Nursing Care plan A

Assessment
Subjective:
dali ra jud ko
kapuyon bskan sa
ginagmay nga lihok
I easily get tired
even with little
effort and movements
I made

Objectives:
Weakness
Easy
fatigability
Diaphoresis
Difficulty
positioning
oneself.

Nursing
diagnosis
Activity
intolerance
related to
prolonged bed
rest as
evidenced by
weakness and
easy
fatigability.

Specific
objectives
Short term:
After 6 hours
of nursing
intervention,
Mr. EM will be
able to:
1. Verbalize a
desire to
cooperate
with the
activities
prepared.
2. Report
weakness
and fatigue
during the
implementat
ion of
activities.

Long term:
After 4 days
of nursing
intervention,
Mr. EM will be
able to:
1.Participate
in desired

Nursing
interventions
Independent

Rationale

1. Make client
report of
weakness and
fatigue.

Symptoms
may be a
result
of/or
continue
to
intoleranc
e of
activity

2. Assess
cardiopulmona
ry response
to physical
activity,
including
taking of
vital signs
before,
during and
after the
activity

To note
the
progressio
n/
accelerati
ng the
degree of
fatigue.

3. Ascertain
ability to
stand and
move about
and degree of
assistance
necessary

To
determine
current
status and
needs
associate
with
participat
ion in

Evaluation
Short term:
After 6
hours of
nursing
interventio
n, Mr. EM
was able
to:
1.
verbalize
cge gusto
nako mu
exercise
gamay para
dali ko
maulian
Now, I want
to exercise
a little
bit so that
I can
easily get
well.
GOAL MET.
2.Pahuway
sa ta
kadali kay
murag kapoy
na as
verbalized
Lets take
a rest for

activities.
2. Achieve
measurable
increase in
the activity
tolerance,
evidenced by
reduced
fatigue and
weakness and
by vital signs
within
acceptable
limits during
activity.
3. Meet own
self care
needs.

4. Adjust
activities.
Reduce
intensity
level or
discontinue
activities
that cause
undesired
physiological
changes.
5. Provide
positive
atmosphere,
while
acknowledging
difficulty of
the situation
for the
client

needed
desired
activities
To prevent
over
exertion.

Helps
minimize
frustratio
ns and re
channel
energy.

a while
because
its quite
tiring
already.
GOAL MET.
Long term
After 6
days of
nursing
interventio
n, Mr. EM
was able
to:
1.Participa
te in
desired
activities
as
evidenced
by moving
oneself
from side
to side,
able to eat
on his own.
Vital signs
BP- 130/80
RR- 23cpm
PR-88bpm
T- 36.8 C.
GOAL MET.

Nursing Care Plan B

Assessment
Subjective
wla najud ko
mayo gna
atipan sa
akong pamilya
(My family
doesnt take
care of me
anymore)
Objectives:
Family
members
seldom
complete
their
caregiving
tasks.
Significant
others
(SOs)
showing
abandonment
and
rejection to
the client.
Neglectful
relationship
with other
family
members.

Nursing
diagnosis
Disabled family
coping related
to family
disorganization
and role
changes as
evidenced by
significant
others not
developmentally
ready for
caregiver role.

Specific
Objectives
After 5 days
of nursing
intervention,
Mr. EM and
family will be
able to:

Nursing
intervention
1. Assess
level of
anxiety
present in
family/so.

1. Identify
resources
within
themselves to
deal with the
situation.

2. Establish
rapport and
acknowledge
difficulty of
the situation
for the
family.

2. Participate
positively in
care of
client, within
limits of
abilities.
3. Engage in
problem
solving with
direct care
providers to
meet clients
individual
needs.

3. Determine
level of
impairment of
perceptual/
physical
abilities.

4. Discuss
underlying
reasons for
client
behaviors with
family.

Rationale

Evaluation

1. Anxiety
level needs to
be dealt with
before
problems
solving.

After 5 days
of nursing
intervention,
Mr. EM and
family were
able to:

2. May assist
SO to accept
what is
happening and
be willing to
share problems
with
healthcare
providers.
3. Information
about family
problems will
be helpful in
determining
options and
developing an
appropriate
plan of care.
4. To help
family
understand and
accept/ deal
with unusual
behavior.

1. Identify
resources
within
themselves by
helping each
other for the
treatment and
rehabilitation
of Mr. EM.
GOAL MET.
2. Participate
positively in
the care of
client by
agreeing to
have a
shifting when
taking care of
Mr. EM.
GOAL MET
3. Mr. EM and
family members
compromised
with solutions
as to helping

5. Assist the
family/client
to understand
who owns the
problem and
who is
responsible
for
resolution.
Avoid placing
blame or
guilt.

5. When these
boundaries are
defined, each
individual can
begin to take
care of own
self and stop
taking care of
others in
inappropriate
ways.

6.Be a liaison
between family
and healthcare
providers

6.To provide
assistance in
information
provided

the client
with his
activities as
a means of
support during
recovery.
GOAL MET.

Nursing Care Plan C

Assessment
Subjective
Budlayan jud
ko usahay mag
ilis sa akong
sanina o
maligo nga ako
ra
(Sometimes I
have
difficulty
putting on my
clothes or to
take a bath on
my own)
Objectives:
Inability to
put on/or
take off
clothing.
Inability to
wash body
parts.

Nursing
diagnosis
Self care
deficit
related to
decreased
strength and
endurance as
evidenced by
inability to
perform
activities of
daily living
(ADLS)

Specific
Objectives
After 5 days
of nursing
interventions,
Mr. EM will be
able to:
1. Demonstrate
techniques/
lifestyle
changes to
meet self-care
needs.
2. Perform
self-care
activities
within level
of own
ability.
3. Identify
personal/
community
resources that
can provide
assistance as
needed.

Nursing
intervention

Rationale

1. Assess
abilities ad
level of
deficit for
performing
ADLs.

1. Aids in
anticipating/
planning for
meeting
individual
needs.

2. Avoid doing
things for Mr.
EM can do for
self, providing
assistance as
necessary.

2. This helps
maintain selfesteem and
promote
recovery.

3. Maintain a
supportive,
firm attitude.
Allow Mr. EM
sufficient time
to accomplish
tasks.

3. Clients
need empathy
and to know
caregivers
will be
consistent in
their
assistance.

4. Provide
positive
feedback for
efforts and
accomplishments

4. Enhances
sense of self
worth,
promotes
independence,
and encourages
client to
continue
endeavors.

Evaluation
After 5 days
of nursing
interventions,
Mr. EM was
able to:
1. Choose his
own clothing
and able to
take off/put
on his
clothing with
assistance
from his wife.
GOAL MET
2. Perform
self care
activities
like washing
his face and
body with his
unaffected
arm.
GOAL MET.
3. Identify
personal
resources like
the use cast,
and seek for
help from
family members

5. Assist and
encourage good
grooming habits
like taking a
bath.

5. Enables
client to
manage for
self, enhance
independence
and self
esteem and to
be more
socially
active.

if needed.
GOAL MET.