UNIVERSITY OF EASTERN PHILIPPINES

University Town, Northern Samar

COLLEGE of NURSING and ALLIED HEALTH SCIENCES

NURSING CARE PLAN

Name of Patient:__________GLORIA DIAZ_________ Date Admitted:_____05-30-20_____ Chief Complaint:______ABDOMINAL PAIN________ Case Number: 1
Age: 64 Gender:_______F______ Civil Status:_ M Address:_______BRGY. TANGOB, PALAPAG_____________ Ward:
 ASSESSMENT NURSING SCIENTIFIC OBJECTIVES/ NURSING INTERVENTIONS SCIENTIFIC RATIONALE EVALUATION
DIAGNOSIS RATIONALE PLANNING

Subjective Data: dysfunctional Increased, • Reestablish and  Assess vital signs, noting  This may suggest hypo • Response to
“ pera naak ka adlaw na dire GASTROIN decreased, maintain normal presence of low blood perfusion or developing sepsis. interventions, teaching,
nautot dikan masuol na ak tiyan TESTINAL ineffective, or pattern of bowel pressure, elevated heart rate, Fever in the presence of bright and actions performed
kay diak lat nakakauro, permi MOTILITY lack of functioning. and fever. red blood in stool may indicate
ak ulo malipong” as stated by peristaltic
related to • Verbalize  Inspect the abdomen, noting ischemic colitis • Attainment or progress
the client activity within
Objective Data: Change in the understanding of contour.  Distention of bowel may toward desired
Change in bowel sounds water source; gastrointestina causative factors and  Auscultate abdomen. indicate accumulation of fluids outcome(s)
Acceleration of gastric unsanitary l system. rationale for  Palpate abdomen (salivary, gastric, pancreatic,
emptying; diarrhea food treatment regimen.  Maintain GI rest when biliary, and intestinal) and gases • Modifications to plan of
Distended abdomen preparation • Demonstrate indicated—nothing by mouth formed from bacteria, care
Increase in gastric residual; appropriate (NPO), fluids only, or gastric swallowed air, or any food or
bile-colored gastric residual behaviors to assist or intestinal decompression fluid the client has consumed.
Vomiting
with resolution of  Administer prescribed  Hypoactive bowel sounds may
M. Doenges, causative factors. prophylactic medications indicate ileus. Hyperactive
Nurses pocket  Administer fluids and bowels sounds may indicate
guide, 15th electrolytes as indicated early intestinal obstruction or
edition  Manage pain with irritable bowel or GI bleeding.
medications as ordered, and  to note masses, enlarged organs
non-pharmacological (e.g., spleen, liver, or portions
interventions such as of colon); elicitation of pain
positioning, back rub, or with touch; and pulsation of
heating pad (unless aorta
contraindicated)  reduce intestinal bloating and
 Instruct in healthier risk of vomiting.
variations in preparation of
foods to reduce the potential for GI
 Discuss fluid intake complications such as bleeding,
appropriate to individual ulceration of stomach mucosa,
situation. and viral diarrheas.
 Collaborate with physician to replace losses and to improve
in medication management. GI circulation and function
 . to enhance muscle relaxation and
reduce discomfort.
as indicated, when these factors
may affect GI health
Water is necessary to general
health and GI function; client
may need encouragement to
increase intake or to make
STUDENT NURSE: _JOSEF ANGELO POLDO_______ CLINICAL INSTRUCTOR: _____JEANETTE ROJO_______

UNIVERSITY OF EASTERN PHILIPPINES

University Town, Northern Samar

COLLEGE of NURSING and ALLIED HEALTH SCIENCES

NURSING CARE PLAN

Name of Patient:__________GLORIA DIAZ_________ Date Admitted:_____05-30-20_____ Chief Complaint:________HEADACHE______________ Case Number: 2

Age: 64 Gender:_______F______ Civil Status:_ M Address:_______BRGY. TANGOB, PALAPAG________ Ward:
 ASSESSMENT NURSING SCIENTIFIC OBJECTIVES/ NURSING INTERVENTIONS SCIENTIFIC RATIONALE EVALUATION
DIAGNOSI RATIONALE PLANNING
S
Subjective Data: risk for Vulnerable to • Verbalize  Provide for isolation, as indicated (e.g.,  This reduces the risk of  Pain is reduced
fever, Headache INFECTIO invasion and understanding of contact, droplet, and airborne cross-contamination.  Body temperature is
“an ako ulo masuol ura- N multiplication of individual causative precautions). Educate staff in infection  Premature decreased to normal
ura dikan mahiragnat pathogenic or risk factor(s). control procedures. discontinuation of
ak” as stated by the organisms, which
• Identify interventions  Emphasize the necessity of taking treatment when client • Responses to
patient may compromise
Objective Data: health. to prevent or reduce antivirals or antibiotics, as directed (e.g., begins to feel well may interventions, teaching,
temp: 38.1 risk of infection. dosage and length of therapy). result in return of and actions performed
PR:78 • Demonstrate  Recommend routine or preoperative body infection and potentiation
RR:22 M. Doenges, techniques and shower or scrubs, when indicated (e.g., of drug-resistant strains. • Attainment or progress
Pain scale: 8/10 Nurses lifestyle changes to orthopedic, plastic surgery),  to reduce bacterial toward desired
pocket guide, promote safe  Monitor medication regimen (e.g., colonization outcome(s)
15th edition
environment. antimicrobials, drip infusion into  to determine
 Reduce fever osteomyelitis, subescharclys is, topical effectiveness of therapy • Modifications to plan of
 Reduce pain antibiotics) and note the client’s response or presence of side care
 Discuss the importance of not taking effects
antibiotics or using “leftover” drugs  Inappropriate use can
unless specifically instructed by lead to development of
healthcare provider. drug-resistant strains or
secondary infections.

STUDENT NURSE: __JOSEF ANGELO POLDO____ CLINICAL INSTRUCTOR: ______JEANETTE ROJO______

UNIVERSITY OF EASTERN PHILIPPINES

University Town, Northern Samar

COLLEGE of NURSING and ALLIED HEALTH SCIENCES

NURSING CARE PLAN

Name of Patient:__________GLORIA DIAZ_________ Date Admitted:_____05-30-20_____ Chief Complaint:_____________ANXIETY______________ Case Number: 3

Age: 64 Gender:_______F______ Civil Status:_ M Address:_______BRGY. TANGOB, PALAPAG_____________________ Ward:
 ASSESSMENT NURSING SCIENTIFIC OBJECTIVES/ NURSING INTERVENTIONS SCIENTIFIC RATIONALE EVALUATION
DIAGNOSIS RATIONALE PLANNING

Subjective Data: impaired Insufficient or • Verbalize awareness of  Determine client’s use of coping  Symptoms associated with social anxiety affect • Responses to
“dire na siya naguwas SOCIAL excessive factors causing or skills and defense mechanisms. ability to be involved in social situations, making interventions,
INTERACTIO quantity or promoting impaired  Interview family, SO(s), friends, client’s life miserable and seriously interfering with teaching, and
san balay kay nalo” as
N related to ineffective social interactions. actions performed
said by the significant spiritual leaders, coworkers, as work, friendships, and family life.
quality of
other Therapeutic • Identify feelings that appropriate  to obtain observations of client’s behavioral
social
Objective Data: isolation exchange. lead to poor social  Provide positive reinforcement for changes and effects on others • Attainment or
Impaired social interactions. improvement in social behaviors  Encourages continuation of desired behaviors and progress toward
functioning • Express desire for, and and interactions. efforts for change desired
Dysfunctional be involved in,  Encourage ongoing family or  While therapy groups can be useful, individuals can outcome(s)
interaction with others achieving positive individual therapy as long as it is become dependent on the process and not move on
changes in social promoting growth and positive to managing on their own. • Modifications to
M. Doenges, behaviors and change.  Others may see behaviors and the problems plan of care
Nurses pocket interpersonal  Review/list negative behaviors associated with them, such as unwillingness to
guide, 15th relationships. observed previously by caregivers, participate in necessary activities (e.g., eating in a
edition • Give self, positive coworkers, and so forth. public place, interviewing for a job) and may
reinforcement for  Compare lists and validate reality provide additional information needed to develop
changes that are of perceptions. Help client an appropriate plan of care.
achieved. prioritize those behaviors needing  Each individual may have a different view of what
• Develop effective social change. constitutes a problem; by comparing lists, each
support system; use  Work with client to alleviate person hears how others view the problems,
available resources underlying negative self-concepts enabling the client/family to identify behaviors or
appropriately concerns to be dealt with
 because they often impede positive social
interactions.

STUDENT NURSE: ______JOSEF ANGELO POLDO_______ CLINICAL INSTRUCTOR: _______JEANETTE ROJO_______