Notre Dame of Midsayap College

Quezon Avenue, 9410 Midsayap

Cotabato, Philippines

Nursing Care Plan

Patient’s Name: Aribal, Aquilina Age: 49y/o Sex: F Date of Admission: March 01, 2010

Address: Montay Libungan, Cotabato

Chief Complaint: Right flank pain Diagnosis: R/I nephrolithiasis, UTI

ASSESSMENT DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATION

(Actual)
S” Lisod maglihok >Impaired physical >Within 5 hours Independent >Goal met. Patient
kay basi matanggal mobility related to span of my care >Establish rapport >To promote good is able to:
ang dagum”. As discomfort patient will be able nurse-client relationship
verbalized by the to: a.resume physical
paient. Definition: limitation a. resume physical >Perform bedside >To provide comfort to mobility
in independent, mobility. care the patient
O> restlessness purposeful physical b.verbalize >Perform and >To provide baseline b.verbalize
noted movement of the understanding of monitor VS data understanding of
>body lalaise body nor of one or the importance of >Assit patient in >To enhance self- the importance of
observed more extremities ambulation to her doing physical concept and sense of ambulation to her
>frequent lying on present condition. mobility such as independence present condition.
bed observed Reference:Nurses walking and deep
>discomfort noted Pocket Guide breathing exercise
>afebrle By:Marilynn >Instruct patient to >To develop individual’s
>slow movements Doenges perform simple exercise or mobility
observed Mary Frances ROM and
VS: Moorhouse ambulation
BP-100/80mmHg Alice Murr >Assist patient in >To promote comfort to
Temp-36.4 C (Pp. 457-461) doing self care the patient
PR-77BPM activities such as
RR-16CPM fixing their bed
linens and changing
clothes
>Instruct patient to >To prevent dehydration
increase OFI
Dependent
>Monitor and >To have an accurate
regulate IVF as flow of the IVF
prescribed
>Give meds as >To promote wellness
prescribed
Patient’s Name: Aribal, Aquilina Age: 49y/o Sex: F Date of Admission: March 01, 2010

Address: Montay Libungan, Cotabato

Chief Complaint: Right flank pain Diagnosis: R/I nephrolithiasis, UTI

ASSESSMENT DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATION

(Actual)
S”Sakit ako >Impaired walking >Within my 6 span Independent Goal met. Patient is
tiyan,kapoy related to pain. of care patient will >Establish rapport >To promote good able to:
maglakay”. As be able to: nurse-client relationship a.move about within
verbalized by the Definition: a.move about within environment as
patient. Limitation of environment as >Perform bedside >To provide comfort to needed within limits
O>Conscious independent needed within limits care the patient of ability.
>afebrile movement within of ability. >Perform and >To provide baseline b.verbalize
>irritability the environment of b.verbalize monitor VS data understanding of
observed foot. understanding of >Assit patient in >To enhance self- situation.
>restlessness situation. doing physical concept and sense of
observed Reference: Nurse’s mobility such as independence
>pain scale 5/10 Pocket Guide walking and deep
>body malaise By:Marilynn breathing exercise
observed Doenges >Assist patient in >To promote comfort to
VS: Mary Frances doing self care the patient
BP-110/80mmHg Moorhouse activities such as
Temp-36.8 C Alice Murr fixing their bed
PR-80bpm (Pp. 774-776) linens and changing
RR-18cpm clothes
>Instruct patient to >To prevent dehydration
increase OFI
 >Instruct patient >To reduce risk of
and significant falls
others in safety
measures
>Encourage active >To increase
and passive endurance
exercises
>Provide ample time >To reduce risk of
to perform mobility falling and manage
–related task fatigue or pain

Dependent
>Monitor and >To have an
regulate IVF as accurate flow of the
prescribed IVF
>Give meds as >To promote
prescribed wellness