ST.

ANTHONY’S COLLEGE
Nursing Department

NURSING CARE PLAN

Name of patient: D.W. Attending Physician:

Age: 46y/o Ward/Bed #: Impression Diagnosis: Bulimia

Clustered Cues: Nursing Diagnosis Rationale Outcome Criteria Nursing Interventions Rationale Evaluation

SUBJECTIVE: Self care deficit Impaired ability to GENERAL: INDEPENDENT: INDEPENDENT: GOALS MET
“I drink alcohol and related to alteration in perform or complete At the end of 8hrs  Establish  Since we are GENRERAL:
smoke pot whenever cognitive functioning bathing, dressing, feeding, nursing intervention rapport to dealing patient After 8hrs
he can, but I don’t (erratic & threatening or toilet activities for self the patient will be able patient. with 'Mental assessment,
have the money behavior) as evidenced [on a temporary, to: Disorder', it is intervention and
available” as patient by disheveled permanent, or progressing  Client will important to health education the
verbalized. appearance with dirty basis]. independently establish patient:
stained clothing, address self therapeutic  Client will
OBJECTIVE: secondary to care needs and relationship to independentl
 Disheveled schizophrenia begin to patient because y address
hair & utilized this could also self-care
unwashed resources that establish as well needs and
appearance will address his 'Trust', that will begin to
 Presence of Doenges,M.E. housing needs able help the utilized
stains and dirt etal.(2016). patient feel free to resources that
in clothes Nurse'sPocket Guide: express his will address
 Beard has Diagnosis Prioritized emotions and his housing
presence of Interventions and feelings towards needs
dirt and Rationales. helping him in
scraggly Philadelphia. F.ADavis SPECIFIC: addressing his GOALS
 Not shaved for Company. At the end of 8 hrs. of problem PARTIALLY
months assessment, (Information also MET:
 Uncombed interventions, and could serve as
hair health education the baseline data for SPECIFIC:
 Loss of weight patient's condition will possible reference After 8hrs
(accdg. To be able to: of interventions) assessment,
clustering)  Client able to  Monitor Vital  Serve as a intervention and
verbalize and Signs baseline health education the
  Inadequate identify the Especially information that patient:
eating patterns ways and Blood Pressure will help the
techniques of and Document healthcare  Client able to
V/S: (Lower than taking care of Patient actual workers to give verbalize and
Normal accdg to self. weight. (NOTE appropriate identify the
simulation) Findings shows intervention ways and
BP= As evidenced by: that patient is techniques of
TEMP=  Appears to be malnourished). taking care of
RR well-groomed self.
PR= and clean  Assess Patient
SP02=  Execute General Status As evidenced by:
behavior that (NOTE for any  Appears to
promote good signs of  Observing patient be well-
hygiene and weakness, general status groomed and
grooming paleness and would serve as a clean
(Bathing, worsening of base line  Execute
shaving, etc.) unhygienic information behavior that
behavior). promote
good hygiene
 Offer positive and
commendations grooming
when Ronald (Bathing,
independently  positive shaving, etc.)
address his reinforcement
self-care needs. enhances self-
esteem and
encourages the
client to continue
to independently
 Offer nutritious address his self-
snacks and care needs
meals.
 Addressing the
client's nutritional
needs is an
important aspect
Dependent: of promoting self-
care
 Dependent:
 Carry out
physicians’
order and  To improve the
treatment plan. patient condition
and provide
immediate and
more effective
Collaborative: intervention

 Refer patient to Collaborative:

the
apsychiatrist/
psychologist.  For further
evaluation and to
provide an avenue
for patient to
express his false
beliefs
(hallucination and
delusion) in either
to give a
additional more
effective
interventions.