DIAZ, FRANCIS POLYCARP C.

BSN 1B NURSING CARE PLAN

Assessment Diagnosis Scientific rationale Goals & objective Interventions Rationale Evaluation

Subjective: Ineffective Inability to form a valid Objective: Assess specific Accurate appraisal can After 4 hours of nursing
She said that her usual mood is calm but in times of coping related to appraisal of the stressors 1. stressors.- facilitate development of intervention, the client
difficulty her mood is mostly irritable. The client difficulty ,inadequate choices of appropriate coping able to describe and
described herself as "maraming anak at nahihirapan". adapting in stress practiced responses, and/or After 1 hour of nursing strategies.- initiates alternative
"Nahihirapan ako, yun yung nafefeel ko..parang gusto inability to use available intervention, the client coping strategies in
ko nang bumigay" .When asked if how she handled big resources. will be able to determine adapting stress.
problems in her life she answered Reference: degree of impairment- Assess level of
“ Doenges, understanding and Appropriate problem
Inaaway ko nalang asawa ko”. Moorhouse & Murr’s Nurse’s readiness to learn solving requires accurate
Pocket needed lifestyle information and
Objective: Guide edition 12,p. 257 changes.- understanding of
- used negative forms of coping like arguing- inability
to meet basic needs including no time for oneself.

Goal:
After 4 hours of nursing intervention, the client will be
able to describe and initiates alternative coping
strategies in adapting stress.
Assessment Diagnosis Scientific rationale Goals & objective Interventions Rationale Evaluation

Subjective: Sexual Due to the altered body Short term: > Obtain sexual history >To maximize Short term:
patient may verbalized:-problem such as loss of sexual desire- Dysfunction structure done by the After 8 hours of nursing including usual patterns of communication and After 8 hours of nursing
inability to achieved desired satisfaction-conflicts involving related to removal of the parts interventions the patient functioning and level of understanding interventions, The patient
values altered body of the sexual organ it will identify stressors in desires identified stressors in
structure results to loss of lifestyle that may contribute > Be alert to comments of >Sexual concerns are lifestyle that
and function sexual desire and to the dysfunction client often disguised as contributes to the
satisfaction Long term: humor, sarcasm, dysfunction
Objective: After 3 day of nursing or offhand remarks Long term:
-alteration in relationship with SO-Change of interest in self and (Masters, W. H. & interventions the patients > identify current > These factors may The patient verbalized
others Johnson, V. E. will verbalize understanding stressors in individual be producing enough understanding of
Human Sexual of individual reasons for situations anxiety to cause individual reasons
Inadequacy (Little, sexual problems depression for sexual problems.
Brown and > Avoid making > They do not help the
Company, 1970) value judgments client

>Establish therapeutic >To promote

nurse- treatment and
client relationship facilitate sharing
of sensitive
>Provide ways to information.
obtain privacy >To allow sexual
expression for
individual
between partners
without
embarrassment.
Assessment Diagnosis Scientific rationale Goals & Interventions Rationale Evaluation
objective

Alteration of nutrition The enzyme After series of Actively listening It will help him to Client was able to
Subjective: less than body phenylalanine nursing to the concerns know further the listen actively in the
“mapayat at mukhang masakitin ang anak ko” requirements as hydroxylase normally interventions, about body size treatment he has to discussion
manifested by the converts the amino acid the client will be can cope up with undergo.
“Kulang na rin ang timbang” weight loss phenylalanine into abe to receive the ability to
tyrosine. If this reaction appropriate perform
“hindi akma ang sukat ng ulo ng anak ko sa kanyang does not take place nutrition as competitively.
katawan” phenylalanine indicated by the
accumulates and individual Provide necessary Giving the Client planned and
As verbalized by the SO of the patient. tyrosine is deficient. needs. materials for appropriate diet for made the appropriate
Excessive nutritional diet the patient will diet for a week.
phenylalanine can be planning. make him be in the
metabolized into normal lifestyle.
Objective: phenylketones, which Inform the patient It will make the
BMI: 15 Malnourished are detected in the about the do’s and patient aware of Client is informed
urine. These include dont’s when it what will happen. about the
Jerking movements in arms and legs phenylacetate comes to food consequences of the
phenylpyruvate and comsumption. action eating other
Small head size( microcephaly) phenylethyamine. foods other than the
Detection of planned meals.
phenylketones in the
urine is diagnostic.
Assessment Diagnosis Scientific rationale Goals & Interventions Rationale Evaluation
objective

Subjective: The client said, “Pakiramdam ko tuloy Spiritual Distress Feelings such as Goal: After 2 Develop Provides insight to After 1 day of nursing
napakalaki ng pag-kukulang ko bilang isang katoliko, sa related to failure to anxiety, fear, guilt, days of therapeutic nurse client s willingness intervention, the client will
Panginoon. Alam kong gusto niyang magkaayos na live within the grief, and despair can nursing client to pursue outside be able to participate in
kami ng panganay ko, pero mas nangibabaw yung inis, precepts of one s produce barriers to intervention, relationship. resources. spiritual practices/religious
at hindi parin buo sa loob ko na ako ang maunang faith. relationships in general the client will activities.
makipag-ayos. Dahil dun, naguguilty ako sa Panginoon, and to the relationship be able to have Convey Provide calm, Provide time and privacy to
isang dahilan bakit hindi narin ako nagsisimba at the person has with the increased acceptance of peaceful setting engage in spiritual growth/
madalang narin ako magdasal. “ Divine. sense of client s beliefs when possible. religious activities.
connectedness and concerns.
to the Divine. Promotes trust and Determine support systems
Objectives: 1. Encourage client comfort, available to client
After 1 day of s expression of encouraging client
nursing concern and to be open about Ongoing support is
intervention, belief about sensitive matters. required to enhance sense
the client will spiritual issues. of connectedness and
be able to Helps in clarifying continue progress towards
express values, ideas, goal.
decreasing Use therapeutic recognizing and
feelings of communication resolving Assist client to identify
guilt. skills of feelings/situation. spiritual resources (spiritual
reflection and advisor).
active listening. Provides answers to
. Helps client find spiritual questions, assist in
Assist client in own solutions to the journey of self-
prayer and concerns. discovery, and can help
forgiveness. client learn to accept and
Others forgive self and others.

To heal past hurts

which are
possible barriers
to practicing
religion. Allows
client to focus on
self and seek
connectedness.
.