Saint Louis University

School of Nursing

NURSING CARE PLAN

EXPLANATION OF
ASSESSMENT GOALS/OBJECTIVES INTERVENTIONS RATIONALE EVALUATION
THE PROBLEM
S > - Has not measured Ineffective Health GOAL:  Assess patient’s - According to the health belief -Not me if the client
any BP reading since Management is defined  The client will adhere to individual model, patient’s perceived will refuse to the
after her last delivery by Doenges, the therapeutic regimen perceptions of susceptibility to a perceived therapeutic regimen
Moorhouse, & Murr management to meet the their health seriousness and threat of disease management to meet
- Complains of (2019) as a “pattern of effective goal of care and problems affect his or her compliance with the effective goal of
headache and regulating and treatment of problem the program. care and treatment of
feeling weak integrating into daily LTO: problem
living a therapeutic  Within 1 week of  Assess patient’s -According to the self-efficacy
- Prior to regimen for the nursing interventions, the confidence in theory, positive conviction that -partially met if the
knowledge of treatment of illness and client will: his or her can successfully execute a client will adhere to the
present its sequelae that is a. Exhibit (continuous) ability to behavior is correlated with therapeutic regimen
pregnancy, unsatisfactory for adherence to perform desired performance and successful management to meet
patient has had meeting specific health treatment plan. behavior outcome. the effective goal of
difficulty in goals.” b. Solve the factors care and treatment of
engaging in interfering with her  Assess for -Awareness of causative factors problem
physical Patient LS verbalized integration of
related provides direction for
activities, difficulty in following therapeutic - fully met if the client
reducing dietary prohibitions and management circumstances subsequent intervention. This will fully adhere to the
smoking, and instructions to reduce STO: therapeutic regimen
that may may range from patient’s culture
refraining from smoking. These were  Within 3 hours of management to meet
dietary prescribed to her in the nursing intervention, the negatively and interest the effective goal of
prohibitions management of her client will: care and treatment of
influence
previous diagnosis of a. Verbalize thoughts problem
- 38 y/o gestational and feelings resolution with
hypertension. This regarding the plan of
following the
- Roman Catholic poses a problem care
because if the patient is b. Verbalize intention program.
- Kankana-ey not able to effectively to follow the
manage her health, it prescribed
O > BP ranges from 110 may increase the risk of therapeutic regimen
gestational hypertension management
 Saint Louis University
School of Nursing

to 120/70 to 80mmhg in her current c. Identify factors  Determine the -To know any alternative diets
pregnancy, especially interfering with her
patient’s that will fit the patient’s meal
- 5'6" in height since history of integration of
hypertension is also therapeutic interest and diet with regards to the patient’s
- 150lbs in weight present in her maternal management and
usual meal diet interest.
and paternal side. ways to prevent it
- with history of d. Identify at least 2
gestational benefits/importance  Allow patient’s - Patients who participate in their
hypertension, of adherence to the participation in care have a greater chance of
diagnosed during prescribed regimen planning the obtaining a positive result and a
e. Verbalize ways on meal diet. better cooperation throughout
- last pregnancy how to incorporate the entire process.
has not measured new health regimens
any high BP into lifestyle such as  Inform patient - Increased knowledge fosters
reading since change in diet, of the benefits compliance.
after her delivery physical activity, of adherence to
habit(smoking), etc. prescribed
- G3P2, 25 weeks  Within 1 day of nursing regimen.
AOG intervention, the client
will:  Coordinate the - This approach promotes
- family history is a. Demonstrate therapy to compliance. A “one size fits all”
positive for behavior/ changes in patient’s is usually ineffective.
hypertension in lifestyle necessary to lifestyle.
both maternal maintain therapeutic
and paternal regimen  Provide - To encourage continuation of
sides positive desired behaviors and
reinforcements cooperation.
Nursing Diagnosis: for efforts.
ineffective health
management r/t to  Develop a - Self-monitoring is a key
difficulty in prescribed system or a component of a successful
regimens planner for the change in behavior. This also
patient to provides a satisfaction for the
observe and
Saint Louis University
School of Nursing

track his or her client because of the evident

own progress. changes that can be seen.

 Encourage the
- Involving significant others
patient’s
promotes support and assistance
significant other in strengthening appropriate
behaviors and promoting
for support and
lifestyle modification.
assistance.

 Provide
information - The needs of one client to
about normal another varies so as their needs.
weight gain The underweight patient may
during need a diet higher in calories, the
pregnancy, obese patient should avoid
modifying it to dieting because it places fetus at
meet client’s risk for ketosis.
needs.
 Saint Louis University
School of Nursing

References:

 Sphweb.bumc.bu.edu. (2019). The Health Belief Model. [online] Retrieved at: http://sphweb.bumc.bu.edu/otlt/MPH-
Modules/SB/BehavioralChangeTheories/BehavioralChangeTheories2.html [Accessed 18 Nov. 2019].
 Verywell Mind. (2019). How Self Efficacy Helps You Achieve Your Goals. [online] Retrieved at: https://www.verywellmind.com/what-is-self-efficacy-2795954 [Accessed
18 Nov. 2019].
 Longtin, Y., Sax, H., Leape, L. L., Sheridan, S. E., Donaldson, L., & Pittet, D. (2010, January). Patient participation: current knowledge and applicability to patient safety.
In Mayo Clinic Proceedings (Vol. 85, No. 1, pp. 53-62). Elsevier
 Saint Louis University
School of Nursing

NURSING CARE PLAN

Submitted by:
Barboza, Mark Joven
Lapidario, Koby R.
Magcalas, Patrick Ivan
Bastian, Myra Flor
Cudal, Pearl Christine
Leal, Daniela R.
Leyco, Shiela Mae
Pugao, Cyprene
Sacpa, Ferjo
Ramos, Ayn
Soriano, Mabelle
Turqueza, Karlyne Dayne