Student: Genamarie F.

Melgar Course/section:BSN 4A
Area of Exposure:Emergency Room Shift: 7AM-3PM
Date Cue Nee Nursing Objectives of Planning Nursing Rationale Evaluation
and s d Diagnosis Care Interventio
Time ns
Subjective: Activity Within 7 hrs of Severity of 1.Establish *fosters open March 18, 2024
7:00 AM As A intolerance nursing care, the Activity rapport to communication
– 3:00 verbalized C related to patient will be Intolerance: Set patient between the @ 3 PM
PM shift by the T generalized able to: realistic goals nurse and
patient: I based on the patient. “GOAL
weakness
March “Wala V a.Have the patient's current
I as limitations. For
18, 2024 naman sakit ability to safely 2.Collaborate *When patients
MET”
ng tiyan ko T evidenced someone with
participate in with the patient actively
@ 7:40 pero medyo Y by verbal mild intolerance, At the end of
self-care
the objective to identify the participate in
AM mahilo lang reports of the 7 hours of
A
activities,
might be most important setting goals for
ako ” dizziness, care, the
N reducing the tolerating care tasks they their care, they
and patient
D risk of falls or dressing for 10 need to perform feel a sense of
Objective: achieved the
decreased
injuries. minutes, while for independently ownership and
1.Skin color: goals set as
E
muscle
someone more ex: brushing control over their
Pallor evidenced by:
X strength limited, it could hair, dressing, health.
and motility eating. a.​ Patient
2.Decreased E b.Increase the be tolerating
muscle R upon putting on a shirt was able
patient's ability 3.Assist the *This reduces to
strength and C assessment for 5 minutes.
endurance- I to tolerate short patient in strain on independ
.
periods of assuming muscles and ently eat
difficulty S activity required Specific Care positions that joints, allowing meal
sitting E for essential Tasks: Identify conserve the patient to served .
upright, weak care tasks (e.g., the most energy during conserve their
and slow
P challenging care care tasks. energy for the b.​ Patient is
bathing,
movements A tasks and actual activity at able to
dressing, groom
T prioritize hand.
VS: T toileting) without improving independ
E needing tolerance for ently
4.Ensure the *To prevent
except
●​ BP: R excessive rest those activities.
environment is unnecessary with
120/8 N breaks. clutter-free and stumbling or
dressing
0 Patient's Goals: reaching
well-lit upper
mmHg c.Improve Involve the
●​ PR: patient in setting garment
independence *To perform care
98 objectives to 5.Educate the
bpm in performing ensure they are patient on activities safely c.​ Patient
and efficiently
●​ RR: self task, aligned with their energy able to
21 minimizing the desired level conservation walk to
cpm amount of technique and bathroom
●​ T: proper body slowly
assistance
36.1 mechanics with
required for minimal
caregivers. assistanc
e