University of the Philippines Manila

The Health Sciences Center

COLLEGE OF NURSING
Sotejo Hall, Pedro Gil St., Ermita, Manila

NURSING CARE PLAN

NAME OF STUDENT: INFANTE, Hene Shane L. DATE OF ASSIGNMENT: April 24, 2017
NAME OF PATIENT: ALPARO, Arnold CIVIL STATUS: Married
MEDICAL DIAGNOSIS: Obstructive jaundice secondary to mass (hepatic vs pancreatic vs biliary) AGE: 37 SEX: M

NURSING
NURSING BACKGROUND GOALS AND
CUES INTERVENTIONS AND EVALUATION
DIAGNOSIS KNOWLEDGE OBJECTIVES
RATIONALE
Subjective: Situational low Situational low self- Goal: The client will
The client reported that: self-esteem esteem is defined as a recognize and
- He frequently gets related to loss of development of a negative incorporate changes into
nervous. health status as perception of self-worth self-concept in accurate
- He manages his evidenced by in response to a current manner without negating
nervousness by negative feelings situation. (NANDA, self-esteem
relaxing himself about his body 2013)
through reflecting on
his past actions on
how he abused his
body and not take Objectives:
care of it. After the nursing
- He has ways on how interventions, the client
to relax himself like will:
taking walks around
the hospital and - Verbalize
reading newspapers. understanding of Actively listen and clarify Client verbalized own
- He stated that he often individual factors that clients perception of current perception of his current
feels depressed. precipitated current status. Rationale: Reflecting health status.
- He describes himself situation. clients statements and
as payatot, thoughts can provide a forum
problemado, at for understanding
pabaya sa sarili. perceptions in relation to
reality for planning care and
Objective: determining accuracy of
- Emotionally stressed interventions needed.
- Facial grimace
- Vital Signs taken as - Identify feelings and Active-listen to clients
follows: underlying dynamics concerns/negative Client verbalized
o BP: 100/70 for negative perception verbalizations without feelings and underlying
o RR: 20 of self. comment or judgment. dynamics for negative
o PR: 86 Rationale: Conveys a self-perception.
o TEMP: 36.2C message of acceptance and
- Admission confidence in clients ability
assessment of the to deal with whatever occurs.
client: Obstructive
jaundice secondary to Discuss the capabilities and
mass (hepatic vs - Express positive self- the positive aspects owned Client identified positive
pancreatic vs biliary) appraisal. by the client. Rationale: aspects about self.
- Patient previously Enables client to identify
complained of RUQ positive aspects about him,
pain promoting feelings of
- Patient is cachexic confidence in own ability.
and has generalized
jaundice Assist client to problem-
- Patient lost 7kg: from solve situation, developing Client demonstrated
50kg to 43kg - Demonstrate behaviors plan of action and setting behaviors that restore
to restore positive self- goals to achieve desired positive self-image.
image. outcome. Rationale:
Personal involvement
enhances commitment to
plan, optimizing outcomes

Encourage use of
visualization, guided
imagery, and relaxation.
Rationale: These strategies
promote a positive sense of
self and general well-being,
enhancing clients coping
ability.

Assist client to identify

 personally achievable goals.
Rationale: Increases Client verbalized
likelihood of clients success compliance of planned
- Participate in treatment and commitment to change. treatments or activities.
regimen/activities to
correct factors that Encourage client to look to
precipitated crisis the future and set long-range
goals for achieving necessary
lifestyle changes. Rationale:
Supports view that this is an
ongoing process, providing
client with hope for the
future.

Identify social supports

available to the client.
Rationale: Available support
systems, such as family and Client verbalized that he
friends, can provide client would seek help from
- Utilize the existing with ability to handle current others.
support system stressful events, and often
taking it out with an
empathetic listener will help
client move forward to
enhance coping skills.

Encourage client to receive

help from the identified
social supports. Rationale:
Enhances SOs
understanding of what client
wishes to accomplish,
increasing the morale of the
client.

References:
Doenges, M. (2013). Nurses pocket guide: Diagnoses, prioritized interventions, and rationales. 13th ed. Philadelphia: F.A. Davis Company.