BSN3-B
NURSING CARE PLAN (PATIENT 1)
ASSESSMENT DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATION

SUBJECTIVE: Activity SHORT TERM DEPENDENT: DEPENDENT: GOAL MET

“meron pa rin intolerance GOAL: -administer the following -to treat the present illness SHORT TERM
yung time na related to After 2 hours of medication ordered by the and improve patients energy GOAL:
hindi ko ma involuntary , rendering attending physician. levels to perform activity -goal met as evidence
control yung uncontrollable nursing by the client’s
pag galaw ng movement of interventions the INDEPENDENT: INDEPENDENT: tolerance to activity
kamay at paa left arm and patient will be -provide adequate bed rest -to preserve energy loss from was increased by the
ko kalawa foot able to tolerate and advise the client to hyper-mobility of muscles due ability to perform daily
normal activities restrict activity as much as to uncontrolled, involuntary activities.
of daily living possible. movements.
OBJECTIVE: with ease and LONG TERM
-to conserve oxygen for vital GOAL:
(-) DOB reports a -advise patient to avoid
organs. - Gola partially met.
(-) decreased of strenuous work activities.
Desaturation assistance. Evident with short
(-) Erythema term goal attained.
(-) Mild Fever LONG TERM -provide calm and quiet -to enhance rest and sleep
GOAL: environment and avoid and gain energy to perform
VITAL SIGN: After 1 week of destruction in the client activities.
BP: 130/90 rendering nursing surroundings.
RR: 19 care the patient
TEMP: 35.9 would be able to -monitor the clients
understand the -to identify the baseline data
02 SAT: 92% tolerance activity and ECG, and prevent complications.
nature of the
PR: 62 disease and to be
vital signs, pulse oximetry
able to levels.
comprehend with
precautionary
measures so as
medication
regimen.

NURSING CARE PLAN (PATIENT 2)

BSN 3B

ASSESSMENT DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATION

SUBJECTIVE: Acute pain related to SHORT TERM: SHORT TERM: SHORT TERM:
“medjo masakit disease process. After 30 mins of DEPENDENT Goal is met as evidence by
parin yung katawan nursing interventions the patient verbalize relief of
ko” as verbalized by the patient will -Administer medication as -To reduce severe pain or pain and rate is 2/10 from
the patient verbalize pain relief indicated promotes rest and relaxes 4/10.
smooth muscle
Pain Scale: 4/10 LONG TERM: INDEPENDENT:
After 8 hours of -Promote bed rest -to reduced intra-abdominal
OBJECTIVE: nursing intervention pressure
-Facial Grimace the patient will
BP: 120/80 relieved and -Encourage use of relaxation -to promote rest, redirect
RR- 21 controlled. technique (deep breathing attention that may enhance
TEMP: 36.2 exercises or distraction) coping.
PR: 56
02 SAT: 98% -Observes and document location -it promotes information about
of pain scale and characteristics disease progression,
of pain development of complications
and effectiveness of
intervention.
LONG TERM:
INDEPENDENT
-Changing position -make the patient more
comfortable.
COLABOARTIVE;
Encourage significant other have -divert attention of patient.
a diversional activity.