PHINMA UNIVERSITY OF PANGASINAN
COLLEGE OF ALLIED HEALTH SCIENCES - DEPARTMENT OF NURSING
NURSING CARE PLAN
CASE SCENARIO:
At the hospital, Mrs. Javier, a 33-year-old woman who is working as a call center agent, was presented with a chief complaint of fatigue,
worry, and eye problem. The patient verbalized, "Sa sobrang pagod ko, hindi na ako makapag focus sa aking mga ginagawa". As a result, she is
having a panic attack—an indescribable feeling of worry. The nurse describes the patient's situation objectively as a lack of energy to focus on
daily living and shows an irritable and worried behavior rather than fear which indicates anxiety. According to the initial assessment, the
temperature is 38.5 degrees Celsius, the respiratory rate is at 11 breath, the pulse rate is 90, and the blood pressure is 80/65 millimeters of
mercury. The patient also mentioned that as a call center agent, she feels pain and discomfort when blinking her eyes. The nurse observes the
patient's eye redness, and stringy mucus near the eye.
ASSESSMENT DIAGNOSIS INFERENCE PLANNING INTERVENTION RATIONALE EVALUATION
Subjective: Risk for ocular Dry eye, a Short-Term Goal: Assess the client’s Assessing client’s Goal was met.
discomfort and
susceptible to After 3 hours of medication noting the medications
damage related
“Ang sakit ng to dryness of eye discomfort nursing use of certain drugs. known to The patients
eyes. showed less
mata ko, pag or damage to the intervention: decrease tear
pinipikit ko at cornea and Instruct high risk production. discomfort.
sobrang hapdi.” conjunctiva due The patients will client in self
show less management Prevent or limit The patient was
to reduced
discomfort. interventions. symptoms of dry able to verbalize the
quantity or
Objective: eye. increased of ability
quality of
Eye redness Long-Term Goal: Wear eyeglasses or to blink and was
tears to moisten
Stringy mucus near After 7 days the safety shield glasses. To protect eyes able to increased
the eye, which
the eye patient will and reduce tear production.
may
increased ability Teach the patient to effects.
compromise
to blink and take lubricating eye The patient
health.
increased tear drops or ointments as When the patient verbalized “My
production. prescribed. is unable to blink eyes are now
or otherwise feeling better.”
protect eyes
while in health
care facility.
ASSESSMENT DIAGNOSIS INFERENCE PLANNING INTERVENTION RATIONALE EVALUATION
Subjective: Anxiety related Anxiety is a Short-Term Monitor vital signs (e.g., To identify Goal was met.
to emotional vague uneasy Goal: rapid or irregular pulse, physical
“ilang araw na overactivity due feeling of In 5 hours of rapid responses The patient was
akong nag aalala to an overactive discomfort or nursing breathing/hyperventilatio associated with able to verbalize
nang hindi ko thyroid gland as dread intervention the n, changes in blood both medical and awareness of
alam ang evidenced by accompanied patient will pressure, diaphoresis, emotional feelings of
dahilan” as irritability and by an verbalize tremors, or restlessness) conditions. anxiety.
verbalized by the worries. autonomic awareness of
Assist the client in Becoming aware The patient was
patient. response (the feelings of
developing self-awareness helps client to able to identify
source is often anxiety.
Objective: of verbal and nonverbal control these healthy ways to
nonspecific or
V/S taken as Long-Term: behaviors. behaviors and deal with and
unknown to the
follows: In 10 days of begin to deal with express anxiety.
individual); a
nursing Provide comfort measures issues that are
feeling of
Temp: 37° apprehension interventions the (e.g., calm or quiet causing anxiety.
Celsius caused by patient will be environment, soft music,
RR: 16 bpm anticipation of able to identify warm bath, back rub, Aids in meeting
PR: 90 bpm danger. It is an healthy ways to Therapeutic Touch). basic human
BP: 120/80 alerting sign deal with and need, decreasing
that warns of express anxiety Be available to the client sense of isolation,
impending for listening and talking and assisting
danger and client to feel less
enables the anxious.
individual to
Establishes
take measures
rapport, promotes
to deal with
expression of
that threat.
feelings, and
helps
client/significant
other look at
realities of the
illness or
treatment without
confronting
issues they are
not ready to deal
with.
ASSESSMENT DIAGNOSIS INFERENCE PLANNING INTERVENTION RATIONALE EVALUATION
Subjective: Fatigue related to Fatigue is an Short term: Asses the vital To evaluate fluid Goal was met.
irritability of the overwhelming After 5 hours of signs status and
“Nahihirapan central nervous sustained sense of nursing cardiopulmonary The patient was
akong mag pokus system as exhaustion and intervention the Establish realistic response to able to verbalized
sa aking mga evidenced by decreased patient will be goals with the activity. understanding of
ginagawa” as impaired ability to capacity for able to verbalize client and factors
verbalized by the concentrate. physical and understanding of encourage forward This enhances the contributing to
patient. mental work at the factors movement. commitment in current situation.
usual level. contributing to promoting
Assess optimal The patient was
current situation.
Objective: psychological and outcomes. able to perform
Long Term: Personality Factors activities of daily
Lack of energy that may affect Client can living and
After 10 days of
Irritable reports of fatigue. potentially have participate in
nursing
Worried Behavior issues that affect desired activities
intervention the
patient will be Note desire and desire to be active at level of ability.
V/S taken as able to perform level of ability to (or work),
follows: activities of daily meet health resulting in over
living and maintenance needs, or under activity
Temp: 37° Celsius
participate in as well as self-care or concerns of
RR: 16 bpm
desired activities activities of daily secondary gain
PR: 90 bpm
at level of ability. living. from exaggerated
BP: 120/80
fatigue reports.
Care may begin
with helping
client make a
decision to
improve
situation, as well
as identifying
factors that are
currently
interfering with
meeting needs.