Wesleyan University – Philippines

College of Nursing and Allied Medical Sciences

Tel No. (044) 463-2162; Fax No 463-0596 local 126

N u r s i n g C a r e P l a n
NAME: KRISTINE ANTONETTE E. BALABA____________________________________________ GROUP NO: ______1_______ BLOCK: ______1_______ DATE: __01/25/2018__

NAME OF PATIENT: PATIENT Y____________________________________________________ MEDICAL DIAGNOSIS: RHEUMATIC HEART DISEASE_____________________________________

ASSESSMENT NURSING DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATION

Independent Nursing Actions:
Objective: Difficulty of After 1 hour of
“nahihirapan po breathing related nursing Elevated the head of the bed Elevation of bed Goal met. Client
akong huminga” as to rheumatic heart intervention facilitates experienced
verbalized by the disease as patient will respiratory function lessened
client manifested by 26 experienced by taking advantage difficulty of
breath per minute lessened of the gravity breathing
Subjective: difficulty of
- Nasal flairings breathing. Encouraged the client to do Deep breathing
- Rapid shallow deep breathing exercises exercises promotes
breathing chest expansion
- RR: 26 Bpm

Dependent Nursing Actions:

Give oxygen therapy as Helps in giving

prescribe by the physician adequate oxygen to
the client

Collaborative Nursing Actions:

Obtain specimen for arterial It helps to assess the

blood gas study condition of the client
 Wesleyan University – Philippines
College of Nursing and Allied Medical Sciences
Tel No. (044) 463-2162; Fax No 463-0596 local 126

N u r s i n g C a r e P l a n
NAME: KRISTINE ANTONETTE E. BALABA____________________________________________ GROUP NO: ______1_______ BLOCK: ______1_______ DATE: __01/25/2018__

NAME OF PATIENT: PATIENT X____________________________________________________ MEDICAL DIAGNOSIS: ACUTE GLUMERULONEPHRITIS___________________________________

ASSESSMENT NURSING DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATION

Independent Nursing Actions:
Objective: Excess Fluid After of
“Nagmamanas ang volume related to nursing 1. Assess fluid status Assessment provides Goal met.
mukha ng anak ako” failure of intervention a. Daily weight baseline and ongoing
as vervalized by regulatory the patient b. Monitor I & O database for
the patient’s mechanism will c. Skin turgor and monitoring changes
mother (inflammation of demonstrate presence of edema and evaluating
glomerular compliance with d. BP, PR,RR interventions.
Subjective: membrane dietary and
(+) facial edema inhibiting fluid 2. Limit fluid intake to Fluid restriction
BP:90/60 mmHg filtration) restrictions. prescribe volume and will be determined on
Temp: 36.8 ℃ evidenced by explain to family the basis of weight,
- Weight: 23.5 Kg facial edema. rationale urine output and
response to therapy.
Dependent Nursing Actions:

Give furosemide as Furosemide helps in

prescribed by the physician facilitating urine

Collaborative Nursing Actions: