Name:Jessica Quiane

Group/Section: 9/3BSN-C

Activity 1: Nursing Care Plan

LET’S ASSESS

ACTIVITY 1.1
Instruction: A case scenario is provided below. Read the case carefully and answer
the question stated below.

Patient G, a 45-year-old, pre-menopausal female working in a BPO company and

earning 45,000 a month is recently diagnosed with renal failure due type 2 diabetes
mellitus. She is separated and living with her 3 kids aged 21 years old, 18 years old,
and 15 years old in a subdivision. Even though she sometimes experiences
hypoglycemia due to her medication regimen, she is not bothered at all because she
just usually manages it with sweet food and
She believes that if it is her time to die, it will come with or without sickness. 3 days ago,
she could not stand up and she experienced shortness of breath, which led her family to
take her to the Emergency Room.

When the nurse assessed her in the emergency room, she was responsive but
very weak that she was unable to move. Her initial vital signs were the following: BP:
200/110, PR: 86 bpm, RR: 28 cpm and temp: 37.5 C, Height: 5’1 ft, Weight 78kgs. The
nurse notices that when it comes to her appearance, she has a moon-face and her
lower extremities are edematous. Her skin is much darker particularly under the eye
area and her skin integrity is impaired.

Upon asking her past medical history, it was found out that she seldom drinks
water because she prefers soft drinks, and this made her become obese. Her lifestyle is
very sedentary that she even just controls her urge to pee because she is busy. She
does not have enough time to have her regular checkup. In her free time, she spent it in
her garden collecting and replanting plants. Since 2014, she has taken in 500 mg once
daily as a maintenance medication for her diabetes and Metoprolol to stabilize her BP.
She is also having her dialysis once a week. She doesn’t have a lot of friends whom she
can go out with, which is why experiences episodes of depression.
 During the first day of admission, the patient has a catheter to facilitate her urine
elimination. However, the amount of urine collected is only 15 ml for eight hours. The
patient also needs oxygen through the mask due to shortness of breath.

On the second day, her laboratories show that her creatinine level is 6 mg/dl and
her BUN is 35mg/dl. Other laboratory tests showed elevated calcium, phosphate and
parathyroid hormone concentrations.

Activity 1.2
Instruction: Based on the case scenario, classify objective from subjective cues/data.
Write your answers in the space provided.

OBJECTIVE CUES/DATA SUBJECTIVE CUES/DATA

OBJECTIVE: SUBJECTIVE:
F, 45 years old • Responsive but very weak that she
is unable to move
• She seldom drinks water because
-Diagnosed with Renal Failure Type 2 she prefers soft drinks
DM • She even just controls her urge to
pe because she is busy
-Responsive but very weak that she was
unable to move

BP: 200/110
PR: 86 bpm
RR: 28 cpm
Temp: 37.5 C

Height: 5’1 ft
Weight: 78 kgs

-Pt has moon-face

 -Lower extremities are edematous
-Skin is darker especially under eye area
-Skin integrity is unpaired
-Obesity

-500 mg once daily as maintenance and

Metoprolol to her BP
-Dialysis once a week

-Pt does not have lot of friends,

experiencing series of depression
-Pt has catheter, urine collected is only
15 ml for 8 hours
-Pt has mask due to shortness of breath
Creatinine level is 6 mg/dl
BUN is 35 mg/dl
-Elevated Calcium, Phosphate,
Parathyroid hormone concentrations.
ACTIVITY 1.3
Instruction: Based on Patient G’s case, identify three priority Nursing Diagnosis
(from NANDA)

PRIORITIZATION NURSING DIAGNOSIS

Impaired Urinary Elimination related to failing glomerular
High filtration AEB Impaired excretion of nitrogenous products

Medium Risk for Impaired Skin Integrity related to impaired circulation

Low Activity Intolerance related to generalized weakness

ACTIVITY 1.4
Instruction: Make a Nursing Care Plan for the three problems identified in managing
the health condition of Patient G’s by using the format below.

HIGH PRIORITIZATION

ASSESSMENT
Subjective:
• She seldom drinks water because she prefers soft drinks
• She even just controls her urge to pee because she is busy
Objectives:
• The amount of urine collected is only 15 ml for eight hours
• Creatinine level is 6mg/dl and her BUN is 35mg/dl
• Elevated calcium, phosphate and parathyroid hormone concentratio ns.
MEDIUM PRIORITIZATION

ASSESSMENT DIAGNOSIS GOAL/PLAN INTERVENTION RATIONALE EVALUAT

Subjective: Risk for LONG • INDEPENDENT: • Promotes Long term
TERM: At Instruct in and
Impaired circulation,maintains The goa
• She the end of 7 assist with
Skin days, the active and joint flexibility, met.
seldom patient will
Integrity passive range- prevents Patient
drinks demonstrate of- motion
related to behaviors to (ROM) contractures, and cooperat
water
impaired avoid skin exercises aids in reducing with the
because breakdown •
circulation Institute a muscle tension. regimen.
she and to planned activity
maintain or exercise • Increases client’s
prefers Short-ter
intact skin program as energy and sense of
soft appropriate, with
The goa
well- being.
drinks client’s input. partially
• Monitor fluid • Detects presence of met.
Objectives: intake and dehydration or over
hydration of skin
Patient h
hydration that affect
• She has and mucous problems
membrane s. circulation and with the
moon-
• Change position tissue integrity at techniqu
face and frequently; move the cellular level. to promo
her patient carefully;
• Decreases healing
lower
pressure on
extremiti
edematous, poorly
es are
perfused tissues to
edemato
reduce ischemia.
us
• Her skin
is much SHORT
TERM: At
darker the end of 1
particula day, the
rly under patient will
verbalize
the eye techniques
area to promote
and her healing and
skin
DEPENDENT:
integrity
is
impaired
 prevent skin
breakdown

LOW PRIORITIZATION

ASSESSMENT DIAGNOSIS GOAL/PLAN INTERVENTION RATIONALE EVALUATION

Subjective: Activity LONG • INDEPENDENT: • Helps Long term:
TERM: At Encourage
Intolerance promote a The goal
• Responsive related to the end of 7 physical activity
days, the consistent with sense of partially
but very patient will the patient’s
generalized autonomy met.
weak that be able to energy levels.
weakness perform • Gradually
while being Patient
she is
activities progress patient realistic cannot fully
unable to without activity with the about perform
move limitations to following: -
movement Range-of-
capabilities. activities
Objectives: and motion. motion (ROM) • Exercise without any
exercises in maintains difficulties.
• Shortness bed, gradually
muscle
increasing Short-term:
of breath strength,
duration and
• 3 days frequency (then
The goal
joint ROM,
ago, she intensity) to met. The
sitting and then and
could not patient
standing. exercise
stand up • Assist with ADLs
performed
tolerance.
while avoiding certain
patient • Assisting activities
dependency the patient such as
• Refrain from with ADLs
performing light
nonessential
allows walking,
activities or conservatio eating, and
procedures. n of drinking
energy. with slight
SHORT
TERM: At Carefully difficulties.
the end of 24 balance
hours, the provision of
patient will
verbalize assistance;
increase facilitating
strength and progressive
ability to
perform light endurance
activities will
ultimately
enhance
the
patient’s
DEPENDENT:
activity
tolerance
and self-
esteem.
• Patient with
limited
activity
tolerance
need to
prioritize
important
tasks first.