NURSING CARE PLAN

Assessment Diagnosis Planning Intervention Rationale Evaluation

Subjective: Impaired physical After 3 hours of Independent: After 3 hours of nurse-
“Nanghihina mobility related to nurse-patient patient intervention,
ako”, as suicidal act as intervention, the • Observe • To note the goal was partially
verbalized by the verbalize by the patient will be able movement when incongruencies with met and able to:
patient. patient, “ to: the client is reports of ability. • Verbalize
Objective: nanghihina ako” • Demonstrat unaware of understanding of
• Intolerance as manifested by: e observation. situation/risk
to activity. • Intolerance techniques/ factors and
• Decrease to activity. behaviour • Encourage • Promote well-being individual
strength • Decrease that enables adequate intake and maximizes treatment
and strength and resumption of fluid/nutritious energy production. regimen and
endurance. endurance. of activities. foods. safety measures.
• Limited • Limited • Maintain/inc • To provide safety to • Maintain and
range of range of rease • Instruct to place the patient. increase
motion. motion. strength. pillows on the strength.
• fatigue • fatigue side. • Enhances to
commitment to
• Encourage plan, optimizing
client’s/SO’s outcomes.
involvement in
decision making
as much as
possible.
NURSING CARE PLAN

Assessment Nursing Planning Intervention Rationale Evaluation

Diagnosis

After 8 hours of Independent: After 8 hours of

nursing rendering nursing
Subjective: Disturbed intervention the • Provided quiet • To enhance client intervention the patient
sleeping pattern patient will be able environment and ability to fall was able to obtained
“Hindi ako secondary to comfort measures asleep.
masyado to identify the the different measures
depression as (e.g backrub,
nakatulog different measures washing hands and of an 8 hours normal
verbalize by the how to obtain a sleeping pattern as
kagabi” as face, cleaning and
patient, “hindi ako normal sleeping straitening sheets) evidenced by (-)
verbalized by the masyado pattern evidenced in preparation to irritability, relax, and
patient nakatulog kagabi” sleep.
by non- irritable, minimal yawning.
as evidenced by: relax, and absence • Caffeine increases Resulting that the goal
• Recommended awaking time
- Irritability of eye bags, and was met.
Objective: limiting intake of during the night.
- fatigue no frequent chocolate and A full stomach
- Presence of yawning. caffeine/alcoholic interferes with
- Irritability
- fatigue eyebags . beverages esp. prior sleep
- Presence of - Frequent to bedtime
eyebags . yawning.
- Frequent • Effective in
yawning. • Encourage the client inducing and
to develop a maintaining sleep
bedtime ritual that
includes quiet
activities such as
reading
pocketbooks or
 watching television

Dependent: • To lessen
excitement,
• Give anti depressant nervousness and
as ordered. irritation.

NURSING CARE PLAN

Assessment Nursing Planning Intervention Rationale Evaluation

Diagnosis
 After 8 hours of Independent: After 8 hours of nursing
nursing intervention intervention the patient
Subjective: Mild anxiety the patient will  Listening actively and  To establish trust appeared relaxed and the
related to suicidal appear relaxed and focus on the patient and showing level of anxiety is reduced
“Nahihiya ako sa act as verbalize the level of anxiety is discussed her personal interest. to manageable level as
ginawa ko.” as by the patient, “ reduced to feelings. verbalize by the patient,
verbalized by the manageable level as “medyo nabawasan na ang
nahihiya ako sa verbalize by the aking problema” and the
patient  Use appropriate touch  To demonstrate
ginawa ko.” As patient, “medyo with patient support. goal was met.
manifested by: nabawasan na ang permission.
aking problema”.
Objective:  Weak  Instructed deep  For relaxation.
looking breathing exercise.
 Weak
looking  Irritability  Speak in brief  To avoid confusion
statements using and easy to
 Irritability  Sleep simple words. understood.
disturbance
 Sleep Dependent:
disturbanc
 Obtain history  To monitor clients
e
including bed time sleeping pattern.
routines