POLYTECHNIC COLLEGE OF DAVAO DEL SUR, INC.

MacArthur Highway, Digos City

NURSING CARE PLAN

Name of Patient: Aurelio Tormis Attending Physician: Dr. Chua

Age: 65 Sex: Male Civil Status: Married Diagnosis: Mild
Highhead injury
grade to consider
glioma right cerebral c
Occupation: Farmer Religion: Roman Catholic frontotemporal lobe
Address: Sitio Siao, Tamugan, Davao City
Ward: Neuro Bed No. 8

DATE/TIME CUES NEEDS NURSING SCIENTIFIC BASIS GOALS NURSING RATIONALE EVALUATION
DIAGNOSIS OBJECTIVES INTERVENTIONS
CRITERIA
11/18/16 Subj: A Ineffective Normally the lungs Within 8 hours of 1. Obtained and 1. To obtain “GOAL MET”
8:00 am “Pag C airway are free from nursing monitor vital signs baseline data
muubo ko T clearance secretions. interventions, the 2. Established 2. To gain Within 8 hours
naay I r/t Pneumonia patient will be able rapport cooperation of nursing
V
plema increased bacteria are to show signs of 3. Elevated head of 3. To ease interventions,
I
maapil” T
mucous invading the lung effective airway bed respiratory the patient was
Y production parenchyma thus clearance as discomfort able to show
Obj. secondary ,producing evidenced by: 4. Encouraged to 4. To loosen signs of
- E to inflammatory increase OFI secretions effective
productive X bacterial process. And these -decreased cough 5. Encouraged to 5. To loosen airway
cough E infection responses leading frequency ambulate when secretions clearance as
noted R to -decreased sputum tolerated evidenced by:
-whitish C filling of the -absent nasal flaring 6. Encouraged to 6. To increase
secretions I alveolar sacs -absent orthopnea perform deep exertional effort -decreased
S
noted with exudates breathing and frequency of
E
-nasal leading to coughing cough
flaring P consolidation exercises -decreased
- A 7. Encouraged to 7. To promote sputum
orthopnea T Kozier and Erb’s have adequate healing production
noted T Fundamentals on bed rest -absent nasal
E Nursing flaring
R -absent
N postural
discomfort
Name: Pryll John O. Colita Section & Year: BSN-III Group No.: 1_ Rating: _______________
Reference: Nurse’s Pocket Guide Diagnoses, Interventions and Rationales 9th Edition, Marilyn E. Doenges, et.al.
Criteria: Promptness (5%) _______ Objective of Care (10%) _______
Format/Neatness (5%) _______ Nursing Actions (40%) _______
Assessment (15%) _______ Evaluation (10%) _______ Clinical Instructor: Lourdes Abecia, RN
Nursing Diagnosis (15%) _______
 POLYTECHNIC COLLEGE OF DAVAO DEL SUR, INC.
MacArthur Highway, Digos City

NURSING CARE PLAN

Name of Patient: Conrado Bonsubre Jr. Attending Physician: Dr. Paglamutan

Age: 56 Sex: Male Civil Status: Married Diagnosis: Mild head subdural
Bilateral injury to consider
hematoma cerebral c
Occupation: Farmer Religion: Roman Catholic parietotemporal area
Address: 80 CM Recto St. Barangay
Ward: Neuro Bed No. 9

DATE/TIME CUES NEEDS NURSING SCIENTIFIC BASIS GOALS NURSING RATIONALE EVALUATION
DIAGNOSIS OBJECTIVES INTERVENTIONS
CRITERIA
11/18/16 Subj: C Acute pain Neuropathic pain is After 8 hours of 1. Monitored vital 1. To obtain “PARTIALLY
9:00 am “Sakit O related to associated with nursing intervention, signs baseline data MET”
kaayo G increased damaged or the patient will 2. Established rapport 2. To gain
akong ulo” N ICP malfunctioning experience cooperation After 8 hours
I
secondary nerves due to decreased pain as 3. Elevated head of 3.To decrease ICP of nursing
T
Obj. I
to bilateral illness (e.g., post- evidenced by: bed interventions,
-pain scale V subdural herpetic neuralgia, 4. Provided safety 4. To maintain the patient
of 8 E hematoma diabetic peripheral -pain scale of 4 out measures such as safety and prevent showed some
-grimace neuropathy), injury of 10 raising side rails and injuries signs of
noted P (e.g., phantom -absent grimace repositioning the decreased pain
-pulse rate E limb pain, spinal -VS within normal patient. levels such as:
of 82 R cord range 5. Encouraged to 5. To minimize pain
-BP of C injury pain), or -verbalization of perform diversional -absent
160/80 E undetermined decreased pain activities such as grimace
P
- reasons. perception talking with SO and -pulse rate of
T
restlessness U
Neuropathic pain is eating 70 bpm
A typically chronic; it 6.Provided comfort 6. To provide -BP of 140/80
L is described as measures such as nonpharmacologic -absent
burning, “electric- back rubbing and measures restlessness
P shock,” and/or hot/cold compress
A tingling, dull, and 7. Provided a quiet 7. To promote
T aching. Episodes of environment. healing
T sharp, shooting 8. Referred to nurse 8. To reduce pain
E pain can on duty; meds given
R
 N also be
experienced.
Neuropathic pain
tends to be
difficult to treat.

Kozier and Erb’s

Fundamentals on
Nursing

Name: Pryll John O. Colita Section & Year: BSN-III Group No.: 1_ Rating: _______________
Reference: Nurse’s Pocket Guide Diagnoses, Interventions and Rationales 9th Edition, Marilyn E. Doenges, et.al.
Criteria: Promptness (5%) _______ Objective of Care (10%) _______
Format/Neatness (5%) _______ Nursing Actions (40%) _______
Assessment (15%) _______ Evaluation (10%) _______ Clinical Instructor: Lourdes Abecia, RN
Nursing Diagnosis (15%) _______
 POLYTECHNIC COLLEGE OF DAVAO DEL SUR, INC.
MacArthur Highway, Digos City

NURSING CARE PLAN

Name of Patient: Eddie Denesa Attending Physician: Dr. Dillera

Age: 37 Sex: Male Civil Status: Single Diagnosis: To consider space occupying lesion
Occupation: Construction worker Religion: Roman Catholic
Address: Proper Talomo Dist., Davao City
Ward: Neuro Bed No. 10

DATE/TIME CUES NEEDS NURSING SCIENTIFIC BASIS GOALS NURSING RATIONALE EVALUATION
DIAGNOSIS OBJECTIVES INTERVENTIONS
CRITERIA
11/18/16 Subj: S Disturbed Sleeping pattern After 8 hours of 1. Monitored vital 1.To obtain baseline “GOAL MET”
10:00 am “Wala koy L sleep can be disrupted nursing intervention, signs data
tarong E pattern due to physical the patient will have 2. Established rapport 2. To gain Within 8 hours
tulog gabii E related to injuries, pain, adequate sleep as cooperation of nursing
P
kay mild emotional evidenced by: 3. Placed patient on a 3. To avoid getting interventions,
nagasakit R
cephalgia disturbances and comfortable position neck cramps the patient had
akong ulo” E environmental -pain scale of 1 out 4. Loosened patient’s 4. To promote adequate sleep
S stimuli. Sleep is of 10 clothes comfort as evidenced
Obj. T important for the -absent dark circles 5. Provided a quiet 5. To lessen by:
-pain scale recovery of under the eyes environment by disturbances
of 3 out of P patients as it -absent eye bags limiting visitors -pain scale of 1
10 A promotes and -absent fatigue 6. Encouraged to 6. To provide out of 10
-frequent T hastens the drink a warm glass of nonpharmacologic -absent dark
yawning T healing process of milk measures in aiding circles
E
-dark circles the body. sleep -absent eye
R
under eyes N
7. Promote safety by 7. To lessen risk of bags
- Kozier and Erb’s raising side rails falls -increased
restlessness Fundamentals on energy levels
-fatigue Nursing
-eye bags
noted
-irritability
Name: Pryll John O. Colita Section & Year: BSN-III Group No.: 1_ Rating: _______________
Reference: Nurse’s Pocket Guide Diagnoses, Interventions and Rationales 9th Edition, Marilyn E. Doenges, et.al.
Criteria: Promptness (5%) _______ Objective of Care (10%) _______
Format/Neatness (5%) _______ Nursing Actions (40%) _______
Assessment (15%) _______ Evaluation (10%) _______ Clinical Instructor: Lourdes Abecia, RN
Nursing Diagnosis (15%) _______