Nursing Care Plan

NAME OF PATIENT: _____________________________AGE: ____SEX: _______ Name of Student: ________________________________________

CIVIL STATUS: ________ RELIGION: __________RM/BED NO. _______________ Area: _______________________Level /Block: _______________
ADDRESS: ______________________________________________________________ Date Submitted: _________________________________________
DATE OF ADMISSION: ______________DIAGNOSIS: ________________________ Rating: ________________________________________________
DAT CUES NURSING DIAGNOSIS NURSING OBJECTIVES NURSING INTERVENTION RATIONALE EXPECTED
E Subjective/Objective OUTCOME
DATE SUBJECTIVE DATA: Self-Care Deficit in At the end of nursing shift Independent Independent At the end of nursing
 “Nahihirapan akong dressing/grooming related to with close monitoring, shift with close
gumalaw kasi pain and discomfort on after independent and 1. Establish rapport and a trusting 1. Helping the patient monitoring, after
masakit yung abdomen as evidence by: dependent nursing relationship with the patient. with setting independent and
bandang ilalim ng  The client’s inability interventions, patient will realistic goals will dependent nursing
tiyan ko” as to ambulate be able to: reduce frustration. interventions, the goal
verbalized by the independently,  Identity individual 2. Monitor the vital signs. 2. To have a baseline was met as the:
client. difficulty to put on areas of needs and data.  Patient are
and take off clothing, perform self-care 3. It is important for already able to
3. Avoid doing things for client that
OBJECTIVE DATA: unpleasant odor, activities within client to do as much identify
the client can do for self,
 The client’s inability inability to wash/fix level of own as possible for self individual areas
providing assistance as necessary.
to ambulate her hair and having ability as to promote of needs and
independently. long and dirty nails. evidenced by recovery. perform self-
 The client’s inability proper hygiene and 4. To provide care activities
4. Provide health teaching on the adequate
to put on and take off self-independence. within level of
Scientific Explanation client regarding the proper way knowledge on the ability ass
clothing.
Self-Care Deficit is defined on effective oral hygiene and bed client. evidenced by
 The client’s
as impaired ability to bathing. proper hygiene
unpleasant odor.
 The client inability to perform or complete 5. It prevents skin and self-
wash/fix her hair. activities of daily living for 5. Educate the client about daily breakdown, itching, independence.
 The client’s long and oneself, such as feeding, personal perineal hygiene. burning, odor and
dirty nails. dressing, bathing, toileting. infections.
6. This helps patient
 6. Use consistent routines and allow organize and carry
adequate time for patient to out self-care skills.
complete tasks.

7. This ensure easier

7. Provide privacy during dressing. dressing and
comfort.
8. The need for
8. Encourage use of clothing one privacy is
fundamental for
size larger.
most patients.

Dependent Nursing Intervention

1.