St.

Anthony’s College
San Jose, Antique
Nursing Department

Name: E.J.M
Age/Sex: 58 y.o/ Female
CC: Dizziness
NURSING CARE PLAN

CUES NURSING RATIONALE PLANNING INTERVENTION RATIONALE EVALUATION

DIAGNOSIS
Readiness for A pattern of After 8 hrs.of nursing
Subjective: Enhanced ease, relief and GENERAL: INDEPENDENT: intervention, patient
“okay ruman Comfort related transcendence in After 8 hours of nursing verbalize feeling of
pamatyag ko, wra to physical, intervention, patient will be  Assess vital signs.  To monitor baseline data. satisfaction and relief.
run mn galingin psycho-spiritual, able to express feeling of  Assess client’s current  First step in helping Comfort status level 5.
ulo ko kg ga alay environmental, relief and satisfaction. level of comfort. client’s to achieve
lubot ko” as or social enhanced comfort. Goal met.
verbalized by dimensions that SPECIFIC:  Helps client understand  Human being strive to have
patient. is sufficient for After 4 hours of nursing that enhanced comfort their basic comfort needs
well- being and intervention, patient will be is desirable, positive met, but comfort is more
Objective: can be able to verbalize sense of
and achievable goal. than just the absence of
VS taken as strengthened. comfort and contentment.
pain. Comfort is best
follows: Reference: recognized when a person
BP- 130/80 mmHg Nurse’s Pocket leaves the state of
PR- 63 cpm Guide, discomfort.
RR- 22 bpm Diagnoses,
O2sat- 95 % Prioritized  Enhance feelings of  Trust is an essential
T- 36.6 Interventions, trust between the client element in the nurse-
and Rationales. and the health care patient relationship. To
M. Doenges, M. provider. attain the comfort level a
Moorhouse, A. client must be able to trust
Murr. the nurse.
12th Edition  Use therapeutic  Massage is helpful for low
massage for back pain.
enhancement of
comfort.
  Evaluate the Establish guidelines for
effectiveness of all frequency of assessment and
interventions at regular document response noting if
intervals and adjust goals are being met.
therapies as necessary.

DEPENDENT:

 Administer 
antihypertensive
drugs as doctor’s
order.

Name of Student: Eden Marie D. Francisco BSN 4 Clinical Instructor: Jerry V. Able MAN,RN
 St. Anthony’s College
San Jose, Antique
Nursing Department

Name: L.Y.C
Age/Sex: 59 y.o/ Female
NURSING CARE PLAN

CUES NURSING RATIONALE PLANNING INTERVENTION RATIONALE EVALUATION

DIAGNOSIS
Subjective: Chronic Pain Unpleasant sensory and After 8 hrs. of nursing
“ Grabe na gid ang related emotional experience GENERAL: INDEPENDENT: intervention, patient
sakit” progression of arising from actual or able to relief from pain.
As verbalized by the 
disease process. potential tissue damage SPECIFIC: Assess and  To monitor baseline Pain scale of 5/10.
patient. After 2 hours of nursing document pain
or described in terms of data especially the
intervention, patient characteristic: Goal partially met.
Objective: such damage temperature of the
Herdman, T.H. shows no signs of quality, severity,
 Facial grimace (International malnutrition. location, onset, patient. Fever may
 pain scale of (2012). NANDA indicate infection.
Association for the Displays weight gain on duration,
8/10 International
Study of Pain); sudden the way to preferred precipitating and
 restlessness Nursing alleviating factors.
Diagnoses. or slow onset of any goal, with normalization
intensity from mild to of laboratory values.
V/S taken as follows:  Assess and note for  Physiological changes
BP- 180/90 severe, constant or
signs and and behaviors
T- 36.7 recurring without an symptoms related associated with acute
PR- 97 anticipated or to chronic pain pain may not be
RR- 22 predictable end and a such as weakness, exhibited by patients
O2sat- 99 % duration of greater than decreased appetite, with chronic pain.
six (6) months. weight loss,
Reference: changes in body
posture, sleep
pattern disturbance,
Nurse’s Pocket Guide, anxiety, irritability,
Diagnoses, Prioritized agitation, or
Interventions, and depression.
Rationales. M. Doenges,
M. Moorhouse, A. Murr.
12th Edition
  Acknowledge and  Conveying an attitude
assess pain matter of empathic
of factly, avoiding understanding of
undue expressions clients disabling
of concern, as well distress can have a
as expressions of beneficial impact on
disbelief about client’s perception of
client’s suffering. health.

 Evaluate pain  Pain behaviors can

behavior, noting include the same ones
past and current present in acute pain.
pain experience Pain may be
using pain rating exaggerated because of
scale. client’s perception that
pain reports are not
believed or because
client believes
caregivers are
discounting reports of
pain.
DEPENDENT:
 Administer
analgesic/ opiods as
 To alleviate pain.
doctor’s order.

Name of Student: Eden Marie D. Francisco Clinical Instructor: Roque B. Cordero III, RN
 St. Anthony’s College
San Jose, Antique
Nursing Department

Name: L.Y.C
Age/Sex: 59 y.o/ Female
NURSING CARE PLAN

CUES NURSING RATIONALE PLANNING INTERVENTION RATIONALE EVALUATION

DIAGNOSIS
Subjective: Risk for Vulnerable to entry of After 8 hrs. of nursing
“gintakdan tana aka aspiration gastrointestinal GENERAL: INDEPENDENT: intervention, patient
NGT kay pira run tan related to secretions, After 4 hours of able to free from any
aka adlaw wara gana presence of oropharyngeal nursing intervention,  Assess vital signs.  To monitor baseline signs of possible
magkaon ”
nasogastric secretions, solids or patient will not data especially the aspiration.
As verbalized by
tube. fluids into the experience possible temperature of the
patient’s folk.
Herdman, T.H. tracheobronchial aspiration. patient. Goal partially met.
Objective: (2012). NANDA SPECIFIC:
passages, which may
V/S taken as follows: International After 2 hours of nursing
Nursing
compromise health. intervention, patient will  Note the client’s As impairment in these
BP- 180/90 mmHg
manifest level of areas may increase the
T- 36.7 Diagnoses.
Reference: consciousness, client’s risk for aspiration
PR- 97
awareness of owing to the inability to
RR- 22
Nurse’s Pocket Guide, surrondings and
O2sat- 99 % cough or swallow well and
cognitive function
Diagnoses, Prioritized the presence of an artificial
Interventions, and airway.
Rationales. M. Doenges,
M. Moorhouse, A. Murr.  Assess the client’s  Sudden respiratory
12th Edition ability to swallow symptoms such as
and cough. Note (severe coughing,
quality of voice.
and wet phlegmy
voice quality) are
indicative of
potential aspiration.
  Note the  The potential exist
administration of for regurgitation and
enteral feeding, aspiration with the
which may be
initiated when oral use of nasogastric
nutrition is not feeding tubes, even
possible. with proper tube
placement.

 Provide a rest  The rested client may

period prior to have less difficulty
feeding time. with swallowing.

 Ascertain that the

 Placement may be
feeding tube is in done under
correct position. fluoroscopy and or
measurement of
aspirate pH
following placement
of feeding tube may
be indicated.

Name of Student: Eden Marie D. Francisco Clinical Instructor: Roque B. Cordero III, RN
 St. Anthony’s College
San Jose, Antique
Nursing Department

Name: L.Y.C
Age/Sex: 59 y.o/ Female
NURSING CARE PLAN

CUES NURSING RATIONALE PLANNING INTERVENTION RATIONALE EVALUATION

DIAGNOSIS
Risk for Vulnerable to changes in After 8 hrs. Of nursing
electrolyte serum electrolyte levels GENERAL: INDEPENDENT: intervention, patient
Objective: imbalance that may compromise After 8 hours of able to be free from
V/S taken as follows: related to health. nursing intervention,  Assess vital signs.  To monitor baseline complications resulting
BP- 180/90 mmHg
insufficient patient will be free data especially the from electrolyte
T- 36.7
fluid volume. from any temperature of the imbalance.
PR- 97
RR- 22 complications from patient.
O2sat- 99 % Herdman, T.H. electrolyte imbalance. Goal partially met.
(2012). NANDA
International SPECIFIC:
After 2 hours of nursing
 Monitor heart rate  Tachycardia,
Nursing
Reference: and rhythm by bradycardia, and
Diagnoses. intervention, patient’s
palpation and other dsyrhythmias
laboratory results within auscualtation.
Nurse’s Pocket Guide, normal rainge. are associated with
Diagnoses, Prioritized potassium, calcium
Interventions, and and magnesium
Rationales. M. Doenges, imbalances.
M. Moorhouse, A. Murr.  Assess  Any disturbances of
12th Edition
gastrointestinal the gastrointestinal
symptoms, noting functioning carries
presence, with it the potential
absence and for electrolyte
character of imbalances.
bowel sounds.
  Assess fluid  Many factors such as
intake and inability to drink,
output. diuresis or chronic
kidney failure,
trauma and surgery
affect an individual
fluid balance.
 Review
 Electrolytes include
laboratory results
sodium, potassium,
for abnormal
calcium and
findings. magnesium. These
chemicals are
essential in many
bodily functions
including fluid
balance.
 Monitor ECG as
indicated.  Abnormal potassium
levels, both low and
high are associated
with changes in the
ECG.

Name of Student: Eden Marie D. Francisco Clinical Instructor: Roque B. Cordero III, RN