University of the Philippines Manila

The Health Sciences Center

COLLEGE OF NURSING
WHO Collaborating Center for Leadership in Nursing Development
Sotejo Hall, Pedro Gil St., Ermita, Manila
Tel.: (632)523-1472 / Telefax: (632)523-1485

N105: NURSING INTERVENTIONS I

Family Health Nursing Focus

FAMILY NURSING CARE PLAN

Head of the Family (Initials): CDN

Address (Barangay/City or Municipality): 1901-K, Interior 53, Zamora St. Brgy. 843, Pandacan, Manila

Disclaimer: This FNCP addresses heart failure, liver cirrhosis, disturbed sleeping patterns, and inadequate nutritional intake of CDN. Liver cirrhosis is only subsumed
under Heart Failure as it is a complication of the latter. Symptoms of liver cirrhosis can also be alleviated with the interventions for heart failure.
Heart Failure of CDN as a Health Deficit
Other problems addressed in this FNCP:
● Liver Cirrhosis of CDN as a Health Deficit
● Disturbed Sleeping Patterns of CDN as a Health Threat
● Inadequate Nutritional Intake of CDN as a Health Threat

Outcomes/ Criteria or Methods/

Family Nursing Goal and Objectives of Indicators/Standards Tools or Data Source
Problem Nursing Care Plan of Intervention
Criteria Standards Methods Tool / Data
Source

Goal: After the Vital signs, Stable vital Assessmen

implementation of nursing Edema signs, t
interventions, CDN will rating, decreased
optimize her current health Dyspnea edema and
status, aeb by decreased rating dyspnea,
dyspnea and edema, enhanced
improved sleeping patterns, comfort
and enhanced overall
comfort. The nurse will:

GUTIERREZ, AKL | 2019-00658 | Group 5 | 10/2022 1

 University of the Philippines Manila
The Health Sciences Center
COLLEGE OF NURSING
WHO Collaborating Center for Leadership in Nursing Development
Sotejo Hall, Pedro Gil St., Ermita, Manila
Tel.: (632)523-1472 / Telefax: (632)523-1485

● Obtain vital signs. Vital Signs Stable vital Vital signs Vital Signs
● Check the patient's respiratory rate, rhythm, and signs checking Paraphernal
quality if in cardiorespiratory distress. ia
● Monitor cardiovascular status.
● Monitor the patient’s activity tolerance.
● Monitor O2 Saturation.
● Monitor for dyspnea, fatigue, tachypnea, and
orthopnea.

2 hours after the

implementation of nursing
interventions, CDN will:

Inability to make 1. Verbalize her ● Assess the client’s overall psychosocial Verbal Personal Interview;
decisions with respect personal perception well-being. feedback verbalization Discussion
to taking appropriate of current health ○ Kamusta po tayo ngayon? of her
health action due to: status. ○ Ano pong nararamdaman natin? personal
- Feeling of ● Alleviate the client’s anxiety and restlessness by perception of
helplessness therapeutic communication. current health
brought about by ● Identify the patient’s methods of handling stress status
perceived ○ Kapag po naiisip ninyo ang sakit ninyo, ano
magnitude/ pong madalas niyong ginagawa?
severity of the ○ Ano po ang mga epektibong paraan para
problem mapagaan ang inyong pakiramdam
- Lack of/ ● Promote effective techniques for reducing stress How to
inadequate ○ How to reduce stress with the 2:1 breathing reduce
knowledge/ technique: stress with
insights to ○ Diversion of attention the 2:1
alternative courses ○ Guided Imagery breathing
of action open to ○ Alam ko po mga simpleng pamamaraan technique
them lamang ito na sa palagay ko tingin niyo ay (Tufts
hindi epektibo. Ngunit, nagbibigay po ako ng Medical
mga paraan para makapili kayo kung ano Center,
ang angkop para sa inyo. 2019)

GUTIERREZ, AKL | 2019-00658 | Group 5 | 10/2022 2

 University of the Philippines Manila
The Health Sciences Center
COLLEGE OF NURSING
WHO Collaborating Center for Leadership in Nursing Development
Sotejo Hall, Pedro Gil St., Ermita, Manila
Tel.: (632)523-1472 / Telefax: (632)523-1485

○ Tingin ko’y mas magiging epektibo siya kung Guided

talagang gagawin ng buong puso, at hindi Imagery
dahil required lamang gawin. (Johns
● Reiterate to the patient that current therapies for Hopkins
heart failure are targeted on reducing the Rheumatolo
progression of disease, promoting comfort, and gy, 2018)
enhancing quality of life.

Inability to provide 2. Report decreased ● Educate client about methods to decrease Verbal Likert scale Interview; Likert scale
adequate nursing care dyspnea with a dyspnea. feedback for Dyspnea Discussion for Dyspnea
to the sick, disabled, rating of 2 or less ○ Current therapies for heart failure (HF) are rating of 2 or
dependent, or using the 5-point followed by strategies to improve comfort less 1-Absence of
dyspnea
vulnerable / at risk Likert Scale for and activity tolerance, besides reducing 2-Mild shortness
family member due to: Dyspnea morbidity and mortality. Cardiorespira No Observation; of breath
- Disability tory distress cardiorespirato O2 3- Moderate
○ Home Oxygen therapy shortness of
progression which ■ Oxygen therapy increases the amount ry distress as saturation
breath,
exhausts of oxygen sent to your body's tissues. evidenced by checking 4-Severe
O2 saturation shortness of
supportive This helps reduce your heart's breath
of 90% and
capacity of family workload. above 5-Worst possible
members ■ Encourage patient to consult with a shortness of
breath.
- Inadequate family healthcare professional, specifically a
resources for care, cardiologist, to determine the
specifically appropriate amount of oxygen needed.
financial ○ Breathing training
constraints Diaphragmatic Deep Breathing
■ Sit in a relaxed position and put one
hand on your stomach, near your belly
button and put your other hand on your
upper chest. Relax your upper chest and
shoulders. Now take a gentle breath in
by gently pushing out your stomach.
Try to keep your chest muscles and
shoulders relaxed.
■ As you breathe out, try to relax. You

GUTIERREZ, AKL | 2019-00658 | Group 5 | 10/2022 3

 University of the Philippines Manila
The Health Sciences Center
COLLEGE OF NURSING
WHO Collaborating Center for Leadership in Nursing Development
Sotejo Hall, Pedro Gil St., Ermita, Manila
Tel.: (632)523-1472 / Telefax: (632)523-1485

can use your hand to press on your

stomach to help a little. Try to keep
your chest and shoulders relaxed.
■ Keep doing this for a couple of
minutes. Stop if you get dizzy. Don’t
take huge breaths. Try and breathe
quite slowly.
■ If you find it difficult, you can make it
happen by deliberately pushing out
your stomach muscles when you
breathe IN and relax your stomach as
you slowly breathe OUT. Or, you can
PUSH your stomach in with your hand
as you breathe OUT.
○ Proper positioning
■ Sitting upright or in a semi-sitting
position reduces venous return in
patients with heart failure.
■ Left lateral decubitus or left recumbent
position also decreases reflux.
● Discuss other tips to reduce dyspnea.
○ Group tasks together
○ Sit when possible when performing ADLs
○ Plan your rest periods
○ Promote restful sleep
○ Avoid rushing activities
○ Avoid performing activities in hot or cold
temperatures

3. Report a decreased ● Explain the mechanism of edema formation in Edema Decreased Observation; Pitting
grade of bilateral heart failure. Rating pitting edema Palpation; Edema
pitting edema to ○ Edema in congestive heart failure is the result rating to Discussion Grading
Grade 3 or less. of the activation of a series of humoral and Grade 3 or Scale
neurohumoral mechanisms that promote less (Healthline,

GUTIERREZ, AKL | 2019-00658 | Group 5 | 10/2022 4

 University of the Philippines Manila
The Health Sciences Center
COLLEGE OF NURSING
WHO Collaborating Center for Leadership in Nursing Development
Sotejo Hall, Pedro Gil St., Ermita, Manila
Tel.: (632)523-1472 / Telefax: (632)523-1485

sodium and water reabsorption by the kidneys n.d.)

and expansion of the extracellular fluid.
● Explain the different grades of Pitting Edema
(Healthline, n.d.).
Grade Depth Rebound time

1 2 millimeter (mm) Immediate

depression, or barely
visible

2 3-4 mm depression, or 15 seconds or

a slight indentation less

3 5-6 mm depression 10-30 seconds

4 8 mm depression, or a more than 20

very deep indentation seconds

● Discuss ways to manage increased fluid volume.

○ Consistent intake of diuretics
What are Diuretics for?
■ Diuretics are the first-line drug of
choice in older adults with HF and fluid
overload. These drugs enhance the
renal excretion of sodium and water by
reducing circulating blood volume,
decreasing preload, and reducing
systemic and pulmonary congestion.
■ Diuretics, better known as "water pills,"
help the kidneys get rid of unneeded
water and salt. This makes it easier for
your heart to pump.
■ If you are taking a single dose a day,
take it in the morning with your
GUTIERREZ, AKL | 2019-00658 | Group 5 | 10/2022 5
 University of the Philippines Manila
The Health Sciences Center
COLLEGE OF NURSING
WHO Collaborating Center for Leadership in Nursing Development
Sotejo Hall, Pedro Gil St., Ermita, Manila
Tel.: (632)523-1472 / Telefax: (632)523-1485

breakfast or right afterward. If you’re

taking more than one dose a day, take
your last dose no later than 4:00 PM.
Side effects of Diuretics:
■ Frequent urination
■ Extreme tiredness or weakness
■ Muscle cramps, thirst, loss of appetite,
nausea, or vomiting
■ Dizziness, lightheadedness
■ Blurred vision, confusion, headache,
increased sweating, and restlessness
Importance of potassium-sparing diuretics
when taking loop diuretics
■ Prevention of potassium deficiency
■ If potassium is deficient, the more
harmful it is for the heart (may cause
arrhythmia)
○ Use of compression stockings
What is it for?
■ Compression stockings increases blood
circulation from the legs back to the
heart, which reduces swelling.
○ Reduced fluid intake
■ Decreasing fluid intake reduces fluid
retention.
● Educate the client about paracentesis procedure.
○ Paracentesis
■ Paracentesis is a procedure in which a
needle or catheter is inserted into the
peritoneal cavity to obtain ascitic fluid
for diagnostic or therapeutic purposes.
■ Watch the procedure here:
https://www.youtube.com/watch?v=-
h6SUIof6Z4

GUTIERREZ, AKL | 2019-00658 | Group 5 | 10/2022 6

 University of the Philippines Manila
The Health Sciences Center
COLLEGE OF NURSING
WHO Collaborating Center for Leadership in Nursing Development
Sotejo Hall, Pedro Gil St., Ermita, Manila
Tel.: (632)523-1472 / Telefax: (632)523-1485

● Encourage the client to consult a healthcare

professional to determine the right course of
action in terms of alleviating the current
symptoms of her heart failure.
○ Gusto ko lamang pong ipaalala na
nagbibigay lamang po ng pwede ninyong
maging options, tulad ng paracentesis
procedure.
○ Doktor pa rin po ang makapagsasabi kung
ano ba talaga ang maaaring pwedeng gawin
sa kondisyon ninyo, dahil malala na, at kung
paano kayo matutulungan mapagaan ang
inyong pakiramdam

4. Discuss at least 3 ● Explain significant findings from the nutrient Verbal Enumeration Interview Heart
important dietary analysis: feedback of at least 3 Failure
guidelines for ○ Nutrient Analysis: important Nutrition:
patients with heart dietary Eating for a
Excessive Inadequate
failure. guidelines for Healthy
Na (mg) Energy (kcal)
patients with Heart
CHON (g)
heart failure
Fat (g)
CHO (g)

Ash (g)
Fiber (g)
Ca (mg)
P (mg)
Fe (mg)
Retinol (µg)
B-carotene (µg)
Thiamin (mg)
Riboflavin (mg)
Niacin (mg)

GUTIERREZ, AKL | 2019-00658 | Group 5 | 10/2022 7

 University of the Philippines Manila
The Health Sciences Center
COLLEGE OF NURSING
WHO Collaborating Center for Leadership in Nursing Development
Sotejo Hall, Pedro Gil St., Ermita, Manila
Tel.: (632)523-1472 / Telefax: (632)523-1485

Vit. C (mg)

● Educate the client about the recommended diet

for patients with heart failure.
● Emphasize the need to significantly reduce salt
intake.
○ Kung titingnan po natin ang nutrient analysis
ng mga kinain niyo. Masyado pa rin pong
mataas sa sodium o asin. Eh iyon po ang
pinakabawal sa mga tulad ninyong may heart
failure.
○ Sodium, a key mineral in salt, helps your
body keep the right amount of fluid in your
bloodstream. When you eat a lot of it, your
blood vessels take in more water. That raises
blood pressure. It also makes heart failure
symptoms worse, like the fluid buildup,
weight gain, bloating, and swelling that
happen when your heart doesn’t pump as well
as it should.
○ A low sodium diet of 2 to 3g/day reduces
fluid retention and the symptoms of
peripheral and pulmonary congestion, and
decreases the amount of circulating blood
volume, which decreases myocardial work.
○ If salt intake must be reduced further, the
patient may need to eliminate high-sodium
foods (e.g., ham, bacon, pickles) and all salt
in cooking, thus reducing sodium intake to 2
g daily.
● Explain the dietary guidelines for patients with
heart failure, including the recommended servings
per each food category.

GUTIERREZ, AKL | 2019-00658 | Group 5 | 10/2022 8

 University of the Philippines Manila
The Health Sciences Center
COLLEGE OF NURSING
WHO Collaborating Center for Leadership in Nursing Development
Sotejo Hall, Pedro Gil St., Ermita, Manila
Tel.: (632)523-1472 / Telefax: (632)523-1485

○ Cereals and Grains

■ Aim for 4-6 serves/day (or to match
energy needs).
■ Choose wholegrain and high fiber
cereal options.
○ Vegetables
■ Aim for 5 or more serves/day.
○ Fruit
■ Aim for 2 serves/day.
○ Dairy Products
■ Aim for 3-4 serves/day
○ Meat/ Meat Alternatives
■ Aim for 2-3 serves/day
○ Patients with HF should not add salt during or
after meal preparation, avoid milk and milk
products, use few canned or prepared foods,
and read food labels to determine sodium
content. This diet is not easily tolerated for
many patients, and the cost of low-sodium
foods can be a financial burden.
● Encourage the client to eat small but frequent
meals.
● Explain to the client the importance of reading
food labels.
● Reiterate the need to reduce fluid intake to
minimize fluid retention.

5. Express adherence ● Discuss the importance of regular monitoring of Verbal Regular Interview; Importance
to regular weight. feedback monitoring Discussion of weight
monitoring of ○ Weight is the most sensitive indicator of and recording monitoring
weight. worsening heart failure. of weight in patients
○ HF patients are required to monitor their daily with heart
weight fluctuations. If the fluctuations were failure
extremely large, the patient should

GUTIERREZ, AKL | 2019-00658 | Group 5 | 10/2022 9

 University of the Philippines Manila
The Health Sciences Center
COLLEGE OF NURSING
WHO Collaborating Center for Leadership in Nursing Development
Sotejo Hall, Pedro Gil St., Ermita, Manila
Tel.: (632)523-1472 / Telefax: (632)523-1485

immediately seek medical treatment.

● Remind the client about the most important key

points when monitoring weight.
○ 1 kg of weight gain or loss equals 1 liter of
retained or lost fluid.
○ The same scale should be used every morning
before breakfast for the most accurate
assessment of weight.
○ Monitor for an expected decrease in weight
because excess fluid is excreted from the
body.

6. Utilize a weight ● Provide a weight monitoring sheet with a record Verbal Accurate Interview;
monitoring record/ of date and time, and weight per day. feedback; daily Record
sheet. Record recording of review
checking weight

7. Express increased ● Assess when the client takes her medications. Verbal Personal Interview
quality and duration ○ Kailan niyo po iniinom ang mga gamot na feedback expression of
of sleep. Furosemide and Spironolactone? sleep that is
● Facilitate the change of the timing of medications undisturbed,
to minimize nocturia. and increased
● Reiterate proper positioning and frequent turning in quality
to promote comfort. and duration

8. Report increased ● Determine client’s thoughts and feelings about the Verbal Report of a Interview Likert scale
comfort as palliative approach to her condition. feedback score of 1-3 for comfort
evidenced by a ● Determine current comfort level after the in the Likert level
score of 1-3 in the implementation of interventions. scale of 1-Totally
comfortable
Likert scale for Comfort level 2-Very
Comfort level. comfortable
3-More or less
comfortable

GUTIERREZ, AKL | 2019-00658 | Group 5 | 10/2022 10

 University of the Philippines Manila
The Health Sciences Center
COLLEGE OF NURSING
WHO Collaborating Center for Leadership in Nursing Development
Sotejo Hall, Pedro Gil St., Ermita, Manila
Tel.: (632)523-1472 / Telefax: (632)523-1485

9. Express adherence ● Determine client’s thoughts and feelings about Verbal Personal Interview 4-Not very
comfortable
to the planned adherence to the planned nursing interventions to feedback expression of 5-No
nursing improve quality of life. adherence to comfortable at
interventions to the planned all

improve quality of nursing

life. interventions

Failure to utilize 10. Determine at least 1 ● Educate the client about community resources Verbal Verbalization Interview; Information
community resources community accessible to her. feedback of 1 Discussion about the
for healthcare due to: resource for ○ UP-PGH community resources
- Lack / healthcare that can ○ Sta. Ana Hospital resource for and
inadequate be utilized. ○ Philippine Heart Center healthcare financial
knowledge of ● Discuss with the client resources on financial that can be assistance
community assistance. utilized offered by
resources for ● Encourage the client to visit a healthcare each
healthcare professional as soon as possible to determine the institution
- Inaccessibility right course of action.
of required
care/ service
due to cost
constraints
- Lack or
inadequate
family
resources,
specifically,
financial
resources
References:
Adler, E.D., Goldfinger, J. Z. Kalmaan, J., Park, M. E., & Meier, D. E. (2009). Palliative care in the treatment of advanced heart failure. Circulation,
120:2597–2606. https://doi.org/10.1161/CIRCULATIONAHA.109.869123
Aponte, E. M., Katta, S.K., O'Rourkem, M.C. Paracentesis. National Library of Medicine. https://www.ncbi.nlm.nih.gov/books/NBK435998/
Heart Foundation. (n.d.). Relaxation techniques. https://www.heartfoundation.org.nz/your-heart/post-heart-attack/relaxation-techniques

GUTIERREZ, AKL | 2019-00658 | Group 5 | 10/2022 11

 University of the Philippines Manila
The Health Sciences Center
COLLEGE OF NURSING
WHO Collaborating Center for Leadership in Nursing Development
Sotejo Hall, Pedro Gil St., Ermita, Manila
Tel.: (632)523-1472 / Telefax: (632)523-1485

Johns Hopkins Rheumatology. (2018, January 31). Reduce stress through guided imagery (2 of 3). YouTube.
https://www.youtube.com/watch?v=TWI639oEzmE
Martin-Du Pan, R.C., Benoit, R., Girardier, L. (2004). The role of body position and gravity in the symptoms and treatment of various medical diseases. Swiss
Med Weekly, 134(37-38):543-51.
https://pubmed.ncbi.nlm.nih.gov/15551157/#:~:text=Sitting%20upright%20or%20in%20a,recumbent%20posture%20also%20decreases%20reflux
NewYork-Presbyterian Hospital. (2020, June 3). Diaphragmatic breathing. YouTube. https://www.youtube.com/watch?v=Mg2ar-7_HfA
Nutrition Education Materials Online (2018). Heart failure nutrition.: Eating for a healthy heart.
https://www.health.qld.gov.au/__data/assets/pdf_file/0033/149892/cardiac_hftalk.pdf
Tufts Medical Center. (2019, April 3). How to reduce stress with the 2:1 breathing technique. YouTube. https://www.youtube.com/watch?v=CQjGqtH-2YI
Weber, C.K., Miglioranza, M.H., de Moraes, M.A.P., Sant’anna, R.T., Rover, M.M., Kalil, R.A.K, & Leiria, T.L. (2014). The five-point Likert scale for
dyspnea can properly assess the degree of pulmonary congestion and predict adverse events in heart failure outpatients. Clinics (Sao Paulo), 69(5),
341–346.doi: 10.6061/clinics/2014(05)08
WebMD Editorial Contributors. (2022). Treating heart failure with diuretics.
https://www.webmd.com/heart-disease/heart-failure/heart-failure-treating-diuretics

GUTIERREZ, AKL | 2019-00658 | Group 5 | 10/2022 12

 University of the Philippines Manila
The Health Sciences Center
COLLEGE OF NURSING
WHO Collaborating Center for Leadership in Nursing Development
Sotejo Hall, Pedro Gil St., Ermita, Manila
Tel.: (632)523-1472 / Telefax: (632)523-1485

Head of the Family (Initials): CDN

Address (Barangay/City or Municipality): 1901-K, Interior 53, Zamora St. Brgy. 843, Pandacan, Manila

Hypertension of RRN as a Health Deficit

Other problems addressed in this FNCP:
● Unhealthful Dietary Habits/practices of RRN as a Health Threat

Outcomes/ Criteria or Methods/

Family Nursing Goal and Objectives of Indicators/Standards Tools or Data Source
Problem Nursing Care Plan of Intervention
Criteria Standards Methods Tool / Data
Source

Goal: After the Blood Normal blood Blood Blood

implementation of nursing pressure pressure pressure Pressure
interventions, RRN will reading of monitoring reading
maintain a blood pressure <120/<80 using
reading of < 120/80 mmHg. mmHg aneroid
(Manual on sphygmoma
the PEN nometer;
Protocol on (Manual on
the Integrated the PEN
Management Protocol on
of the
Hypertension Integrated
and Diabetes, Managemen
2011) t of
Hypertensio
n and
Diabetes,
2011)

GUTIERREZ, AKL | 2019-00658 | Group 5 | 10/2022 13

 University of the Philippines Manila
The Health Sciences Center
COLLEGE OF NURSING
WHO Collaborating Center for Leadership in Nursing Development
Sotejo Hall, Pedro Gil St., Ermita, Manila
Tel.: (632)523-1472 / Telefax: (632)523-1485

Objectives:
2 hours after the The nurse will:
implementation of nursing
interventions, RRN will:

Inability to 1. Discuss hypertension ● Reiterate to the client the BP reading during the Verbal Verbalization Interview; Hypertensio
provide adequate in his own words. previous house visits. feedback of Discussion n: Ang
nursing care to ○ (10/11/2022) BP: 140/120 mmHg hypertension mataas na
the sick, ○ (10/13/2022) BP: 160/100 mmHg using his own presyon ng
disabled, ● Conduct a health teaching about hypertension. words (BP > dugo
dependent, or ○ Ano ang hypertension? 120/80 (RiteMed,
vulnerable/ at ■ Labis na taas ng blood pressure na mmHg) n.d.)
risk family dumadaloy sa mga ugat.
member due to: ■ Ang malakas na pwersa ng dugo ay
- Lack of/ maaaring makapinsala sa mga ugat at
inadequate makaapekto sa takbo ng puso. Ito ay
knowledge maaaring magdulot ng malubhang
about the komplikasyon tulad ng atake sa puso,
disease/ stroke at sakit sa bato.
health ○ Ano ang mga sanhi ng pagtaas ng BP?
condition ■ Sobrang pag-konsumo maalat na pagkain
- Inadequate ■ Paninigarilyo at pag-inom ng alak
family ■ Katandaan (Edad 55 pataas)
resources for ■ Kakulangan sa calcium, magnesium, at
care, potassium
specifically ■ Pagiging overweight at kakulangan sa
financial ehersisyo
constraints ■ Laging stressed at pagod
■ Namana sa pamilya
○ Negatibong epekto ng labis na pagtaas ng BP
■ Atake sa puso
■ Heart Failure
■ Stroke
■ Hypertensive na krisis

GUTIERREZ, AKL | 2019-00658 | Group 5 | 10/2022 14

 University of the Philippines Manila
The Health Sciences Center
COLLEGE OF NURSING
WHO Collaborating Center for Leadership in Nursing Development
Sotejo Hall, Pedro Gil St., Ermita, Manila
Tel.: (632)523-1472 / Telefax: (632)523-1485

2. Verbalize the normal ○ Klasipikasyon ng BP Verbal Verbalization Question Manual on

blood pressure feedback of the normal and the PEN
reading. Average Blood Pressure Reading blood answer; Protocol on
Classification
pressure Discussion the
Systolic (mmHg) Diastolic (mmHg)
reading Integrated
(<120/80 Managemen
< 120 < 80 Normal
mmHg) t of
120-139 80-89 Prehypertension Hypertensio
n and
140-159 90-99 Stage 1 Diabetes,
Hypertension 2011
> 160 > 100 Stage 2
Hypertension

Source: (Manual on the PEN Protocol on the

Integrated Management of Hypertension and Diabetes,
2011)

3. Explain at least 3 ● Reiterate the results of the nutrient analysis of RRN’s Verbal Enumeration Interview; Tulungan
important dietary 24-hour food recall. feedback of at least 3 Question ang Iyong
modifications in ● Nutrient Analysis: important and answer Puso:
patients with Excessive Inadequate dietary Discussion Kontrolin
hypertension Fat (g) Energy (kcal) modifications ang Iyong
consistent with the CHO (g) CHON (g) in patients Altapresyon
DASH Diet. Na (mg) with (National
Ash (g), Fiber (g) hypertension Heart,
Ca (mg), P (mg), Fe consistent Lung, and
(mg), Retinol (µg),
with the Blood
B-carotene (µg),
Thiamin (mg), DASH Diet Institute,
Riboflavin (mg), 2008)
Niacin (mg), Vit. C
(mg)

GUTIERREZ, AKL | 2019-00658 | Group 5 | 10/2022 15

 University of the Philippines Manila
The Health Sciences Center
COLLEGE OF NURSING
WHO Collaborating Center for Leadership in Nursing Development
Sotejo Hall, Pedro Gil St., Ermita, Manila
Tel.: (632)523-1472 / Telefax: (632)523-1485

● Conduct a health teaching about Dietary Approaches

to Stop Hypertension (DASH Diet).
Magbawas ng asin.
○ Basahin ang Nutritional Fact Labels ng mga
pagkain upang maihambing ang dami ng asin sa
pagkain.
○ Pumili ng mga pagkaing < 5% ang asin o mas
mababa. Limitahan ang mga pagkaing may < 20
% ang asin.
○ Limitahan ang iyong pagkain ng asin sa 2,300
milligrams (mg) o mas mababa sa bawat araw.
○ Bumili ng mga prutas at gulay para sa mga
merienda sa halip na maalat na sitsirya at biskwit.
○ Bumili ng mga gulay na sariwa, frozen, o de
latang walang idinagdag na asin. Bawasan ang de
lata at naiprosesong mga pagkaing kagaya ng
pinausukan, ibinabad, at naiprosesong baka;
pagkaing-dagat; manok; at baboy, tulad ng
hamon, longganisa, at karne norte.
○ Bumili ng mga pagkain na namarkahang “low
sodium” o “reduced sodium.”
○ Bawasan ang dami ng mayaman sa asing mga
sarsa, paste, at pampalasa, tulad ng toyo, patis,
tuyo, bagoong, at alamang.
○ Sa halip na asin, timplahan ang mga pagkain
gamit ang mga dahong makakain at pampalasa.
○ Banlawan ang mga de latang gulay upang
mabawasan ang dami ng asin.
Kumain ng mga pagkaing nakakalusog sa puso.
○ Magluto nang may mas maraming mga prutas,
gulay, at whole grains.
○ Pumili ng mga produktong low-fat o fat-free.
○ Magluto ng mga karne na kakaunti ang taba,
manok na walang balat, aat isda.

GUTIERREZ, AKL | 2019-00658 | Group 5 | 10/2022 16

 University of the Philippines Manila
The Health Sciences Center
COLLEGE OF NURSING
WHO Collaborating Center for Leadership in Nursing Development
Sotejo Hall, Pedro Gil St., Ermita, Manila
Tel.: (632)523-1472 / Telefax: (632)523-1485

○ Pumili ng mga walang-asing nut, buto, at lutong

pinatuyong mga beans.
○ Magluto sa kaunting fats at mantika.

4. Explain what a ● Discuss and provide materials about Pinggang Pinoy. Verbal Accurate Interview; Pinggang
balanced diet is and ○ Para po sa inyo, ano ang isang balanseng feedback explanation Question Pinoy
its importance to nutrisyon? of a well- and answer (DOST-FN
one’s health, using ○ Pinggang Pinoy balanced diet RI, 2016)
their own words. ■ A new, easy-to-understand food guide that and its
uses a familiar food plate model to convey importance to
the right food group proportions on a one’s health
per-meal basis to meet the body's energy
and nutrient needs of adults.
■ Pinggang Pinoy serves as a visual tool to
help Filipinos adopt healthy eating habits at
meal times by delivering effective dietary
and healthy lifestyle messages.
○ Pinggang Pinoy (Adults 15-59 yo)
● Emphasize the importance of Pinggang Pinoy and of
conforming with the national guidelines related to
nutrition.
○ Mahalaga po ang Pinggang Pinoy dahil ito ang
nagsisilbing gabay natin sa tamang proporsyon
ng pagkain na angkop sa edad ng isang tao.
○ Sa isang tingin mo pa lamang ay kaya mo nang
sabihin na tama ang naging preparasyon ng dami
ng pagkain para sa bawat miyembro ng pamilya.

● Differentiate Go, Glow, and Grow Foods and provide

5. Classify at least 4 examples of food ingredients under each category. Verbal Accurate Question Pinggang
food ingredients as ○ Go Foods (Energy-giving) feedback classification and answer Pinoy
Go, Glow, and Grow ○ Grow Foods (Body-building) of at least 4 (DOST-FN
foods accurately. ○ Glow foods (Body regulating) food RI, 2016)
ingredients as

GUTIERREZ, AKL | 2019-00658 | Group 5 | 10/2022 17

 University of the Philippines Manila
The Health Sciences Center
COLLEGE OF NURSING
WHO Collaborating Center for Leadership in Nursing Development
Sotejo Hall, Pedro Gil St., Ermita, Manila
Tel.: (632)523-1472 / Telefax: (632)523-1485

Go, Glow,
and Grow
foods
● Discuss the food proportion sufficient for
6. Determine the RRN’s nutritional needs according to his age, Verbal Accurate Question Pinggang
sufficient amount per as per Pinggang Pinoy. feedback verbalization and answer Pinoy
food category of (DOST-FN
recommended for Food options for RRN: understandin RI, 2016)
their age. g of the
RRN
sufficient
Go ● ¾ cup of cooked rice amount per
● 3 pcs. small pandesal food category
● 3 slices of small loaf bread recommende
● ¾ cup of cooked noodles (ex. d for their
Pansit) age
● ¾ medium pc. of root crop (ex.
camote)

Grow ● 2 pcs. medium variety of fish

(ex. galunggong)
● 2 slices of large variety of fish
(ex. bangus)
● 2 pcs. of small chicken leg
● 2 servings of lean meat, 30 g
each (ex. Chicken, pork, beef)
● 2 pcs. cf tokwa, 6x6x2 cm each
● 1 pc. of small chicken egg + 1
piece of any food items
mentioned above

Glow ● ¾ cup of cooked vegetables

(ex. Malunggay, saluyot, gabi
leaves, talinum, ampalaya,

GUTIERREZ, AKL | 2019-00658 | Group 5 | 10/2022 18

 University of the Philippines Manila
The Health Sciences Center
COLLEGE OF NURSING
WHO Collaborating Center for Leadership in Nursing Development
Sotejo Hall, Pedro Gil St., Ermita, Manila
Tel.: (632)523-1472 / Telefax: (632)523-1485

kalabasa, carrots, sitaw)

● 1 medium size fruit (ex.
Saging, dalanghita mangga)
● 1 slice of big fruit (ex. Papaya,
pinya, pakwan)

● Explore client’s thoughts and feelings about

7. Express adherence to continuous application of the planned interventions to Verbal Expression of Interview
consistent application maintain normal blood pressure. feedback adherence to
of the planned the planned
activities in nutrition interventions
to maintain normal
blood pressure.
● Discuss the health programs and services offered at
Failure to utilize 8. Verbalize adherence the Bagong Barangay Health Center. Verbal Verbalization Interview
community in utilizing ● Encourage CDN to continue to go on follow feedback of adherence
resources for community resources check-ups based on the doctor’s order. in utilizing
healthcare due to address ○ Mahalaga po ang regular na pagbisita sa doktor community
to: hypertension. kahit walang nararamdamang sakit dahil ito resources to
- Lack/ ang magsisilbing patunay na tayo’y nasa address
inadequate pinakamataas na antas ng ating estadong hypertension
knowledge of pangkalusugan.
community ○ Mahalaga rin ang pagbalik sa araw na itinakda
resources for ng inyong doktor upang malaman ang progreso
healthcare ng paggaling mula sa sakit, upang masiguro na
- Lack or epektibo ang mga gamot na inireseta para sa
inadequate altapresyon, at upang matiyak na walang
family naging problema ang naunang medikal na
resources, konsultasyon.
specifically, ● Encourage the client to visit the healthcare center for
financial BP monitoring.
resources ● Encourage the client to log his BP readings on a
small notebook for easier tracking of his hypertensive

GUTIERREZ, AKL | 2019-00658 | Group 5 | 10/2022 19

 University of the Philippines Manila
The Health Sciences Center
COLLEGE OF NURSING
WHO Collaborating Center for Leadership in Nursing Development
Sotejo Hall, Pedro Gil St., Ermita, Manila
Tel.: (632)523-1472 / Telefax: (632)523-1485

condition.

References:
Department of Health. (2011). Manual on the PEN Protocol on the Integrated Management of Hypertension and Diabetes.
https://dmas.doh.gov.ph:8083/Rest/GetFile?id=336917
National Heart, Lung, and Blood Institute. (2021). DASH eating plan. https://www.nhlbi.nih.gov/education/dash-eating-plan
National Heart, Lung, and Blood Institute. (2008). Tulungan ang iyong puso: Kontrolin ang iyong altapresyon.
https://www.nhlbi.nih.gov/sites/default/files/publications/08-6346.pdf
RiteMed. (n.d.). Hypertension: Ang mataas na presyon ng dugo. https://www.ritemed.com.ph/tamang-kaalaman/hypertension
United Healthcare Community Plan. (2019). Pamamahala sa iyong presyon ng dugo.
https://www.uhccommunityplan.com/assets/plandocuments/memberinformation/CA-Taking-Charge-of-Blood-Pressure-TL.pdf

GUTIERREZ, AKL | 2019-00658 | Group 5 | 10/2022 20

 University of the Philippines Manila
The Health Sciences Center
COLLEGE OF NURSING
WHO Collaborating Center for Leadership in Nursing Development
Sotejo Hall, Pedro Gil St., Ermita, Manila
Tel.: (632)523-1472 / Telefax: (632)523-1485

Head of the Family (Initials): CDN

Address (Barangay/City or Municipality): 1901-K, Interior 53, Zamora St. Brgy. 843, Pandacan, Manila

Risk for falls for RRN as a Health Threat

Outcomes/ Criteria or Methods/
Family Nursing Goal and Objectives of Indicators/Standards Tools or Data Source
Problem Nursing Care Plan of Intervention
Criteria Standards Methods Tool / Data
Source

Goal: After the Verbal Expression of One-one PPT

implementation of nursing feedback adherence to Discussion; presentation
interventions, the client will the use of Interview
express adherence to the use precautionary
of precautionary measures to measures to
reduce risk for falls. reduce risk
for falls
2 hours after the
implementation of nursing
interventions, RRN will: The nurse will:

Inability to 1. Identify at least 2 ● Educate the client about various precautionary Verbal Accurate Question Falls and
provide adequate precautionary measures he can utilize to reduce risk for falls. feedback verbalization and Fractures in
nursing care to measures to reduce ● Stand up slowly. Getting up too quickly can of 2 answer; Older
the sick, risk for falls. cause your blood pressure to drop. That can precautionary Interview Adults:
disabled, make you feel wobbly. Get your blood pressure measures to Causes and
dependent, or checked when lying and standing. reduce risk Prevention
vulnerable / at ● Use an assistive device if you need help feeling for falls (National
risk family steady when you walk. Using canes and Institute on
member due to walkers correctly can help prevent falls. Aging)
lack of/ ● Utilize handrails and bars when necessary.
inadequate ● Take extra caution when walking on wet
knowledge and surfaces.
GUTIERREZ, AKL | 2019-00658 | Group 5 | 10/2022 21
 University of the Philippines Manila
The Health Sciences Center
COLLEGE OF NURSING
WHO Collaborating Center for Leadership in Nursing Development
Sotejo Hall, Pedro Gil St., Ermita, Manila
Tel.: (632)523-1472 / Telefax: (632)523-1485

skill in carrying ● Keep your hands free. Use a shoulder bag,

out the necessary fanny pack, or backpack to leave your hands
interventions free to hold on to railings.
/procedure / care ● Choose the right footwear. To fully support
your feet, wear non -kid, rubber-soled,
low-heeled shoes. Don’t walk on stairs or
floors in socks or in shoes and slippers with
smooth soles.
● Light up your living space. Keep your home
brightly lit to avoid tripping on objects that are
hard to see.
● Reiterate to the client the importance of delegating
tasks at home (especially heavy tasks utilizing the
stairs.
○ Kung kaya po sanang iwasan mag-buhat ng
tubig sa hagdan, iwasan po para mabawasan
ang risk na malaglag pa.
○ Pwede naman din pong iutos sa ibang
kapamilya ang pag-akyat ng tubig sa 2nd floor.

2. Express adherence to ● Explore client’s thoughts and feelings about Verbal Expression of Interview
the use of adherence to the use of precautionary measures to feedback adherence on
precautionary reduce risk for falls. the use of
measures to reduce ○ Kaya po bang masunod ang mga nabanggit? precautionary
risk for falls. measures to
reduce risk
for falls
References:
National Institute on Aging. (n.d.). Falls and fractures in older adults: Causes and prevention.
https://www.nia.nih.gov/health/falls-and-fractures-older-adults-causes-and-prevention
Mayo Clinic Staff. (n.d.). Fall prevention: Simple tips to prevent falls.
https://www.mayoclinic.org/healthy-lifestyle/healthy-aging/in-depth/fall-prevention/art-20047358

GUTIERREZ, AKL | 2019-00658 | Group 5 | 10/2022 22