NURSING CARE PLAN

A Requirement Submitted to
The College of Nursing Faculty
Notre Dame of Tacurong College
Tacurong City

____________________________________
Clinical Instructor

In Partial Fulfillment
Of the Requirements for the Subject
Nursing Care Management 112 RLE

by:

_________________________________
 Name of Student

Copyright © 2022 by NDTC Nursing Department | No part of this document may be reproduced, distributed, or transmitted in
any form or by any means, including photocopying, recording, or other electronic or mechanical methods, without the prior
written permission from the owner.
 NOTRE DAME OF TACURONG COLLEGE
COLLEGE OF NURSING
Lapu-Lapu St., Tacurong City, Sultan Kudarat, Philippines
Telephone No. : (064) 200-3631 Fax No. : (064) 200-4131

NURSING CARE PLAN

Name of Patient: tim Diagnosis: acute gastritis and mild dehydration

Area: pediatric ward

ASSESSMENT NEEDS NURSING GOALS NURSING RATIONALE EVALUATION

DIAGNOSIS INTERVENTION
Subjective Data Nutritional General 1. To reduce anxiety
The patient deficient at the end of the and increase No dehydration noted
verbalized “Masakit Metabolic hypotonic shift the nursing INDEPENDENT cooperation.
ang tiyan ng aking FLUID cares the patient 1. Established rapport with 2. Serve as baseline no indigestion felt by
anak, at siya ay Pattern VOLUME will understand the SO and patient. data he patient
inaantok sa lahat ng treatment plan for 2. Monitored Vital Sign. 3. Promote comfort of
oras at siya ay hid gastritis with 3.Bedside care done by fixing the pt. Goal met the patient
patuloy na Rationale medication the bed. stated that his pain
4. To determine if the
nagsusuka kahapon” prescribed by the scale is 0/10
4.Determined total daily client was able to
Decreased physician, the
food intake. ingest the food.
intravascular, patient exhibits The patient
5. Evaluated total daily 5. To reveal possible
interstitial, normal findings demonstrated that he
food intake. cause of malnutrition.
and/or would change his
restore normal fluid COLLABORATIVE 6. reduce the risk of
intracellular dietary plans to avoid
fluid. This refers volume in 1-2 days 6. Provide health teaching on recurrence of gastritis
reoccurrence
Objective Data to dehydration the client regarding on proper and Dehydration
-tiredness noted with changes in diet and hydration 7. facilitate timely
The patient adheres to
-drowsiness sodium dependent intervention to prevent
the regiment provided
- loss of appetite Specific 7. administer medication and reduce the effects
by his physician
-weakness The patient will ordered by the doctor of gastritis
BP: 120/80 mm/Hg understand and 8. Insert IVF D5LR 1L x 80 8.
Temp: 37. 2C comply with all the gtts/min and Regulated as 9.
PR: 88 bpm dietary changes to ordered by the doctor
his usual meals to
RR: 21 cpm
reduce the
References reoccurrence of
gastritis and its
 symptom
Nurse’s Pocket
Guide

Prepared by: __________________________________________ Year &Section: ____________ Date: __________________________

Copyright © 2022 by NDTC Nursing Department | No part of this document may be reproduced, distributed, or transmitted in any form or by any means, including
photocopying, recording, or other electronic or mechanical methods, without the prior written permission from the owner.

NOTRE DAME OF TACURONG COLLEGE

COLLEGE OF NURSING
Lapu-Lapu St., Tacurong City, Sultan Kudarat, Philippines
Name of Student: ______________________________________ Subject: ___________________________ Score: ________

NURSING CARE PLAN

CRITERIA EXCEEDS EXPECTATIONS (4) MEETS EXPECTATIONS (3) APPROACHING EXPECTATIONS (2) DOES NOT MEET WEIGHT Score
EXPECTATIONS
(1)

Includes all pertinent data related to the Includes all pertinent data related Does not include all pertinent data related X1
nursing diagnosis and does not include to the nursing diagnosis, but also to the nursing diagnosis. May also include Incomplete or missing
Assessment
data that is not related to the nursing includes data not related to the data that does not relate to the nursing assessment.
diagnosis. nursing diagnosis. diagnosis.
Three or more diagnoses are identified, 1-2 diagnoses are identified, X2
Diagnoses may not be NANDA-approved,
prioritized, NANDA-approved, and in NANDA-approved, and supported incomplete or
Diagnosis appropriate, or prioritized. Lack of clear
PES format, demonstrating accurate by assessment data. May lack irrelevant 8
support from assessment data.
clinical judgment. prioritization or proper PES format.
Short-term and long-term goals are Goals are patient-focused and X1
patient-focused, realistic, and clearly related to diagnoses. Goals are not relevant to diagnoses, not Incomplete or
Planning
(Goal Setting) related to diagnoses. Each has clear Measurement criteria may be patient-centered, not measurable, or lack completely unrelated
measurement criteria and a timeframe. unclear or timeframes unrealistic. achievable target dates. to nursing diagnoses. 4
The interventions section includes 3-5 X2
specific actions with defined Adequate number of interventions,
Implementatio Inadequate number of interventions, or
frequencies, classified as independent, but may lack specificity, proper Incomplete or
n interventions lack specificity, labeling, or 8
dependent, or collaborative, each with classification, or referenced irrelvant.
(Interventions) rationales.
referenced rationales to facilitate the rationales.
patient/family achieving their goal.
Contains data from goal criteria, clearly Contains data from goal criteria Lacks data from goal criteria, may not X1
describes goal status (met, partially but may not clearly describe goal describe goal status, and may not include Incomplete or
Evaluation
met, not met), and includes status or include revision/new date revision/new date if needed. irrelvant.
revision/new date if needed. if needed. 4
Total
/28
Promptness
On or before the deadline : 10%
Within 24 hours after the deadline: 5%
After 24 hours: 0%
RLE: ALL requirements must be completed on the last day of the rotation except for documentation and case study. Day
2-Day7: 50% transmuted grade
Day 8: 0%, requirements will not be accepted
Copyright © 2022 by NDTC Nursing Department | No part of this document may be reproduced, distributed, or transmitted in any form or by any means, including
photocopying, recording, or other electronic or mechanical methods, without the prior written permission from the owner.
Copyright © 2022 by NDTC Nursing Department | No part of this document may be reproduced, distributed, or transmitted in any form or by any means, including
photocopying, recording, or other electronic or mechanical methods, without the prior written permission from the owner.
 DRUG STUDY

A Requirement Submitted to
The College of Nursing Faculty
Notre Dame of Tacurong College
Tacurong City

_______________________________________
Clinical Instructor

In Partial Fulfillment
Of the Requirements for the Subject
Nursing Care Management 112 RLE

by:

__________________________
 Name of Student

Copyright © 2022 by NDTC Nursing Department | No part of this document may be reproduced, distributed, or transmitted in
any form or by any means, including photocopying, recording, or other electronic or mechanical methods, without the prior
written permission from the owner.
 NOTRE DAME OF TACURONG COLLEGE COLLEGE OF NURSING Picture Here
Lapu-Lapu St., Tacurong City, Sultan Kudarat, Philippines
Telephone No. : (064) 200-3631 Fax No. : (064) 200-4131

DRUG STUDY

Name of Patient: _____________________ Diagnosis: ________________________________

Area: _____________________
NAME DRUG ACTION SIDE EFFECT CONTRAINDICATION NURSING RESPONSIBILITIES
Generic Name Mechanism of Action

Brand Name

Classification
SPECIAL PRECAUTION

Indication
ADVERSE EFFECT

MODE OF
ADMINISTRATION
 DRUG INTERACTION
Route

Dosage

Time

Prepared by: __________________________________________ Year &Section: ____________ Date: ___________________________

Copyright © 2022 by NDTC Nursing Department | No part of this document may be reproduced, distributed, or transmitted in any form or by any means, including
photocopying, recording, or other electronic or mechanical methods, without the prior written permission from the owner.
NOTRE DAME OF TACURONG COLLEGE
COLLEGE OF NURSING
Lapu-Lapu St., Tacurong City, Sultan Kudarat, Philippines

Name of Student: ______________________________________ Subject: ___________________________ Score: ________

DRUG STUDY

CRITERIA EXCEEDS MEETS EXPECTATIONS (3) APPROACHING EXPECTATIONS DOES NOT MEET WEIGHT SCORE
EXPECTATIONS (2) EXPECTATIONS
(4) (1)
Contents and Content is complete and well-presented. Content well-presented with one Content is presented with two (2) Content is presented with 3
Organization Chooses appropriate words relevant to (1) lacking in entries. Choosing lacking in entries. Chooses lacking in entries. Chooses
the topic appropriate words is somewhat somewhat inappropriate words is inappropriate words irrelevant to x2
irrelevant to the topic somewhat irrelevant to the topic the topic
8
Statement of Nursing The statement includes rights in drug The statement includes rights in The statement includes rights in The statement includes rights
Responsibilities administration, three (3) checks, and drug administration, three (3) drug administration, three (3) in drug administration, three
nursing responsibilities. It also includes at checks, and nursing checks, and nursing (3) checks, and nursing
least three (3) health teachings specific to responsibilities. It also includes at responsibilities. It also includes at responsibilities. It did not include x2
the medication least two (2) health teachings least one (1) health teaching health teaching specific to the
specific to the medication specific to the medication medication 8

Grammar and Spelling and grammar are perfect, Spelling and grammar have few Spelling and grammar have Spelling and grammar have
Spelling consistent and appropriate mistakes, consistent and some mistakes, somehow many mistakes, not x1
appropriate consistent and appropriate consistent and inappropriate
10 Errors or more
0 Error 1-5 Errors 6-10 Errors 4

TOTAL
____/20
Promptness
On or before the deadline : 10%
Within 24 hours after the deadline: 5%
After 24 hours: 0%
RLE: ALL requirements must be completed on the last day of the rotation except for documentation and case study. Day
2-Day7: 50% transmuted grade
Day 8: 0%, requirements will not be accepted

Copyright © 2022 by NDTC Nursing Department | No part of this document may be reproduced, distributed, or transmitted in any form or by any means, including
photocopying, recording, or other electronic or mechanical methods, without the prior written permission from the owner.