Student Staff Nurse: Khlerdenz D.

Villezon
Student Head Nurse: Karyll Dianne Amamangpang

Nursing Care Plan

CUES NURSING PLANNING NURSING INTERVENTIONS RATIONALE EVALUATION
DIAGNOSIS

Subjective: Risk for Impaired Within 4 hours of 1. Assess patient’s feeling of dizziness 1. To check signs and symptoms of high Within 4 hours of nursing
“Wala man nuan ko Tissue Perfusion nursing interventions, 2. Take the vital signs particularly the blood pressure interventions, the patient
naglipong” as related to the patient will be able pulse and blood pressure in one full 2. To obtain more accurate values of VS was able to maintain
verbalized by the increased blood to maintain adequate minute 3. The positioning of the head of the bed adequate tissue perfusion
patient. pressure tissue perfusion as 3. Elevate head of the bed for about 35- might be one of the causes of increased as evidenced by stable
evidenced by stable 45 degrees angle BP vital signs particularly
Objective: vital signs particularly 4. Position the patient comfortably in 4. To have a proper positioning and make the blood pressure of normal
• Lying on bed blood pressure of accordance to the elevation of the patient comfortable range of 120/80 mmHg.
with slight normal range head of the bed
low head of 5. Administer antihypertensive 5. To lower the blood pressure and prevent
the bed medications as prescribed by the further complications GOAL MET.
position healthcare provider.
6. Educate the patient about the purpose, 6. To provide knowledge to the patient about
• Vital Signs: dosage, and potential side effects of the medication and treatment regimen
T- 35.5 C prescribed medications.
P- 60 bpm 7. Encourage the patient to reduce 7. Foods containing sodium increases blood
(fluctuating sodium intake, increase consumption pressure
from 45-60 of fruits and vegetables
in one full 8. Monitor for medication side effects 8. To evaluate if medication is not suitable
minute) and adverse reactions, such as for the patient to continue taking
R- 20 cpm hypotension or electrolyte
BP – 170/100 imbalances. 9. To check the efficacy of the
O2 sat- 97% 9. Monitor the patient's blood pressure antihypertensive drug
regularly and document findings.
10. Refer to nurse on duty if there are 10. To inform the physician and make orders
abnormalities in the vital signs after for modification of treatment
medication administration.
 Student Staff Nurse: Khlerdenz D. Villezon
Student Head Nurse: Karyll Dianne Amamangpang

Nursing Care Plan

CUES NURSING PLANNING NURSING INTERVENTIONS RATIONALE EVALUATION
DIAGNOSIS

Subjective: Acute Confusion Within 4 hours of 1. Assess the patient's hydration status 1. To check if the patient is dehydrated Within 4 hours of nursing
“Wala na daw kaon- related to nursing interventions, regularly, including skin turgor, 2. Replenishing fluids helps restore interventions, the patient
kaon ug inom ug dehydration the patient will be able mucous membranes, and urine output. electrolyte balance and improves mental was able to maintain
tubig ni sya,”as to maintain cognitive 2. Encourage the patient to drink fluids clarity. cognitive function and
verbalized by the function and orally, offering water, oral rehydration orientation, and
watcher. orientation, and solutions, or other clear fluids. 3. To allow the patient to be oriented restore fluid balance to
Objective: restore fluid balance 3. Orient the patient to time, place, and alleviate confusion as
• Lying on bed to alleviate confusion. person frequently, using cues such as evidenced by
with in clocks, calendars, and familiar objects. responsiveness.
supine 4. Ensure adequate lighting and remove 4. A calm and supportive environment
position obstacles or hazards that may reduces sensory overload and promotes
• confused contribute to confusion or falls. cognitive function.
• Dry lips 5. Monitor the patient's mental status 5. To evaluate if the patient is still confused GOAL MET.
• Unresponsive regularly, including level of and modify interventions needed
• Vital Signs: consciousness, orientation, and
T- 36.0 behavior. 6. Vital signs play a big role for baseline
P- 78 6. Assess vital signs frequently, paying data and helps in identifying health
R- 28 attention to changes in blood pressure, problems
BP- 120/80 heart rate, and temperature. 7. To have a good positioning and comfort
O2- 94 7. Elevate the head of the bed for about
35-45 degrees angle 8. To ensure that the patient has adequate
8. Provide assistance with feeding if food and fluid intake
necessary, ensuring the patient's 9. To allow the patient to rest and
nutritional needs are met. regenerate cells and provide comfort
9. Provide adequate rest for the patient
10. Refer to nurse on duty about the 10. To inform the healthcare provider about
abnormalities present. the patient’s condition