NURSING CARE PLAN

ASSESSMENT DATA GOALS AND NURSING INTERVENTIONS AND EVALUATION

NURSING DIAGNOSIS OBJECTIVES RATIONALE
(Subjective & Objective Cues)
(Problem and Etiology)
Independent:

Subjective: >Impaired Physical Long Term: 1. Note situation such as Goal’s Partially met:
Mobility related to activity surgery and tubing.
intolerance, pain or Rationale: That may restrict
discomfort, deficient movement.
“Gasakit akong tiyan After 1-2 days of 1. Patient was
pagmulihok ko” as verbalized knowledge regarding value nursing care, the able to
2. Assess degree of pain.
by patient. of physical activity patient will be able to: Rationale: To assess and evaluate maintain
degree of pain. position of
function and
3. Observe movement when skin integrity
1. Maintain client is unaware of as evidenced
position of observation. of absence of
function and Rationale: To note any in contractures,
skin integrity as foot drop, and
Objective: congruencies with reports of
evidenced by decubitus.
ability. 2. Patient was not
absence of
contractures, able to
4. Instruct in use of side rails
foot drop, and verbalized
➢ Pain scale of 7/10 Rationale: For position changes
decubitus. understanding
➢ PR: 120 bpm and transfers. of situation.
➢ Pain at abdominal 3. Patient was
region 5. Schedule activities with
Short Term: able to
➢ With peritoneal shunt at adequate rest periods
participate in
the epigastric region during the day
desired
 ➢ Limited ability to Rationale: To reduce fatigue activities.
perform gross or fine 4. Patient was not
motor skills After 1-4 hours of 6. Encourage participation in totally
➢ Slowed movement nursing care, the self-care demonstrated
➢ Engages in substitution patient will be able to: Rationale: Enhances self concept behaviors that
for movement(focus on and sense of independence. enable
pre-illness disability or resumption of
activity) 7. Encourage significant activities.
1. Verbalize other’s involvement in
understanding decision making as much
of situation and as possible.
individual
treatment
regimen and Dependent:
safety
measures. 1. Administer medications
2. Participate in prior to activity as needed
desired for pain relief
activities. Rationale: To permit maximal
3. Demonstrate effort and involvement in activity.
behaviors that
enable
resumption of
activities. Collaboration:

1. Assist with treatment of

underlying condition
causing pain or
dysfunction

Assessment/ Nursing Objective/ Nursing Intervention Evaluation

Cues
SUBJECTIVE:
“Nakabantay lage ko ma'am
na dako kay ang ulo sa akong
anak!”as verbalized by the
mother.
OBJECTIVE:
• Restlessness
• Irritability
• Change in vital signs.
Diagnosis
Ineffective cerebral tissue
perfusion related to
decrease arterial or
venous blood flow.
Goal
At the end of 8 hours INDEPENDENT: Goals Met. After 8
of nursing hours of
interventions, the
client will be able to nursing
➢ Monitor vital signs. interventions,
demonstrate improve RATIONALE: to observed for any the patient was
vital signs and unusualities. able to
absence of sign of demonstrate
increase ICP. ➢ Monitor intake and output, improved vital
note skin turgor, status and signs and
mucous membrane. absence of
RATIONALE: Useful indications of signs of
body waters in which integral part Increased ICP.
of tissue perfusion.
➢ Maintain head and neck in
neutral position.
RATIONALE: Turning the head
from one side compresses the
jugular vein and inhibits cerebral
venous drainage that cause
increase ICP.
➢ Provide rest between cares of
activities and limit duration of
procedures.
RATIONALE: Continual activity
can increase ICP by producing a
comulative stimulant effect.
 ➢ Elevate the bed gradually to
15-30 degrees as tolerated
as indicated.
RATIONALE: Promotes venous
drainage from head, reducing
cerebral congestion, edema and
increase ICP.

DEPENDENT:

➢ Administer medication:
Omeprazole 40mg O.D-
prophylaxis for ulcer, as
ordered.

COLLABORATIVE:

➢ Consult Dietician
(nutritionist), as desired.