DON MARIANO MARCOS MEMORIAL STATE UNIVERSITY

South La Union Campus

College of Community Health and Allied Medical Sciences
Agoo, La Union
Tel. 072.682.06.63/[email protected]
NURSING DEPARTMENT

NURSING CARE PLAN

ASSESSMENT EXPLANATION OF OBJECTIVE INTERVENTIONS RATIONALE EVALUATION
THE PROBLEM
Subjective: Anemia occurs when there After 7 days of nursing Document the patient’s Weight loss can be  Demonstrate
“nahihilo ako ma’am, tapos aren’t enough healthy red intervention the patient will progressive weight
weight. Weight the measured accurately
nang hihina po ako” blood cells to carry oxygen be able to: gain toward goal
to your body’s organs. As a Increase body weight 20% patient daily in the with a patient’s actual  Demonstrate
Objective: result, it’s common to feel or more under ideal. mornings. weight rather than by behavior, lifestyle
 Weakness cold and symptoms of estimate. The patient’s changes to regain
 Chest pain tiredness or weakness. There and/or maintain
weight is also an ideal
 Cold hands and feet are many different types of appropriate weight
anemia, but the most tool in the assessment
 Dizziness
common type is iron- of a person’s nutritional
V/S taken as follows: deficiency anemia. You can requirements.
 BP: 180/120 begin to ease symptoms of
 TEMP: 36.7 this type of anemia by Assess what the patient Patients with dysphagia
adding iron to your diet. can safely eat and drink.
 O2: 97 may be able to tolerate
 PR: 97
thickened liquids and
 RR: 19
pureed food. Assessing
NURSING DIAGNOSIS: what the patient can
Imbalance nutrition less tolerate will help
than body requirements support nutrition and
arrange food choices to
Weigh the patient become available.
 DON MARIANO MARCOS MEMORIAL STATE UNIVERSITY
South La Union Campus
College of Community Health and Allied Medical Sciences
Agoo, La Union
Tel. 072.682.06.63/[email protected]
NURSING DEPARTMENT

regularly and document The patient’s weight will

readings. help in the evaluation of
the patient’s progress.

NURSING CARE PLAN

ASSESSMENT EXPLANATION OF THE OBJECTIVE INTERVENTIONS RATIONALE EVALUATION
PROBLEM
 DON MARIANO MARCOS MEMORIAL STATE UNIVERSITY
South La Union Campus
College of Community Health and Allied Medical Sciences
Agoo, La Union
Tel. 072.682.06.63/[email protected]
NURSING DEPARTMENT

SUBJECTIVE: Obstructive uropathy is a After 8 hours of nursing  Record accurate Goal met patient has
Namamanas ako at hindrance to normal urinary intervention the patient will intake and output  Accurate I&O is displayed appropriate
nanghihina katawan ko” flow that can be caused by a display appropriate urinary  Weight daily at same necessary for urinary output with specific
variety of structural and output with specific time of the day, on determining renal gravity/laboratory studies
OBJECTIVE: functional etiologies. This is gravity/laboratory studies same scale, with function and fluid near normal; stable weight;
a common and potentially near normal; v/s within same equipment and replacement needs V/S within the patient’s
 Generalize edema serious condition that affects patient’s normal range; and clothing and reducing risk of normal range; absence of
 Patient reports of people across all ages and absence of edema  Assess skin dace, fluid overload edema
fatigue, weakness, walks of life. To avoid the dependent areas for  Daily body weight is
and malaise morbidity and mortality edema best monitor of fluid
 V/S taken as follows associated with this  Plan oral fluid status
 BP: 130/90 condition, it must be replacement within  Edema occurs
 TEMP: 36.7 promptly diagnosed and multiple restrictions primarily in
 O2: 99% treated. This activity reviews dependent tissues of
 PR: 107
 RR: 22
the evaluation and the body
management of patients with  Helps avoid periods
NURSING DIAGNOSIS: obstructive uropathy. It without fluid
FLUID VOLUME EXCESS represents a common minimizes boredom
R/T COMPROMISED presentation affecting of limited choices
REGULATORY multiple medical specialties
MECHANISM (RENAL and highlights the role of the
FAILURE) interprofessional team in
early identification and
improved care for patients
with this condition.