Bulacan State University

COLLEGE OF NURSING
City of Malolos, Bulacan

INDIVIDUAL NURSING CARE PLAN

Patient’s Initial: R.R. Age: 52 y/o Gender: Date Handled: October 28, 2019
Medical Diagnosis: Non-compliance Chief Complaint: “Pag malakas ang ulan naamoy namin yung kanal sa harap mahirap huminga.”as verbalized by the patient.
Clinical Area: Community

Problem: Presence of Asthma

1st Level of Assessment: Presence of health threat as manifested by asthma.
2nd Level of Assessment: Inability to provide a home environment conducive to health maintenance and personal development due to inadequate family resources specifically the
lack of space to construct facility and also the lack of knowledge about preventive measures.

Cues Analysis of the Objectives Nursing Rationale Method of Family Resources Expected Outcome
Problem Intervention Contact Required
Subjective: Inability to provide a Short Term:  Establish rapport  To build trust  Home visits  Material Short Term:
“Pag malakas ang home environment After 1-2 days of with the family and familiarity resources: After 1-2 days of
ulan naamoy namin conducive to health patient teaching, the with the family a. Visual aids and patient teaching, the
yung kanal sa harap maintenance and client together with  State the purpose and to create materials needed client together with
mahirap huminga.”as personal development her family will be of the action common her family was well
verbalized by the due to: knowledgeable and grounds.  Human informed and shall
patient. able to verbalize  Assess the Resources: have verbalized
 Inadequate family understanding about family’s  To obtain  Home visits a. Time and Effort to understanding about
resources precautionary willingness to baseline data, both student nurse precautionary
Objective: specifically the measures against the participate in prevent and the family measures against the
 Open lack of space to stink canal as solving the problems and stink canal as
drainage construct facility. evidenced by wearing problem. minimize  Financial evidenced by wearing
 Lack of of mask to prevent the accidents related Resources: of mask to prevent
 Presence of knowledge about short in breathing and to chemical a. Money for the the short in breathing
stagnant preventive the inhalation of air exposure. student nurse and the inhalation of
water at the measures. Bourne  Discuss with the transportation. air bourne
end of the microorganisms that family their  This will  Home visits microorganisms that
drainage may cause harm to present condition decrease the may cause harm to
canal their health. and allow them to occurrence of their health.
verbalize their diseases.
Long Term: perception about Long Term:
After 3-4 days of the problem.  To gain  Home visits After 3-4 days of
nursing intervention, important nursing intervention,
The open canal will  Discuss with the knowledge to The open canal will
be placing a cover to family the ensure the be placing a cover to
prevent the stinky importance of wellness of the prevent the stinky
smell every rainy having a proper family. smell every rainy
season drainage system. season and the
symptoms such as
shortness of breathing
and elevation of vital
signs already
subsided.