Nursing Care Plan

Far Eastern University

Institute of Nursing
LEADERSHIP AND MANAGEMENT

Student Nurse In –Charge: Student Head Nurse: LEOCHICO, Maricris M.

Patient: Alfredo Martinez Date: 12/15/2010
Room and Bed No.: 505 Bed D
Nursing Analysis Goals and Intervention Rationale Evaluation
Diagnosis/Cues Objectives
Readiness for A pattern of Goal: • Verify client’s • Provides EFFECTIVENESS:
enhanced regulating and Remain free of level of opportunity to The nursing
therapeutic integrating into preventable understanding assure interventions
management daily living a complications/ of therapeutic accuracy and implemented are
program(s) for progression of regimen. Note completeness effective since
Subjective: treatment of illness and specific health of knowledge the goal was met
>: “kailangan ko illness and its sequelae. goals. base for as evidenced by
lang pala I sequelae that is future the client’s
maintain yung sufficient for Objectives: learning. verbalization of
gamut ko at hindi meeting health- • Identify / use • Identify steps her needs to
ito itigil hangga’t related goals and additional necessary to • Understandin comply with the
di ko siya can be resources as reach desired g the process disease
kinukonsulta sa strengthened. appropriate health goals. enhances management
doctor.” • Demonstrate commitment
>: “Ano nga ba proactive and the
yung mga dapat management likelihood of EFFICIENCY:
kong gawin para by achieving the The interventions
makaiwas sa anticipating goals. done are efficient
mga susunod na and planning • Accept client’s since they
mga atake?” for evaluation of performed in the
eventualities own • Promotes best possible
Objective: of condition/ strengths/ sense of self- manner with
>: The patient potential limitations esteem and least waste of
shows positivity complications while working confidence to time and effort;
towards the • Assume together to continue having and using
treatment responsibility improve efforts. requisite
>:There are no for managing abilities. knowledge, skill,
unexpected treatment industry and
acceleration of regimen • Acknowledge competency.
illness symptoms. individual
efforts/ • Provides ADEQUACY:
capabilities to positive The interventions
reinforce reinforcement are sufficient to
movement encouraging achieve the goal.
toward continued
attainment of progress
desired toward APPROPRIATENES
outcomes. desired goals. S:
The interventions
planned and
• Promote carried out are
client/ care appropriate to
giver choices the identified
and problem. They
involvement were also
in planning for appropriate for
implementing the client’s age
added tasks/ and level of
responsibilitie understanding.
s.

• Assist in • Promotes ACCEPTABILITY:

implementing proactive The interventions
strategies for problem are acceptable
monitoring solving. since they
progress/ yielded positive
responses to results and
therapeutic promoted client’s
regimen. wellness.