NURSING CARE PLAN

ASSESSMENT NURSING DIAGNOSIS BACKGROUND GOAL AND NURSING INTERVENTION AND EVALUATION
KNOWLEDGE OBJECTIVES RATIONALE
Subjective: Acute pain related to leg According to NANDA, NOC – Pain Control NIC- Pain Management
cramps as evidenced by acute pain is an unpleasant
The client verbalized that verbal report. sensory and emotional
she would often be awaken experience associated with Goal:
from her sleep due to pain actual or potential tissue -The client will be
damage, or described in able to report reduced
She rated her pain as 10 on terms of such damage level of pain and
a scale of 1-10, 1 as the (International Association demonstrate ways on
lowest and 10 as the for the Study of Pain); how to
highest when she sudden or slow onset of avoid/minimize leg
experiences leg cramps. any intensity from mild to cramps after 1-2
She added that “kaya 10 severe with an anticipated weeks of nursing
kasi may mga times na or predictable end, and interventions.
halos maiyak na ako sa with a duration of less than
sakit.” 6 months. Objectives: Objectives:
Short term: Short term:
Client reported pain in the After 2-3 hours of After 2-3 hours of
calf area whenever she nursing intervention, nursing intervention,
experiences leg cramps the client will: the client:
Identified possible
Objective Data: Know the possible The nurse will identify ways of relaxation skills to be
HEIGHT: 150 cm relaxation skills to minimizing/managing the pain. done to manage the
WEIGHT: 60 kgs manage the pain due pain.
BMI: 26.7(Overweight) to leg cramps. a. Stretch and massage
Stretching and massaging may help
alleviate the pain and decrease muscle
tension
b. Adjust sleeping position
Nighttime leg cramps may be
related to foot position. We often sleep
with our feet and toes extending away
from the rest of our bodies, a position
called plantar flexion. This shortens
the calf muscles, making them more
susceptible to cramping.
c. Apply hot or cold compress
Adding heat to your cramping muscles
with either a heating pad or a warm
bath can help relax and increase blood
flow to the cramping muscle(s). 
while cold compress can help ease the
pain of a leg cramp while you wait for
it to subside

d. Consider the use of

pharmacological interventions
if pain is no longer tolerable
for the client
Pharmacological interventions are the
cornerstone of pain management
(Acute Pain Management Guideline
Panel, 1992; McCaffery, Pasero,
1999), however, the client should seek
for medical attention first on what
medication to use.

The nurse will discuss ways in

avoiding/minimizing and managing leg
cramps:
Identify techniques to Enumerated at least 3
avoid/minimize and a. Advise client to elevate measures to
manage leg cramps. legs avoid/minimize and
Elevate leg above heart level to manage leg cramps
promotes circulation and relieves
pressure.
b. Instruct client to
avoid standing in
prolonged period
To reduce risk of leg cramps
c. Educate the client on the
foods that help aid in leg
cramps but taking into
consideration her health
condition
One way to stop cramps is to eat foods
that are rich in electrolytes such as
potassium, calcium, and magnesium
d. Educate the client on the
effect of being overweight
in relation to leg cramps
Obesity and overweight are factors of
leg cramps
e. Help the client develop
dietary and exercise plan
Leg cramps can be related to
overeating and lack of exercise.
Long term:
After 1-2 weeks of Provide a chart to keep track of the Long term:
nursing intervention, client’s progress After 1-2 weeks of
the client will: This will help evaluate if the goal was nursing intervention,
met. the client:

Report that pain is Verbalized minimal

relieved or controlled pain level compared
at a scale of 3 in a to the baseline.
rating of 1-10, 1 as the
lowest and 10 as the
highest. Encourage non-pharmacological pain
relief methods (relaxation exercises,
breathing exercises, music therapy).
Some medications are not of easy
Manage the pain access, non-pharmacological pain
through the use of relief methods are easily accessible Verbalized that she is
non-pharmacological and can be easily recalled. able to the handle the
pain relief methods pain and reported
improved wellbeing,
The nurse will provide ways on how to coping and sleep
avoid/minimize leg cramps at night:
a. Advise stretching before
going to bed
Report reduced May prevent leg cramps before Reported reduced
episodes of leg cramps going to bed experiences of leg
especially at night. b. Drinking plenty of water cramps especially at
Since muscle cramps are sometimes nighttime.
caused by dehydration, drinking plenty
of fluids may help to ward off cramps.
 c. Avoid heavy or tucked-in
bedding.

Heavy or tucked-in bedding could

push your feet downward while you
sleep. Choose loose, untucked sheets,
and a comforter that will allow you to
keep your feet and toes upright while
you sleep.

The nurse will encourage the t to go

for a check-up.
This will help the clientt experience
better comfort, gain deeper knowledge
about the problem and be aware for
The client will agree
any underlying illness that needs
to consult a doctor Scheduled a check up
medical attention.
regarding her leg on her most
cramps convenient time

NURSING CARE PLAN

ASSESSMENT NURSING DIAGNOSIS BACKGROUND GOALS AND NURSING INTERVENTIONS EVALUATION

KNOWLEDGE OBJECTIVES AND RATIONALE

Subjective: Ineffective health According to NANDA, NOC: Health-Promoting NIC: Health System Guide
maintenance related to Ineffective health Behavior
- The client admitted that engagement in risky maintenance is defined as
she still eats prohibited behavior that worsens the state of a person Goal: The client will be
foods even knowing the health as evidenced by wherein he or she is unable able to attain effective
effects of it and also verbal report of to identify, manage and ask health maintenance by
verbalized, “Yes, pag may consumption of prohibited help in maintaining his/her adjusting her lifestyle (i.e.
lechon, kapag may family foods. healthy well-being. to eliminate pre disposing
gatherings.” She added that factors that contribute to
she doesn’t mind the Health maintenance is a the development of
effects sometimes because very crucial process to a hyperacidity) in 14 days
according to her, “May person because he/she after teaching interventions
gamot naman.” needs to maintain a healthy by the nurse.
body with proper
functioning at all times. It Objectives:
is a crucial process because Short term:
Objective: it entails a lot of resources After 1-2 hours of nursing
- Client GA is taking up in maintaining one’s health. intervention, the client will Short term:
Omeprazole which was be able to: After 1-2 hours of
prescribed by her doctor. nursing
The drug is used for her intervention the
hyperacidity. Know about the client:
appropriate diet designated
Height- 4’11” for her condition. The nurse will discuss lifestyle Learned about the
Weight- 60 kgs modification: type of diet that is
BMI- 26.7(overweight) a. Nutritional counseling appropriate for her
b. Limit intake of fatty, oily , condition.
high in sodium, and spicy
food
The information allows the nurse to
focus on resolving the specific
cause of the non-compliant
Learn that being behavior. 
overweight is one of the
factors that aggravate Was educated that
hyperacidity. The nurse will educate the client being overweight
 that weight is one of the factors that is one of the
aggravate hyperacidity. factors that trigger
Studies have shown that overweight hyperacidity.
or obese individuals are more
prone to suffer from acidity than
people in the normal weight range.
Develop an exercise plan to
help lessen her weight to Was able to
achieve a normal body The nurse will help the client create develop an
mass index. a daily weight chart and a food and exercise plan for
fluid chart. weight loss.
To keep a record and for easy
monitoring of the client’s
improvement as she goes with the
Long Term: care plan
After 14 days of nursing Long Term:
interventions, the client: After 14 days of
nursing
interventions the
client:
Will apply her learning in
developing a dietary plan. Developed a
The nurse will assist the client in dietary plan using
creating a dietary and exercise plan her learning.
in accordance to her convenience.
Since the client needs to restrict
herself from consuming prohibited
foods and do regular exercises to
Will completely avoid promote weight loss.
eating foods that may Completely
trigger her hyperacidity. The nurse will educate the client avoided eating
about the foods that trigger foods that is
 hyperacidity such as: known to trigger
 High-fat foods such as her hyperacidity.
french fries, onion rings,
full-fat dairy products fatty
or fried cuts of beef, pork,
or lamb, oily and greasy
foods.
 Tomatoes and citrus fruits
such as oranges, grapefruit,
lemons, limes, and
pineapple.
 Spicy and tangy foods, such
as onions and garlic.
These types of foods put the client
at a greater risk for hyperacidity.

Will follow her exercise

plan as scheduled. The nurse will assist the client in Was able to follow
creating an exercise plan applicable her exercise plan
to the client’s age. as scheduled.
Designing an appropriate exercise
plan can help reduce injury and
customize the plan in accordance to
the client’s needs, especially if they
are new to exercise or haven’t done
any physical activity for a while.

NURSING CARE PLAN

 ASSESSMENT NURSING DIAGNOSIS BACKGROUND GOAL AND NURSING INTERVENTION AND EVALUATION
KNOWLEDGE OBJECTIVES RATIONALE
Subjective: Risk for bleeding related to Hyperacidity is a medical NOC: Risk Control NIC: Risk Identification
excessive acid in the condition in which the
stomach secondary to stomach secretes a lot of Goal: The client will be
The client mentioned hyperacidity acids. Excessive acids in able to lessen the risk for
that it occurs whenever the stomach could lead to bleeding through self-
she eats oily and sour serious complications control especially when it
foods and whenever especially bleeding. comes to foods that are
she is stressed. Bleeding in the digestive extremely prohibited after
tract is a symptom of a 14 days of nursing
The client verbalized, disease rather than a intervention.
“sumasakit ang disease itself. Bleeding
sikmura ko at can occur as the result of Objectives:
dumidighay ako.” a number of different Short Term:
conditions, some of After 2-3 hours of Short Term:
which are life nursing intervention, the After 2-3 hours of
Pain level of 8 on a threatening. client: nursing
scale of 1-10 intervention, the
client:
Client mentioned that Will know that eating
she still eats the hastily may lead trigger Instruct the client to eat slowly and Discussed the
prohibited foods and hyperacidity. masticate foods well and avoid risks of eating
when asked when, she consuming large meals and eat on hastily.
verbalized, “Yes, pag smaller plates to help control food
may lechon, kapag portions.
may family Helps prevent hyperacidity.
gatherings.”
Will be informed of the
She added that she advantages of adding Encourage the client to eat more fruits Included fruits and
does not mind the fruits and vegetables to and vegetables but avoid lemons, vegetables in her
aftermath of her her daily food intake. tangerines and grapefruit because they daily meals.
actions because are might trigger hyperacidity.
according to her, “may Increasing intake of veggies and fruit
gamot naman.” reduce the acid load of your diet.

The client mentioned

going for a checkup Encourage the client to follow
three months ago for Will be informed of the appropriate meal times and meal
her hyperacidity due to disadvantages of skipping portions. Cited three
stress and verbalized meals as well as too To ensure that the client does not eat a disadvantages of
“dahil sa pagwoworry much or too little food huge meal, or that she does not eat skipping meals
ko sa mga apo at anak intake. late at night/before bedtime as both of and too much or
ko lalo na yung mga these contribute to hyperacidity. too little food
malayo sa akin at intake.
pagod din sa gawaing Long term:
bahay minsan.” After 7-14 days of Long term:
nursing intervention, the After 7-14 days of
Objective: client: nursing
∅ Educate the client about stress intervention, the
management and provide four simple client:
Will remember to use the ways of managing stress.
four simple ways taught Identified four
by the nurse to manage a. Listen to music. simple ways to
stress. Playing calm music has a positive manage her stress
effect on the brain and body, can and was able to
lower blood pressure, and reduce use it whenever
cortisol, a hormone linked to stress. she gets stressed.

b. Talk it out with a friend.

Good relationships with friends and
loved ones are important to any
healthy lifestyle. A reassuring voice,
 even for a minute, can put everything
in perspective.

c. Talk yourself through it. Sometimes

calling a friend is not an option. If this
is the case, talking calmly to yourself
can be the next best thing.

d. Breathe easy.
The advice “take a deep breath” may
seem like a cliché, but it holds true
when it comes to stress. For centuries,
Buddhist monks have been conscious
of deliberate breathing during
meditation. While shallow breathing
causes stress, deep breathing
oxygenates your blood, helps center
your body, and clears your mind.

Assist the client in developing a

dietary plan.
A healthy eating plan gives the body
the nutrients it needs everyday while
Will utilize her learning staying within a daily goal for Followed her
to develop an appropriate nutrition. dietary plan even
dietary meal plan. after the nursing
Reiterate the risks and fall backs of intervention.
having an excessive acid in the
stomach and implement strict
Will limit herself from avoidance of foods that may trigger
eating foods that may hyperacidity. Developed a
trigger her hyperacidity. For the client to be knowledgeable dietary plan
Moreover, the client will enough of what she has to avoid in without any of the
also keep in mind that order to not worsen her condition.  foods that are
excessive acid in the prohibited due to
stomach may pose an her condition.
imminent danger to her
health.
Encourage the client to always follow
the prescribed medication
Will take her medications (Omeprazole) and educate the client
whenever her about the importance of the prescribed
hyperacidity occurs. medication to her condition. Was able to take
Omeprazole reduces the amount of her medication
acid your stomach makes. It's a widely whenever her
used treatment for indigestion and hyperacidity
heartburn and hyperacidity. occurs and was
also able to state at
Initiate the client’s self-reliance in least two
taking her medicines and by preparing importance of
her balanced meal. taking her
Will practice self-reliance Being self-reliant will enable the client maintenance
to ensure that she can still to ensure that she can still manage her medications.
manage her health health condition even when she’s
condition even when alone Showed self-
she’s alone. reliance in taking
her medication
whenever her
hyperacidity
occurs and
preparing her daily
meals.
 FAMILY NURSING CARE PLAN

Problem # 1: Broken Stairs

1st Level Assessment: Presence of Health Threat
2nd Level Assessment: Inability to provide a home environment conducive to health maintenance and personal development due to lack of skill carrying out measures to improve home
environment.
Cues Analysis of the Objectives Nursing Interventions Rationale Method of Resources Expected
Problem Family Required Outcomes
Contact
Subjective The family is Short Term:  Establish rapport  To acquire the Home visit Time, patience Short Term:
- “yung hagdan unable to provide a After two hours of with the family trust of the and effort of After two hours of
naming sira, yung home environment health teaching, the and maintain family members Health student nurse health teaching, the
apo kong isa, ilang conducive to health family will be able therapeutic and to have Education family was able to
beses ng maintenance and to know the risks of communication close and Proper use of know the risks of
naaksidente diyan.” personal having faulty stairs, harmonious Interview verbal and non- having faulty stairs,
- “Pati pala yung development due to apply temporary relationship verbal apply temporary
isang apo ko, lack of skill measures to especially to the Observation communication measures to
muntik din carrying out manage if not solve involved client. manage if not solve
mahulog dyan.” measures to the problem and In-depth the problem and
- “Hindi naman improve home will feel motivated  For the family knowledge of motivated on taking
mapagawa kasi environment. in taking the  State the purpose to be aware on student nurse action for the
wala pang appropriate action of action. what to do problem.
pumupunta dito sa for the problem. Cooperation of
bahay at walang  Help the family  Immediate the family
may kaya saamin Long Term: to formulate an planning is members
mag-ayos.” After five days of appropriate plan necessary for Long Term:
- “natatanggal yung home visit, the for the problem. this kind of Willingness of After five days of
hawakan kasi family will be able hazard because family home visit, the
neng.” to devise a plan to it can cause members to family was able to
permanently solve danger and formulate a devise a plan to
Objective: and manage the injury. plan for action. permanently solve
problem. and manage the
 Motivate the  For the family PHN Bag problem.
family in taking to be able to
 the appropriate solve the Financial Effort
action: hiring a problem
skilled carpenter. permanently. Cooperation of
the barangay in
aiding help
 Encourage the
family to  The barangay
collaborate with can provide aid
their barangay. in fixing the
broken stairs.

 Encourage the  To make the

family to put a stairs safer and
non-slip carpet to avoid any
on the stairs so incidents of
that it can slipping and
be safer falling.
especially for
older adults and
children.

 Discuss about  To prevent any

supervision accidents from
especially for the happening.
children at home.

 Educate the
family about the  To provide
possible risks of awareness about
having a faulty or the risks of such
broken stair such hazard or
as falls that can problem.
result
in broken bones,
spinal cord
 injury,
lacerations, soft
tissue damage,
traumatic brain
injury, and other
serious types of
harm—not to
mention the
mental trauma
from such an
event.

 Provide
knowledge on  To avoid and
safety prevent any
precautions and potential
injury accident from
prevention. happening.

 Encourage the
family to voice  To identify
out any concerns. other problems
that need to be
addressed.
 FAMILY NURSING CARE PLAN

Problem # 2: Presence of breeding sites of vectors of diseases and foul order due to open drainage
1st Level Assessment: Presence of Health Threat
2nd Level Assessment: Failure to utilize community resources for health care due to: unavailability of required care/services
Cues Analysis of the Objectives Nursing Interventions Rationale Method of Resources Expected
Problem Family Required Outcomes
Contact
Subjective: The family is Short Term:  Establish rapport  To acquire the Home Visit Time, patience Short Term:
- the client unable to utilize the After two hours of with the family trust of the and effort of After two hours of
verbalized, “yung community health teaching, the and maintain family members Health student nurse health teaching, the
mga apo ko resources for health family will be more therapeutic and to have Education family was able to
nagkadengue na care due to knowledgeable of communication close and Proper use of be more
nga dahil diyan, unavailability of the situation and its harmonious Interview verbal and non- knowledgeable of
nireport naman na required risks, and will be relationship verbal the situation and its
rin namin yan pero care/services. able to provide especially to the Observation communication risks, and was able
di pa rin naayos.” ways in managing involved client to provide ways in
their environment In-depth managing their
and health  For the family knowledge of environment and
Objective:  State the purpose to be aware on student nurse health
-presence of Long Term: of action. what to do
breeding sites of After seven days of Cooperation of Long Term:
mosquitoes and home visits, the the family After seven days,
flies due to the family will be able  Educate the  Being aware of members the family was able
open drainage to report the family about how such to report the
-foul smell drainage system to drainage systems information PHN Bag drainage system to
the authority and and its gives them the the authority and
ask for an maintenance, if right to report was able to ask for
immediate action neglected, could the problem to an immediate
for the problem. pose a threat in the authority action for the
both community and ask for an problem.
and healthcare immediate
causing action.
infections as well
as emergence of
multi-resistant
 bacteria that
could cause
unpredictable
clinical
manifestations.

 Educate the
family about the
diseases  To help the
that flies can family be aware
transmit include of the diseases
enteric infections that can be
such as transmitted by
dysentery, flies.
diarrhea, typhoid,
cholera and
certain helminth
infections.

 Encourage the
family to report  To let the family
the problem know that one
again to the of the duties of
barangay barangay
officials. officials is to
ensure pollution
control and
protection of
the environment
.

 To protect the
 Encourage the family against
family to wear mosquitoes and
long sleeved reduce the risk
shirts and long of diseases they
 pants when transmit.
outside the
house, apply
mosquito
repellent to
exposed skin and
take special care
during peak
mosquito biting
hours, especially
around dawn and
dusk and remove
potential
mosquito
breeding site
such as
containers where
there is stagnant
water around the
area.

 Encourage the
family to join the  To be able to
clean and green emphasize to
programs in the the family that
community if a clean
there are any. environment is
essential for
healthy living:
the more they
do not care
about
our environment
, the more it will
 become polluted
with
contaminants
and toxins
that have a
harmful impact
 Assess the on their health.
family’s learning
about the Health  To make sure
Education that the family
conducted learned what
through a have been
question and taught.
answer portion.

FAMILY NURSING CARE PLAN

Problem # 3: Hypertension
1st Level Assessment: Presence of Health Deficit due to Hypertension
2nd Level Assessment: Inability to make decisions with respect to taking appropriate health action due to failure to comprehend magnitude of the condition.
Cues Analysis of the Objectives Nursing Interventions Rationale Method of Resources Expected
Problem Family Required Outcomes
Contact
Subjective: The family is Short Term:  Establish rapport  To acquire the Home visits Adequacy and Short Term:
- “Sa akin, wala. unable to make After 2 hours of with the family. trust of the accuracy of After 2 hours of
Iyong mga decisions with nursing family members Observation knowledge nursing
anak ko, nasa respect to taking interventions, and to have regarding the interventions,
lahi na nila.” appropriate health the family will be close and Health problem the the family was able
- Nanay GA, her action due to able to verbalize harmonious Teachings nurse has to verbalize their
mother failure to their understanding relationship understanding of
verbalized that comprehend of hypertension, the especially to the Interview Time, effort hypertension, the
GJ drinks beer magnitude of the risk factors that involved client. student nurse risk factors that
twice a week condition. contribute to it and contribute to it and
 and enjoys enumerate at least 3 Willingness of enumerate at least 3
eating meat, measures to the family to measures to
fried foods and manage/prevent the participate and manage/prevent the
unhealthy disease.  For the family cooperate with disease.
snacks to be aware on the student
what to do nurse
Objective: Long Term:  State the purpose Long Term:
-BP ranges from After 1 month of of action.  To know if the Use of visual After 1 month of
130/110 to 110/90 home visits, the family perceives aids to impart home visits, the
-Diagnosed with family will develop  Assess the the magnitude information to family was able to
hypertension last necessary measure willingness of the of the problem. the family develop necessary
2018 to manage and family in solving (Pamphlet) measure to manage
prevent the disease the problem.  To have a and prevent the
such as maintaining baseline data. PHN Bag disease such as
proper nutrition as ssess maintaining proper
evidenced by client’s general nutrition as
BP Apparatus
avoidance of health status and evidenced by
alcoholic health history avoidance of
beverages, fatty  Assess the alcoholic
and salty foods. client’s general  To make sure beverages, fatty
health status and that the family and salty foods
health history. is ready to
receive
information and
 Assess the level to have a
of family’s baseline data.
understanding
and knowledge
about  To provide
hypertension. awareness in the
family

 Discuss
hypertension, its
nature, risk  This can aid the
 factors and signs client in
and symptoms. reconsidering
her choices on
 Explain the foods and
effects of alcohol
unhealthy eating consumption.
and drinking for
her health
condition.
 This will
provide the
client a guide
 Help the client in and basis for
developing daily
dietary plan consumption.

 High sodium
and fatty foods
worsen and
 Educate the client increase blood
in modifying the pressure
risk of
hypertension
through low
sodium, low fat
diet

 Alcohol does
contribute to
 Counsel the high blood
client to pressure
gradually lessen
her alcohol intake
until such time
 she can avoid it.
 For the client to
 Educate the client be prepared and
on what to do knowledgeable
incase and for the
hypertension family to be
occurs and how able to help in
the family can managing the
aid. situation
effectively.

 Monitoring BP
at home
 Demonstrate promotes early
proper techniques detection
in taking blood
pressure.
 Failure to
comply will just
 Specify the make the
importance of situation worst.
treatment plan This will
and having prevent further
regular check ups complication
and worsening
of the situation.

 This will aid the

family to be
more familiar
 Let the family with the disease.
have pamphlets
or written
 materials that
contain details
about
hypertension and
its management.

 To address any
 Assess the clarifications
family’s and
understanding misconceptions.
after conducting
health education
through question-
and-answer
portion