UNIVERSITY OF SAN JOSE – RECOLETOS

School of Allied Medical Science

Nursing Department

NURSING CARE PLAN

Patient’s Name: _______M.M_________________________________ Age: _35 __ Gender: ____Female_____ Status: ____Single________________

Medical Diagnosis: _________________________________________ Physician: _________________________________________________
Date of Admission: _________________________________________ Hospital: __________________________________________________

SUBJECTIVE OBJECTIVE NURSING PLAN OF CARE

IMPLEMENTATION RATIONALE EVALUATION
CUES CUES DIAGNOSIS / OBJECTIVES

- Demonstrates a Readiness for After nursing 1. Identify the stressors 1. Accurately identifying the client's After the nursing intervention,
willingness to enhanced coping. intervention, the client that are currently situation provides information for the client was able to:
participate in (pp. 214-217) will be able to: affecting the client. planning interventions to enhance A. Explaining her situation and
recreational A. Accurately assess 2. Identify the social coping abilities. suggesting ways to improve it.
activities and the current situation. support available to the 2. Available family and friends can B. Demonstrated willingness to
routine. B. Identify effective client. provide the client with the ability to follow a routine.
coping behaviors 3. Review coping handle current stressful events, and C. Able to gradually express
currently in use. strategies that the client often “talking it out” with an needs and talk it out to see the
C. Express feelings that is currently aware of empathetic listener will help the big picture picture clearly, thus
correspond with the and using. client m0ove forward to enhance arriving at a concrete solution
behaviors. 4. Discuss the desire to coping skills. through thorough self-reflection.
improve clients' ability 3. The desire to improve coping
Reference: to manage stressors in ability is based on awareness of the
Doenges, M.E., life. current status of the stressful
Moorhouse, M.F. & 5. Assist the client in situation.
Murr, A.C. (2016). developing problem- 4. Accepting the reality that some
Nurse’s pocket guide: solving skills. things cannot be changed allows the
Diagnoses, prioritized client to focus energy on dealing
interventions, and with what can be changed.
rationales (15th ed.). 5. Learning the process of problem-
Philadelphia: F.A. solving promotes the successful
Davis Company. resolution of potentially stressful
situations that arise.

UNIVERSITY OF SAN JOSE – RECOLETOS

 School of Allied Medical Science
Nursing Department

NURSING CARE PLAN

Patient’s Name: _________________________________________________ Age: ______ Gender: _________________ Status: _________________________

Medical Diagnosis: _________________________________________ Physician: _________________________________________________
Date of Admission: _________________________________________ Hospital: __________________________________________________

SUBJECTIVE OBJECTIVE NURSING PLAN OF CARE

IMPLEMENTATION RATIONALE EVALUATION
CUES CUES DIAGNOSIS / OBJECTIVES

Demonstrates a Readiness for After nursing 1. Determine the client's 1. This provides a baseline for After the nursing intervention,
- willingness to enhanced decision- intervention, the client usual ability to manage their understanding the client's the client was able to:
participate in making (pp.231-233) will be able to: own affairs. decision-making process and A. Elaborate on further regarding
self-reflecting A. Explain the possible 2. Note expressions of measuring growth. her understanding of her
activities and choices for decision- decision, dependability, and 2. Having support for decision- condition.
routines. making availability of support making and good information B. Able to explore by asking
B. Identify risks and persons. regarding pros and cons of questions and listening carefully
benefits of each option. 3. Active - Listen and choices helps client feel to the nurses and medical staff.
C. Make decisions that identify reason/s the client comfortable with the decisions C. Display awareness of her
are congruent with would like to improve their made. condition and how it affects her
personal and decision-making abilities 3. As the client holistically. appears to appreciate
sociocultural values or and their expectations of articulates/clarifies reasons for guidance or pieces of advice from
goals. change. improvement, direction is other medical staff from time to
Reference: 4. Promote a safe and provided for change. time, while at the same time
Doenges, M.E., hopeful environment. 4. This provides an opportunity never failing to incorporate her
Moorhouse, M.F. & 5. Provide opportunities for for the client to discuss own ideas into decisions.
Murr, A.C. (2016). the client to recognize his or concerns/thoughts freely.
Nurse’s pocket guide: her own inner control in the 5. Individuals with an internal
Diagnoses, prioritized decision-making process. locus of control believe they
interventions, and have some degree of control in
rationales (15th ed.). outcomes and that their own
Philadelphia: F.A. actions/choices help determine
Davis Company. what happens in their lives.