POLYTECHNIC COLLEGE OF DAVAO DEL SUR, INC.

MacArthur Highway, Digos City

NURSING CARE PLAN

Name of Patient: Mr.Yunting Attending Physician: _________________________________

Age: _____ Sex: ___ M ___ Civil Status: _____Married________ Diagnosis: _______________________________________
Occupation: _______________ Religion: ______Catholic_________ Chief Complaint: _________________________
Address: __Hagonoy, Davao del Sur_________________________ Date of Admission: ___________________________________
Ward: __Medical Ward_ Room No.: ____33___Bed No.:___1_______
DATE/ CUES NEEDS NURSING SCIENTIFIC GOALS NURSING RATIONALE EVALUATION
TIME DIAGNOSIS BASIS OBJECTIVES INTERVENTIONS
CRITERIA
Subjective: Nutritional- Risk for Deficient Deficient Fluid After 8 hours of >Established rapport. >To promote client`s After 8 hours of nursing
Metabolic Fluid Volume Volume (also nursing intervention, cooperation and interventions the patient was
¨Usahay rajud ko gainom Pattern known as Fluid the patient will be able alleviates client`s anxiety. able to :
3 –11pm
ug tubig mam. Kanang Volume Deficit to :
shift >Monitored vital
makabati nakog uhaw¨ as >Hypotension,  ¨Mas daghan nakog
(FVD) , signs.
verbalized by the patient.
hypovolemia) is a  Verbalized a tachycardia, fever can
ginainom nga tubig
clear indicate response to or
Objective : state or condition effect of fluid loss. rom kaysa sa una,
where the fluid knowledge dili na nako
output exceeds the of the role ginahulat nga
 Pallor is noted that water >To replace fluids and
fluid intake. It >IVF regulated @ uhawon pako¨ as
 Patient´s skin plays in prescribed rate. electrolytes and maintain
was dry occurs when the verbalized by the
keeping our fluid and electrolyte
body looses both patient.
 Skin turgor is bodies balance
water and  Increased fluid
noted healthy.
electrolytes from intake as evidenced
 VS the ECF in similar  Increased
>Monitored intake by the patient
4pm fluid volume >This provides
proportions. and output, character showing the amount
intake. information about overall of fluid consumed in
Temp: and amount of stools ;
 presented estimated insensible
fluid balance, renal
a water bottle.
BP: functions and bowel
RR: Derived from : good skin fluid losses,  Maintained adequate
turgor, disease control, as well as
PR: https://nurseslabs.co fluid volume as
guidelines for fluid
SATo2: m/deficient-fluid- maintained evidenced by good
replacement.
volume/ an >Observed for skin turgor and
appropriate excessively dry skin
>This indicates excessive balanced or equal
fluid and mucous
fluid loss or the result of intake and output.
volume, and membranes,
dehydration. VS:
decreased skin turgor,
balanced
slowed capillary refill.
intake and 8pm
output. Temp:
BP:
 >Encouraged patient RR:
to weigh daily PR:
>This is an indicator of SATo2:
>Maintained oral
restrictions, bed rest overall fluid and
and avoidance of nutritional status.
exertion.
>Colon is placed at rest
for healing and to
>Administered decrease intestinal fluid
medications as losses,
indicated.
>To prevent occurrence
>Encouraged client to
of deficit.
maintained a diary of
food/fluid intake.

>To promote wellness.

Name: _Eden Claire P. Relacion__ Section & Year: ____BSN – 2B________________ Group No.: ______12_____________ Rating: _______________
Reference___________________________________________________________________________________________
Criteria: Promptness (5%) _______ Objective Of Care (10%) ________
Format/Neatness (5%) _______ Nursing Actions (40%) ________
Assessment (15%) _______ Evaluation (10%) ________
Diagnosis (15%) _______ Clinical Instructor: Ms. Lovely Faith Amolo

POLYTECHNIC COLLEGE OF DAVAO DEL SUR, INC.

MacArthur Highway, Digos City
NURSING CARE PLAN

Name of Patient: _ ____________________________ Attending Physician: _________________________________

Age: _____ Sex: ___ ___ Civil Status: ____________________ Diagnosis: __________________________________________
Occupation: _______________ Religion: _____________________ Chief Complaint: _____________________________________
Address: _______________________________________________ Date of Admission: ___________________________________
Ward: _______ Room No.: ________ Bed No.: ________________
DATE/ CUES NEEDS NURSING SCIENTIFIC GOALS NURSING RATIONALE EVALUATION
TIME DIAGNOSIS BASIS OBJECTIVES INTERVENTIONS
CRITERIA
Subjective: Fatigue related to Iron deficiency Short-term goal: Independent:  Post-blood transfusion
iron deficiency anemia is a client’s feeling of
3 – 11pm ¨Bisan wala koy himuon, anemia common type of After 5 days of >Established rapport. >To promote client`s fatigue is relieved.
Shift Bisan pa ug mag sigi ko anemia — a nursing
ug higda kapoy ra interventions, client
cooperation and  Client has improved
condition in alleviates client`s sense of energy and is
gihapon akong lawas¨ as will report
verbalized by the patient.
which blood improved sense of
anxiety. able to accomplish some
lacks adequate energy. ADLs such as eating
>IVF regulated @
Objective: healthy red blood >To replace fluids alone and walking.
prescribed rate.
cells. Red blood Long-term goal:
 Verbalization cells carry >Evaluated client`s >This establishes
VS:
of oxygen to the After 1-2 weeks of response to activity. Note client`s capabilities
body's tissues. nursing and needs, and Temp:
overwhelming reports of dyspnea,
interventions, client increased weakness, facilitates choice of BP:
lack of energy
even during As the name will be able to fatigue, and changes in interventions. RR:
implies, iron perform ADLs and vital signs during and PR:
rest periods participate in
deficiency after activities. SATo2:
 Inability to desired activities at
maintain usual anemia is due to level of ability. >Planned care to allow
routines and insufficient iron.
for rest periods.
ADLs Scheduled activities for >Frequent rest
 Seen watcher periods when patient has periods and naps are
Derived from : needed to restore and
assisting client most energy. Involved
in performing client and watcher in conserve energy.
https:// Planning will allow
ADLs schedule planning.
www.mayoclinic.o client to be active
 Hemoglobin rg/diseases- during times when
level of 63 g/L conditions/iron- energy level is
(Normal: 120- higher, which may
deficiency-
150 g/L) restore a feeling of
anemia/symptoms-
 Hematocrit well-being and a
causes/syc- sense of control.
level of 0.24 >Established realistic
20355034#:~:text= activity goals with client.
L/L (Normal:
Iron%20deficiency >Weakness may
0.37-0.47 L/L)
%20anemia%20is make ADLs difficult
 RBC level of to complete or place
%20a,is%20due
3.20x1012/L the client at risk for
(Normal: 4.2- %20to
 5.4 x1012/L %20insufficient injury during
 O2saturation of %20iron. >Explained importance activities
96% of rest in treatment plan
and necessity for >To decrease
 Respiratory
balancing activities with metabolic demands,
rate of26cpm rest. thus conserving
 skin and lips energy.
are pale in >Assisted to assume
color comfortable position for
rest and sleep.
>To promote rest
>Encouraged watcher to
stay at bedside always.

>Assisted with self-care

>To assist patient’s
needs and to secure
activities as necessary
such as ambulation, safety.
sitting up in chair,
bathing, etc. >Minimizes
exhaustion and helps
>Encouraged to consume reduce oxygen
foods rich in iron such as demand
beans, egg yolk, kidney,
liver, and oatmeal.

>Ascertained client`s >To aid in

ability to stand and move increasing iron levels
about and degree of in the body.
assistance needed or use
of equipment.
>To sustain
motivation of client.
Dependent:

>Provided supplemental
oxygen as ordered.

>Administered iron >To promote balance

supplements as ordered between oxygen
supply and demand

> to treat or prevent

anemia (a lower than
normal number of red
blood cells) when the
 amount of iron taken
in from the diet is not
>Transfused 1 unit of enough
PRBC as ordered by the
physician.

>To correct anemia

immediately
Name: ___ Section & Year:____________________ Group No.: ___________________ Rating: _______________
Reference___________________________________________________________________________________________
Criteria: Promptness (5%) _______ Objective Of Care (10%) ________
Format/Neatness (5%) _______ Nursing Actions (40%) ________
Assessment (15%) _______ Evaluation (10%) ________
Diagnosis (15%) _______ Clinical Instructor: _________________________________________

POLYTECHNIC COLLEGE OF DAVAO DEL SUR, INC.

MacArthur Highway, Digos City
NURSING CARE PLAN

Name of Patient: _ ____________________________ Attending Physician: _________________________________

Age: _____ Sex: ___ ___ Civil Status: ____________________ Diagnosis: __________________________________________
Occupation: _______________ Religion: _____________________ Chief Complaint: _____________________________________
Address: _______________________________________________ Date of Admission: ___________________________________
Ward: _______ Room No.: ________ Bed No.: ________________
DATE/ CUES NEEDS NURSING SCIENTIFIC GOALS NURSING RATIONALE EVALUATION
TIME DIAGNOSIS BASIS OBJECTIVES INTERVENTIONS
CRITERIA
 Subjective: Risk for bleeding Leukemia is Short Term: Independent: Patient take measures to prevent
related to cancer of the  Established >To promote client`s bleeding ang recognized signs of
“Medyo okay raman mam decreased platelet white blood cells. After 8 hours of cooperation and bleeding that need to be reported
3 – 11pm rapport.
Shift pero luya ug kapoy jud count. White blood cells nursing alleviates client`s immediately to a health care
kasagaran akong ma bati” interventions anxiety. professional.
help your body
as verbalized by the
fight infection.
patient.  Skin will  IVF regulated >To replace fluids Short Term:
Your blood cells
remain @ prescribed
Objective: form in your After 3 hours of nursing
intact rate.
bone marrow. In interventions
with no
 Body weakness leukemia, >Early detection of
signs of  Assess vital
is noted. however, the bleeding helps  Skin is intact with no
bleeding signs every4
 Pallor noted bone marrow prevent significant sign of bleeding
produces hours and
 Blood count  Mucous
blood loss and  Mucous membrane is
abnormal white body systems potential shock.
shows reduced membran intact
blood cells. every shift for Occult blood shows
e will bleeding: internal hemorrhage
>HGB- 63 These cells Long Term:
remain intracranial bleeding
>Platelet-30 crowd out the
intact >Skin, mucous affects mental status
>HCT-0.246 healthy blood membranes for
After 4 days of nursing
and LOC interventions, the client will:
cells, making it petechiae, ecchymoses,
hard for blood to and hematoma
do its work. In Long Term: formation.  Urine and stool are free
acute After 4 days of from blood
lymphoblastic nursing >Gums and nasal  Normalized RBC count
leukemia (ALL), interventions, the membranes for bleeding
there are too client will:
many of specific >Vomitus, stool and
types of white  Urine and urine for visible occult
stool will blood
blood cells called
lymphocytes or be free
>Neurologic
lymphoblast. from
changes(e.g., headache,
These leukemic blood. visual changes,
cells are notable  Restores/ decreased LOC seizure)
to fight infection normalize
very well. Also, s RBC  Encourage use
count >Fragile tissues and
as the number of of soft-bristle
altered clotting
leukemic cells tooth brush,
increases in the mechanisms increase
sponge or mild
blood and bone the risk of
mouthwash to
clean teeth and hemorrhage
gums. following even minor
trauma
  Instruct client
to avoid >These activities can
forceful damage mucous
blowing, membrane increasing
coughing, the risk of bleeding.
sneezing and
straining to
have a bowel
movement
Name: ___ Section & Year:____________________ Group No.: ___________________ Rating: _______________
Reference___________________________________________________________________________________________
Criteria: Promptness (5%) _______ Objective Of Care (10%) ________
Format/Neatness (5%) _______ Nursing Actions (40%) ________
Assessment (15%) _______ Evaluation (10%) ________
Diagnosis (15%) _______ Clinical Instructor: _________________________________________

DRUG STUDY

Name of Patient: Attending Physician:_____________________________________

Age:_____Sex: Civil Status: Diagnosis:_____________________________________________
Occupation: Religion: Chief Complaint:________________________________________
Address:
DATE/ ROUTE/ PRECAUTION
TIME BRAND NAME ACTION INDICATION DOSAGE/TIME DRUG ADVERSE CONTRAINDICA- NURSING
ORDERED INTERVAL INTERACTION EFFECT TIONS RESPONSIBILITIES
 Inhibits reabsorption of Drug-drug: >Increased CNS: dizziness, Contraindicated with Before:
sodium and chloride risk of cardia vertigo, paresthesia, allergy to furosemide, > check doctor’s order
3-11pm Shift LASIX from the proximal and Oral/IM arrhythmias with xanthopsia, sulphonamides; > assess allergy to
distal tubules and cardiac glycosides; weakness allergy to tartrazine; furosemide, sulfonamides,
ascending limb of the Availability: anuria, severe renal tartrazine
loop of Henle, leading Tablets – 20, 40, >increased risk of CV: orthostatic failure; hepatic coma; > do not mix parenteral
to a sodium-rich 80mg; oral solution – ototoxicity with hypertension, pregnancy; lactation. solution with highly acidic
dieresis 10mg/ml, 40mg/ml; aminoglycoside thrombophlebitis solutions with ph. below
injection – 10mg/ml antibiotics, cisplatin; 3.5
>decreased absorption Dermatologic: Precaution: Use > do not expose to light,
of furosemide with photosensitivity, cautiously with SLE, which may discolor tablets
phenytoin; decreased GI pruritus, urticaria, gout, diabetes mellitus or solution
absorption with purpura > educate the patient about
GENERIC HALF-LIFE charcoal; the purpose and
NAME GI: nausea, importance of the drug
Onset: 5 min >may reduce effect of anorexia, vomiting,
Furosemide Peak: 30 min insulin or oral oral and gastric During:
Duration: 2 hr antidiabetics because irritation > check the patency of the
Metabolism: hepatic; blood glucose levels IV site and IV line
30-60 min can become elevated GU: nocturia, > Give early in the day so
glycosuria, urinary that in-creased urination
CLASSIFI- ABSORPTION EXCRETION bladder spasm will not disturb sleep
CATION > administer the right dose
Pharmacologic: Hematologic: at the right time
Loop diuretic feces, urine leukopenia, anemia, > measure and record
thrombocytopeniaOt weight to monitor fluid
Therapeutic: her: muscle cramps changes
Loop diuretic and muscle spasms. After:
> monitor blood glucose
Pregnancy levels
Category Risk: C > arrange to monitor serum
electrolytes, hydration,
liver and renal function
> arrange for potassium-
rich diet or supplemental
potassium as needed
> report loss or gain of
more than 1.5kg in 1 day,
swelling in your ankles or
fingers, unusual bleeding
or bruising
> document and record

Ward: Room No: Bed No: Date of Admission:____________________________________

Student Name: Year & Sec.: Group No.: Rating:__________________
References:______________________________________________________________________________________________________________________________________
Criteria: Promptness (15%), Format/Neatness (15%), Assessment (15%), Nursing Diagnosis (15%), Objectives (15%),
Objectives of Care (10%), Nursing Action (30%), Evaluation (10%)
Clinical Instructor:____________________________________________________
 POLYTECHNIC COLLEGE OF DAVAO DEL SUR, INC.

MacArthur Highway, Brgy. Kiagot, Digos City, Davao del Sur, Philippines 8002

DRUG STUDY

Name of Patient: Attending Physician:_____________________________________

Age:_____Sex: Civil Status: Diagnosis:_____________________________________________
Occupation: Religion: Chief Complaint:________________________________________
Address:
Ward: Room No: Bed No: Date of Admission:____________________________________

DATE/ ROUTE/ PRECAUTION

TIME BRAND NAME ACTION INDICATION DOSAGE/TIME DRUG ADVERSE CONTRAINDICA- NURSING
ORDERED INTERVAL INTERACTION EFFECT TIONS RESPONSIBILITIES
 Binds to an >GERD PO(Adults): Drug – Drug :B CNS: seizures, Contraindicated in Assessment
3-11pm Shift enzyme on gastric GERD-20mg once  Omeprazole dizziness, headache, -Hypersensitivity  Assess patient
PRILOSEC parietal cells in >Duodenal ulcers daily- Duodenal is weakness. routinely for
the presence of ( with or without ulcers associated metabolized Use cautiously in: epigastric or
acidic gastric pH, anti-infectives for with H.pylori-40mg by the CV: Chest pain >Liver disease (dosage abdominal pain
preventing the Helicobacter daily in the morning reduction may be
CYP450 and frank or
final transport of pylori) with clarithromycin GI: abdominal pain, necessary)
GENERIC hydrogen ions for 2 weeks, then
enzyme anorexia, and
occult blood in
NAME into the gastric >Pathologic 20mg twice daily system and regurgitation, >Pregnancy. Lactation the stool,
lumen. hypersecretory with clarithromycin may compete constipation, or children <2 years emesis, or
Omeprazole conditions, 5oomg twice daily with other diarrhea, flatulence, old (safety not gastric aspirate.
Therapeutic including and amoxicillin agents nausea, vomiting. established)  May cause
Effects: Zollinger-Ellison 1000mg twice daily metabolized serum gastrin
CLASSIFICATION Diminishes syndrome for 10 days (if ulcer by this Derm: Itchiness, concentrations
accumulation of is present at system, rashes to during 1-2
Therapeutic : acids in the gastric >OTC: Hear turn beginning of therapy,  Decrease weeks of
Antiulcer agents lumen with occurring twice a continue omeprazole Misc: allergic
metabolism therapy. Levels
lessened week. 20mg daily for 18 reaction
Pharmacologic : and may return to normal
gastroesophageal more days) has also
Proton-pump reflux. been used with increase after
inhibitors clarithromycin and effects of discontinuation
Healing of metronidazole. diazepam, of omeprazole.
Pregnancy duodenal ulcers, Gastric Ulcer- 40mg flurazepam,  Monitor with
Category Risk: C once daily for 4-6 triazolam, differential
weeks. Gastric cyclosporine, periodically
hypersecretory disulfiram during therapy.
conditions- 60mg  May cause AST,
once daily initially, ALT, alkaline
may be increased up
phosphate and
to 120mg 3x daily
doses>80mg /days
bilirubin.
should be given in  Advice patient
divided doses. to report onset
of black, tarry
OTC-20mg once stools, diarrhea,
daily for up to 14 abdominal pain,
days. or persistent
headache to
PO(children) >2 y.o. health care
and < 20 kg.): 10mg professional
once daily
promptly.
PO(children) >2 y.o.  Advice patient
and > 20 kg.): 20mg to avoid alcohol
once daily. products
containing
 aspirin or
NSAIDs and
foods that may
cause an
increase in GI
irritation.
HALF-LIFE
EVALUATION
0.5 – 1hr( increased
Effectiveness of therapy
in liver disease)
can be demonstrated by :
Decrease in abdominal
ABSORPTION EXCRETION pain or prevention of
gastric irritation and
bleeding. Healing of
Rapidly absorbed Extensively duodenal ulcers can be
following oral metabolized by the seen on x-ray examination
administration liver. or endoscopy.
Decrease in symptoms of
GERD. Therapy is
continued for 4-8 weeks
after the initial episode.

Ward: Room No: Bed No: Date of Admission:____________________________________ Student Name:

Year & Sec.: Group No.: Rating:__________________
References:______________________________________________________________________________________________________________________________________Criteria:
Promptness (15%), Format/Neatness (15%), Assessment (15%), Nursing Diagnosis (15%), Objectives (15%),

Objectives of Care (10%), Nursing Action (30%), Evaluation (10%)

Clinical Instructor:____________________________________________________
 DRUG STUDY

Name of Patient: Attending Physician:________________________________

Age: Sex Civil Status: Diagnosis: ________________________________
Occupation: Religion: Chief Complaint: ________________________________
Address:
DATE/ ROUTE/ PRECAUTION
TIME BRAND NAME ACTION INDICATION DOSAGE/TIME DRUG ADVERSE EFFECT CONTRAINDICA- NURSING
ORDERED INTERVAL INTERACTION TIONS RESPONSIBILITIES
Antipyretic: Temporary Metoclopramide CNS: Headache  Contraindica >Do not exceed the
3- 11pm Shift PANADOL, Reduces fever by reduction of fever, CV: Chest pain, ted with recommended dosage.
CALPOL, acting directly on temporary relief of Propantheline dyspnea. Myocardial allergy to
TYLENOL the hypothalamic minor aches and Oral damage when doses of 5- acetaminoph >Give drug with food if GI
heat-regulating pains caused by 8g per day are ingested upset occurs,
en.
center to cause common cold and daily for several weeks
vasodilation and influenza, or when doses of 4g per
 Use >Discontinue drug if
GENERIC sweating, which headache, sore HALF-LIFE day are ingested for 1 cautiously hypersensitivity occurs.
NAME helps dissipate throat, menstrual year. with
heat. cramps and others. GI: hepatic toxicity and impaired >Reduce dosage with
Paracetamol 1-2 hours failure jaundice hepatic hepatic impairment
function.
Chronic
 CLASSIFI- ABSORPTION EXCRETION GU: Acute renal failure. alcoholism,
CATION Renal tubular necrosis pregnancy, >Assess patient fever or
Urine Hypersensitivity: lactation. pain; type of pain,
Analgesic and Rashes, fever location, intensity,
Antipyretic duration, temperature, and
diaphoresis.
Ward: Room No: Bed No: Date of Admission:____________________________________
Student Name: Year & Sec.: Group No.: Rating:__________________
References:______________________________________________________________________________________________________________________________________
Criteria: Promptness (15%), Format/Neatness (15%), Assessment (15%), Nursing Diagnosis (15%), Objectives (15%),
Objectives of Care (10%), Nursing Action (30%), Evaluation (10%) Clinical Instructor:____________________________________________________