Name of Patient: N. K. J.

Date of Admission: February 09, 2024 Room: 405B

Age: 68 yrs. old Sex: Male Civil Status: Chief Complaint:
Religion: Attending Physician: Dr. Miranda
DATE/ GOALS/OBJECTIVES NURSING
CUES NURSING DIAGNOSIS RATIONALE EVALUATION
TIME CRITERIA INTERVENTIONS
Subjective: Nursing Diagnosis: After 8 hours of nursing Independent: Independent: February 09, 2024;
February • “Umiinom parin ako Ineffective Health Self- interventions, the 1. Educate the client about 1. Helps the client understand @6:00pm
09, 2024; ng alak ngayon dahil Management related to patient will be able to: the treatment regimen that why treatment is needed
@10:00am parati akong iniimbita unhealthy lifestyle choices he will undergo. and gain full trust to comply
ng aking kabitbahay. as evidenced by ineffective a. Verbalize in the treatment regimen. “GOAL MET”
Minsa’y ako lang choices in daily living for acceptance of need
mag-isa na meeting health goals and desire to change 2. Emphasize the importance 2. To promote health and
nagtatagay sa bahay actions to achieve of good nutrition. well-being After 8 hours of nursing
kung wala akong Scientific Basis: agreed-on health intervention, the patient
ibang ginagawa. Di Ineffective health self- goals 3. Stress necessity of follow- 3. Provides evaluation of was able to:
ko narin gusto management is defined as b. Verbalize up care and adherence to effectiveness of regimen.
gumalaw-galaw. unsatisfactory understanding of therapeutic regimen. a. Verbalized
Parati lang akong management of symptoms, factors or blocks acceptance of need
nakahiga dahil treatment regimen, involved in individual 4. Teach the client self-care 4. Allows participation in their and desire to change
lumalala yung physical, psychosocial, and situation skills related to nutrition, care and fosters a sense of actions to achieve
paghingal ko sa spiritual consequences and c. Demonstrate exercise, medication control over their health agreed-on health
tuwing ako’y lifestyle changes. behaviors and management, stress outcomes. goals
lumalakad” as Ineffective health self- changes in lifestyle reduction, and symptom b. Verbalized
verbalized by the management can be due necessary to monitoring. understanding of
patient. to patient’s lack of maintain therapeutic factors or blocks
• “Sinabihan na ako ng engaging in self-care. A regimen 5. Assist the client in 5. To promote health, involved in individual
doktor ko noon na patient displaying poor d. Increase knowledge reducing alcohol mitigating risks, fostering situation
tigilan kona ang health maintenance due to on the importance of consumption, such as motivation, and improve c. Demonstrated
aking paninigarilyo, lifestyle choices or following and limiting the number of overall well -being. behaviors and
kaso nga lang ay disinterest in making completing the drinks per day or changes in lifestyle
tuloy parin ang changes presents a prescribed length of abstaining from alcohol on necessary to
nakagawian kong different challenge. medical treatment certain days of the week. maintain therapeutic
paninigarilyo at nasa regimen. regimen
isang kaha ng Reference: e. Identify resources 6. Create a goal with the 6. To increase the likelihood d. Increased
sigarilyo ang Doenges, M., Moorhouse, necessary to support client of quitting smoking of successful regimen. knowledge on the
nauubos ko sa loob M. F., & C. Murr, A. (2019). health maintenance into smaller, manageable importance of
ng isang araw.” Nursing Care Plans steps following and
Stated by the patient Guidelines for completing the
Individualizing Client Care 7. Provide positive 7. Increase the likelihood that prescribed length of
Objective: Across the Life Span (10th reinforcement and patients will adhere to medical treatment
• (+) shortness of ed). encouragement recommended health regimen.
breath behaviors. e. Identified resources

Name of Student Nurse

 • (+) decreased activity necessary to support
level 8. Introduce different 8. To promote a successful health maintenance
• (+) jaundice resources to support regimen
• (+) mild abdominal health maintenance
pain
• Heavy smoker for 40 Dependent: Dependent:
years 9. Administer prescribed 9. Manage underlying health
• Alcoholic beverage medications as per conditions and promote
drinker at least 4–5 physician’s order health maintenance.
days a week.
• Five years ago, the Collaborative: Collaborative:
patient was 10. Collaborate with dietitians 10. Helps in supporting the
diagnosed with to develop a tailored body's ability to heal and
Hypertension but did nutrition plan. function optimally.
not follow his
regimen diligently 11. Coordinate with a physical 11. Helps the patient overcome
due to financial therapist to develop an barriers to exercise and
constraints. individualized exercise promote adherence to a
program to improve regular exercise regimen.
Vital Signs: mobility, strength, and
• RR - 23 cpm overall physical fitness.
• BP - 140/90 mmHg

Reference(s):
Doenges, M., Moorhouse, M. F., & C. Murr, A. (2019). Nursing Care Plans Guidelines for Individualizing Client Care Across the Life Span (10th ed).

Name of Student Nurse