NURSING CARE PLAN

Name: Mrs. Cruz

Date: October 11, 2020
CUES NURSING OBJECTIVE/ NURSING INTERVENTIONS RATIONALE EVALUATION
DIAGNOSIS EVALUATION CRITERIA
Subjective: Insomnia related to Within 2 hours of  Determine patterns of - Each individual has After 1 hour of nursing
“I never sleep more physical discomfort nursing interventions the sleep in the past in a different patterns of sleep. interventions the client was
than 3 hours a night.” client will be able to normal environment: Information about this topic able to identify individually
identify individually amount, bedtime provides baseline data for appropriate interventions
Objective: appropriate routines, depth, evaluating means to improve to promote sleep
Swollen knees and interventions to promote length, positions, aids, the patient’s sleep.
ankles, with limited sleep and other interfering
mobility of the lower factors.
extremities.
 Evaluate the patient’s - The patient may have
knowledge on the insights about the existing
cause of sleep problems (e.g., anxiety or GOAL PARTIALLY MET
problems and fear about a certain situation
potential relief in life). This data will
measures to facilitate determine appropriate
treatment. therapy.

 Suggest an - A lot of people sleep better

environment in cool, dark, quiet
conducive to rest or environment.
sleep.

 Place patient in a - The nursing station is often

room away from any the centre of noise and
distraction or noise activity. Nikolai P. Funcion, FSUU-SN
such as the nursing
station.

 Help patient - Misconceptions and myths

understand the main about sleep exist. Wrong
cause of sleeping notions about sleep
difficulties. disturbances may cause fear
and anxiety.
 NURSING CARE PLAN #2
Name: Alexa
Date: January 8, 2020
CUES NURSING OBJECTIVE/ NURSING INTERVENTIONS RATIONALE EVALUATION
DIAGNOSIS EVALUATION CRITERIA
Objective: Impaired ability to Within 2 hours of  Assess the client’s -The client may only need After 1 hour of nursing
-Diaper with poop perform activities nursing interventions the strength to help with some self-care interventions the client was
of daily living for client will be able to accomplish ADLs measures. able to perform self-care
oneself, such as perform self-care efficiently and activities such as toileting
toileting r/t activities within level of cautiously daily using the comfort room.
alteration in own ability.
cognitive  Determine the specific -Various etiological factors
functioning. cause of each deficit may need more explicit
such as cognitive interventions to enable self-
impairment care.

 Guide the client in -Client may require help in GOAL PARTIALLY MET
accepting the needed determining the safe limits of
amount of trying to be independent
dependence. versus asking for assistance
when necessary.

 Present positive -External resources of

reinforcement for all positive reinforcement may
activities attempted; promote ongoing efforts.
note partial
achievements.

 Render supervision -Client’s ability to perform

for each activity until self-care measures may Jewel June Gutierrez, FSUU-SN
the client exhibits the change often over time and
skill effectively and is will need to be assessed
secured in regularly.
independent care.

 Implement measures - An appropriate level of

to promote assistive care can prevent
independence but injury from activities without
intervene when the causing frustration.
client cannot function.

 Boost maximum
independence.
-The goal of rehabilitation is
one of achieving the highest
level of independence
 Apply regular routines possible.
and allow adequate
time for the client to - An established routine
complete task. becomes rote and requires
less effort. This helps the
client organize and carry out
 Include significant self-care skills.
other to the
discussions -To provide continuous of
care and guidance to the
client
 NURSING CARE PLAN #3
Name: Alexa
Date: January 13, 2020
CUES NURSING OBJECTIVE/ NURSING INTERVENTIONS RATIONALE EVALUATION
DIAGNOSIS EVALUATION CRITERIA
Subjective: Imbalanced Within 2 hours of  Note real, exact -These anthropomorphic After 1 hour of nursing
“Fried foods ang nutrition: less than nursing interventions the weight; do not assessments are vital that intervention the mother
favorite ni Alexa”, as body requirements mother will be able to estimate. they need to be accurate. was able to verbalize 3
verbalized by her r/t unwillingness to verbalize understanding These will be used as basis understanding of causative
teacher. eat secondary to of causative factors when for caloric and nutrient factors.
developmental known and necessary requirements.
Objective: delay interventions.
 Take a nutritional - Family members may
history with the provide more accurate
participation of details on the client’s eating
significant others. habits, especially if client has
altered perception. GOAL PARTIALLY MET

 Look for physical - The client encountering

signs of poor nutritional deficiencies may
nutritional intake. have decreased attention
span, confused, pale and dry
skin, etc.

 Ascertain -To determine informational

understanding of need of client/SO.
individual nutritional
needs

 Provide a pleasant - A pleasing atmosphere Jewel June Gutierrez, FSUU-SN

environment. helps in decreasing stress
and is more favorable to
eating.

 Provide small, - To reduce fatigue and

frequent feedings improve intake.

 Encourage significant -To stimulate appetite

other to choose food
that is appealing