1. FAR EASTERN UNIVERSITY
INSTITUTE OF NURSING
Requirement on Nursing Elective-Geriatrics
NURSING CARE PROCESS
SUBMITTED BY: RONDA, JENNAN A.
SUBMITTED TO: PROF. PADILLA, RN, MAN

2. TABLE OF CONTENTS
I. CLINICAL SUMMARY
a. Biographic data
b. History of present illness
c. Past medical history
d. Familial history
e. Physical assessment
f. Patterns of functioning
g. Daily activity patterns
II. Nursing care plan
a. Problem identification
b. Problem prioritization
c. Nursing care plan
d. Discharge planning

3. I. CLINICAL SUMMARY
a. Biographic data
Name: A.M.R.
Address: 1015 Bangon-Sarimanok st., Marawai City, Lanao Del Norte
Age: 65 years old
Gender: Male
Religious: Muslim
Occupation: Businessman, Ministry Employee
Marital Status: Married
Chief Complaint: Difficulty of Breathing
b. History of present illness
Patient A.M.R. experiences generalized body weakness and severe dizziness.He was asked
about his daily activities and said that he mostly works at the office for the whole day. He
just finishes some paper works, have meetings and at times goes on a Business trips. And
he drives his car to work. Moreover, the patient added, “Hind naman ako palainom ng tubig
kadalasan tea ang iniinom ko” The patient also stated that, “Nagpipigil din akong ihi minsan
dahil kadalasan nasa meeting ako.” The patient likeseating grilled food especially grilled
chicken. But he still makes sure he eats a lot of vegetables and fruits as well.
c. Past medical history
As the patient stated, he never had any kind of childhood diseases except chicken pox and
measles. The patient has never been immunized because his family could not afford it.The
patient has no known allergy and has neither accidents nor injuries. The patient had recent

4. travel last January 2013 in Malaysia for his business trip. The patient has no any other vices
and never drinks alcoholic beverages. He tried smoking when he was younger but now
claims that he has stopped.
d. Familial history
Based on the interview, the mother of the patient had Hypertension and his father as well.
But both parents died during the war.He has 10 siblings but one of them died at a young
age and another died at old age, so only 9 of themare in the family. And he said that 6 of
them have hypertension.
e. Physical assessment
Review of System:
General: (-) weight loss; (-) fatigue; (-) loss of appetite; (+) dizziness.
Interpretation:
The patient is conscious, coherent, oriented to time, place and person. Well groomed, looks
his age, with the ff VS: BP120/80 mmHg, CR 80 bpm, RR – 20 cpm
Analysis:
Relaxed, erect posture; coordinated movement, increased blood pressure due to fluid
overload and production of vasoactive hormones
Skin: (-) Itchiness; (+) dryness; (-) sweaty; (-) paleness; (-) hair color
Interpretation:

5. The patient has a light brown complexion; skin has a normal degree of elasticity, mobility
and thickness. With no superficial blood vessels, no lesions, hair are thin in distribution and
gray in color. Nails are smooth, pink and have normal folds.
Analysis:
Presence of dehydration.
Heent: (-) headache; (-) vertigo; (+) vision blur; (-) double vision; (-) deafness; (-) tinnitus;
(-) ear discharge; (-)smell change; (-) nose bleed; (-) nasal obstruction; (-) pain around the
nose; (-) toothache; (-) sore throat; (-) difficulty of swallowing; (+) use of glasses
Interpretation:
no tumor and patients hair is black. Asymmetrical face, with abnormal facie deviation to
the right, no involuntary facial movement.
Eyes: eyebrows are symmetrical, colorblack, the eyelashes grows outwards and upwards.
Eyelids, no tremors and no edema with lagging of the eyelids. Sclera is white, , iris is black,
pink conjunctiva.
Ears: Auricles are symmetrical, Ear canal is patent, no discharge, mucosal wall is pink, no
exudates.
Nose: nasal vestibule are patent, no discharge and no edema. Nasal septum in the midline, ,
no perforation and mucosal wall is pink, no discharge.
Mouth: lips are asymmetrical, moist, pink, no lesions, the soft and hard palate are pink in
color and no lesions noted.
Neck: (-) pain; (+) limitation of movement; (-) mass; neck vein engorgement.
Interpretation:

6. Neck: the neck is supple, symmetrical, no mass and no lesion. The trachea is in the midline
and not deviated. Lymphnodes are not enlarged, thyroid glands is not enlarged. There is no
neck vein engorgement.
Analysis:
The normal limitation to movement at each joint helps decrease the likely hood and
potential of inadvertently damaging a joint even further or surrounding tissues, and this
increases the safety of the massage for the client.
Respiratory: (+) dyspnea; (-) chest pain; (-) cough; (-) sputum; (-) hemoptysis; (+) crackles;
(+) wheezes.
Analysis:
Nose straight, without flaring or discharge; nares patent, mucosa pink and moist; septum
midline, without masses or perforation.Crackles on the lower left lung field; wheezing
sound over the trachea.
Reference: Medical-Surgcal Nursing, Clinical Management for Positive Outcomes, 8th
Edition, Volume 2, page 1531
Gastrointestinal: (-) abdominal pain; (-) nausea; (-) vomiting; (-) dysphagia; (-) diarrhea; (-)
constipation; (-) hematemesis; (-) melena; (-) hematochezia’ (-) regurgitation; (N) bowel
movement
Interpretation:

7. Abdomen: soft, globular, non-tender, no palpable masses, no costovertebral angle
tenderness, normoactive bowel sounds.
Analysis:
Bowel sound present in all four quadrants. Liver and spleen palpable. Abdomen soft,
nontender, no massesor rebound tenderness; muscle tone firm, relaxed.
Reference: Medical-Surgcal Nursing, Clinical Management for Positive Outcomes, 8th
Edition, Volume 1, page568
Gastrourinary: (+) dysuria; (N) frequency of urine; (-) urgency; (-) hesitance; (-) polyuria; (-
) hematuria; (-) incontinence; (-) genital pruritus; (-) urethral discharge
Interpretation:
Difficulty voiding, changes in urine flow.
Extremities: (+) edema; (-) swelling of joints; (-) stiffness and numbness
Interpretation:
Adjust fluid intake to avoid volume overload and dehydration.
f. Patterns of Functioning
A. PSYCHOLOGICAL HEALTH
1. COPING PATTERNS
When he and his family encounters problem, he easily handles them since they
effectively express their emotions through communication with each other. He doesn’t

8. dwell with the problems if ever it arises. He is very tranquil and composed in handling
things but sometimes, there are times that he gets angry easily and lose control of his
temper. But then apologizes for hos irrational behavior because he knows getting angry
scares his family.
INTERPRETATION:
The client has effective coping skills since he was able to solve problems with his
family through the help of communication. He knew how to properly address and manage
and handle the problems although there are some instances that when he is out of control.
ANALYSIS:
Coping strategies vary among individuals and are often related to the individual’s
perception of the stressful event. (Fundamentals of Nursing, Kozier, 7th edition pg. 1020)
A coping strategy is a natural or learned way of responding to a changing
environment or specific problem or situation. (Fundamentals of Nursing, Kozier, 8th edition
pg. 1068)
2. INTERACTION PATTERNS
He has good relationship with his family, friends and neighbors. He spends time with them
and talks to them when his free. He is well-rounded and well-loved by his loved ones.
Through interaction, he can easily express himself and can easily adjust with different
situations. Upon our interview, he is very expressive, honest and very detailed in
answering the questions being asked to him. He explains things very clearly, maintains an
eye contact while speaking as well as very sincere in giving out details about his life. His
facial expression, body language is congruent with his words, feelings and to the situations.

9. He shares some of the significant accounts of his life without hesitation and distrust
instead; he shares them with full honesty and openness. In like manner, he can easily gain
the trust of the people since he trusts them back with full sincerity. During the interview,
we observed that the client is very honest and genuine in sharing some details of his life. He
shares his life stories like he was just narrating it to someone whom he is close with and
whom he trusts very well.
INTERPRETATION:
The client has good interaction skills to the people around her. He can easily relate
with them since he is very open, honest and sincere with his words and actions as
evidenced by his being expressive in any possible ways or instances. He can easily trust
other people and vice versa.
ANALYSIS:
Language and communication assessment tests the ability to express and
comprehend one’s environment. (Medical –Surgical Nursing, 8th edition, Volume 2, page
1776)
Communication is an essential part of establishing a relationship with the client and
her family. It is also an important for developing effective working relationships with
health care colleagues. (Kozier and Erb’s Fundamentals of Nursing, Vol.1 page 321)
Communication can be a transmission of feelings or a more personal and social
interaction between people. It is basic component of human relationships. (Kozier and
Erb’s Fundamentals of Nursing, 8th Edition, Vol.1 page 460)
Communication between two participants involves all of the verbal and non-verbal
behaviour that they perceive in each other. Non-verbal communication includes tone and

10. volume of voice, eye contact, facial expression, body posture and other body language. We
expect to find congruence between the words and non-verbal cues; the words match the
feeling and tone of the body. (Medical –Surgical Nursing, 8th edition, Volume 1, page 423)
3. COGNITIVE PATTERNS
The client relates to reality and is conscious of what is happening to his environment
and to the people around him. His thoughts, ideas and perceptions in life are in congruent
with the situations being related to him. During the interview, the client is conscious,
coherent and oriented to time, place, person, event or situation. When asked about various
questions, he was able to recall significant information about his life and was able to
express them properly and appropriately.
INTERPRETATION:
The client is well-oriented to her environment and the people. She has good cognition
of things and her ideas, thoughts and perceptions relate to the right situations. She has
good memory since she was able to recall and relay some of the significant experiences in
her life.
ANALYSIS:
The mental status examination includes assessment of level of consciousness,
orientation, memory, mood and affect, intellectual performance, judgment and insight, and
language and communication. (Medical –Surgical Nursing, 8th edition, Volume 2, page
1775)
4. SELF-CONCEPT PATTERNS

11. The client views himself as a disciplined, hardworking, persistent and positive
thinker. He believes and trusts his capabilities and potentialities and has self-
determination. When he has things to accomplish in life, he is determined and strong-
minded that he can achieves them as long as he believes in himself. He also believes that if
you think that these things will happen, it will happen. On the other hand, he is satisfied
about himself and has uncertainties in life.
INTERPRETATION:
The client is satisfied with what God has given him and with who and what he is right
now as a person. He strongly believes in the power of his own capabilities and
potentialities and what it can do once used and strengthened. He believes that it depends
upon the person how he/she will strive to achieve their goals in life. Furthermore, what
makes him happy is his family.
ANALYSIS:
Self-concept is one’s mental image of oneself. A positive self-concept is essential to a
person’s mental and physical health. Individuals with a positive self-concept are better able
to develop and maintain interpersonal relationships and resist psychological and physical
illness. An individual possessing a strong self-concept should be better able to accept or
adapt to changes that may occur over the lifespan. How one views oneself affects
interaction with others. (Kozier and Erb’s Fundamentals of Nursing, 8th Edition, Vol.2 page
1003)
Viewing one’s self includes his or her self-worth/conception, comfort, body image,
feeling state. (Kozier and Erb’s Fundamentals of Nursing, Vol.1 page 190)
5. EMOTIONAL PATTERNS

12. The client admitted that he is emotional in some instances such as when he has
problems relating to family matters. He easily gets irritated or angry. However, he can
easily manage himself by trying to control his temper and emotions. Sometimes, when
confronted with situations that involve heavy emotions or feelings, he can’t easily express
or voice it out with his family. Upon our interview, the client cried when he tries to recall
and remember those sad times he had experienced and those disheartening moments of his
life. When tried to calm him down and gave him emotional support through touch therapy
and therapeutic communication, he said, “hindi ko kasi mapigilan ang sarili kong umiyak
kapag naaalala ko yung mga malulungkot na pangyayari sa buhay ko.”
INTERPRETATION:
The client is very emotional and sensitive especially when it comes to his family. He
can handle and manage things, however, there are instances that he hardly expressed
himself and pour out his true feelings and emotions because he kept it by himself. He easily
cries when remembering sad experiences happened in hislife.
ANALYSIS:
Expressing of emotions includes thoughts and actions to relieve emotional distress.
It does not improve the situation but makes the person feel better. (Kozier and Erb’s
Fundamentals of Nursing, Vol 2 page 1068)
6. SEXUALITY PATTERNS
This pattern was not assessed as the patient was not comfortable at this topic.
7. FAMILY COPING PATTERNS

13. As a family, they can easily cope up with their problems since they approach that
situation appropriately by means of open communication with one another. Through good
communication, they can solve their problems easily. He even uttered, “kahit anong bagay o
problema natin sa buhay at pamilya, nadadaan yan sa maayos na pag-uusap. Kelangan lang
na makinig tayo sa sinasabi ng bawat-isa at irespeto kung ano man ang magiging desisyon
nila. Kung makakabuti iyon para sa lahat, mas ok yon.” In addition, the client said that when
confronted with problems, he knew that God is there for him and his family, guiding and
directing them to the right path of decisions. Her faith to God is extremely and undoubtedly
unfailing. Through prayers and effective communication with each of the family members,
he can solve problems effortlessly.
INTERPRETATION:
The client manages to use communication as an influential and powerful tool in
solving their family members. However, when a problem in their family was not addressed
properly and effectively, conflicts and consequences usually occur. When these situations
usually happen, she relies to God as his protector.
ANALYSIS:
The effectiveness of family communication determines the family’s ability to
function as a cooperative, growth-producing unit. Messages are constantly being
communicated among family members, both verbally and non-verbally. The information
transmitted influences how members work together, fulfill their assigned roles in the
family, incorporate family values, and develop skills to function in society. Families that
communicate effectively transmit messages clearly and members are free to express their
feelings without fear of jeopardizing their standing in the family. Family members support

14. one another and have the ability to listen, empathize, and reach out to one another in times
of crisis. (Kozier and Erb’s Fundamentals of Nursing, 8th Edition, Vol.1 page 434)
B. SOCIO-CULTURAL PATTERNS
1. CULTURAL PATTERNS
The client was raised as a person possessed with qualities such as being God-
fearing, humble, compassionate, sincere, genuine, kind-hearted and forgiving. His parents
taught him good morals and right conducts that made his whole personality desirable.
Likewise, he grew up with culturally-sensitive beliefs and is bounded with norms and
tradition of their family. He still believes in cultural beliefs and even practices them until
now.
INTERPRETATION:
The client valued the cultural beliefs that had been passed to him by his parents and
by past generations. He believes in them since it was part of his life.
ANALYSIS:
Cultural and developmental considerations are essential elements in knowing the
client well and being able to plan individualized care that will focus on client strengths as
well as special needs. (Fundamentals of Nursing, Kozier & Erbs, 7th edition, page 413).
Culture is a complex whole in which each part is related to every other part. It
depends on an underlying social matrix, including knowledge, belief, art, law, morals and
customs. (Kozier and Erb’s Fundamentals of Nursing, Vol.1 page 315)
2. SIGNIFICANT RELATIONSHIPS

15. He has good relationship to his family. They are very bonded to each other and are able to
relate to each other’s individualities and differences. They loved and valued each other as
evidenced by her verbalization of how close they are. He highly values and respects his
family, relatives and friends. Hisfamily are the most important people in his life.
INTERPRETATION:
The client has good relationship with his family and to people around him. He highly
respects and values his family since they are the most important people in his life.
ANALYSIS:
It is important to give attention to people we considered as significant to our lives.
Valuing others strengthens the relationship or commitment we have. (Kozier and Erb’s
Fundamentals of Nursing, Vol.1 page 318)
3. RECREATION PATTERNS
The patient’s recreational activities’ aside from his work includes reading, watching
and cooking.He articulated, “mahilig ako magbasa at manoud ng news kahit noon pa. At
natutu kong magluto para sa pamilya ko kasi minsan busy si misis”
INTERPRETATION:
The client’s recreational activities are his routinely works and some household chores
only. He is fond of watching television as his past time.
ANALYSIS:
An activity-exercise pattern refers to a person’s routine of exercise, activity, leisure
and recreation. It includes activities of daily living that require energy expenditure such as

16. cooking, working and home maintenance. (Kozier and Erb’s Fundamentals of Nursing, 8th
Edition, Vol.2 page 1106)
4. ENVIRONMENT PATTERNS
The patient’s environment is very clean since they have a maid who cleans it
regularly. Hiswife loves planting and they are both nature-lover. He regularly cleans their
backyard and wants his environment to be clean and green all the time. He also added that
he is satisfied with their living place since the environment is conducive for a good, safe
and healthy living.
INTERPRETATION:
The client is fully aware of the importance of a clean environment to a healthy living
that’s why he regularly has his place cleanedbecause he believes that a clean and green
environment promotes good health and prevents from acquiring an illness.
ANALYSIS:
People are becoming aware of their environment and how it affects their health and
level of wellness. Different factors of environment affect a person’s health such as
geographic location, pollution, etc. (Kozier and Erb’s Fundamentals of Nursing, Vol.1 page
301)
5. ECONOMIC PATTERNS
He practices budgeting in their family. His salary as well as hiswife combined together for
their family’s expenses and other needs. They koew how to do budgeting and often, they
can manage to allocate their resources and money effectively and sufficiently. There is also

17. enough money to be spent on other basic necessities in their family such as allocation for
medical or health services when a family member needs it.
INTERPRETATION:
The client knows how to properly allocate and utilize the resources available.
Through budgeting, he and his family were able to use the money effectively in supplying
for their daily needs. He is very economical and efficient in handling financial matters.
ANALYSIS:
The economic resources needed by the family are secured by adult members. The
family protects the physical health of its members by providing adequate nutrition and
health care services. (Kozier and Erb’s Fundamentals of Nursing, 8th Edition, Vol.1 page
429)
C. SPIRITUAL PATTERNS
1. RELIGIOUS BELIEFS AND PRACTICES
The client is very faithful and loving person. She is very religious and pays a lot of
respect, trust and love to God. He prays regularly five times a day and on Fridays he
goes to the mosque to pray.He is very hopeful and optimistic about things and when
faced with problems, he knows that God will not let him down. On the contrary, when it
comes to religious practices, he is still doing most of them since he grew with his
parents valuing religious beliefs and practices.
INTERPRETATION:

18. The client values, respects and loves God with all her heart. He prays to Him and goes
to mosque. He believes that when you are facing problems in life, God will not let you solve
it alone. He grew up with religious beliefs and practices, that’s why, he values them until
now.
ANALYSIS:
Religion gives a person a frame of reference and a perspective with which to
organize information. It may be considered a system of beliefs, practices, and ethical values
about divine or superhuman power or powers worshipped as the creator and ruler of the
universe. (Kozier and Erb’s Fundamentals of Nursing, 8th Edition, Vol.1 page 315)
2. VALUES AND VALUING
The client’s values are shaped by his parents. Because of his parents’ teachings
about life, he grew up decisive and determined in life. That’s why, whenever he
encounters problems, he tries his best to solve them eagerly and with full responsibility
and determination.
INTERPRETATION:
The client gives importance to values and morality since his parents at a young age
taught him different values of life. Among these includes his being self-determined in
decision-making.
ANALYSIS:

19. Values are enduring beliefs or attitudes about the worth of a person, object, or action.
Values are important because they influence decisions and actions and ethical decision
making. (Kozier and Erb’s Fundamentals of Nursing, Vol.1 page 80)
g. Daily activity patterns
ADL Before During Interpretation Analysis
Hospitalization Hospitalization
Nutrition The client When hospitalized, The client eats Nutrition is the
usually eats fish, the client’s served healthy foods sum of all the
vegetables, foods consist of even before he interactions
vegetables (with
fruits, meat and was between an
sabaw), fish, and
poultry. He rice. But she only hospitalized. organism and athe
doesn’t eat pork eats small of what But during his food it consumes.
since it is is being served to hospitalization, In other words,
against his her approximately he eats little of nutrition is what a
religion. ½ cup of rice only. what is served person eats and
The client prefers because he gets how the body uses
to eat fruits
stomach ache it. The body’s most
specially after
taking his and he vomits basic nutrient is
medications the foods that water. Because
because he is easily he eats. The every cell requires
irritated by the client prefers to a continuous
medications. eat fruits after supply of fuel, the
taking his most important
The client
medicines to nutritional need ,
verbalized:
 tsaka kung prevent the after water, is for
minsan wala irritation that nutrients that
akong ganang he feels after provide fuel, or
kumain. Medyo drinking energy. Kozier,
hirap ding medicines. Fundamentals of
akong lumunok
Nursing, 8th
at ngumuya
kaya madalas edition)
puro prutas na
lang ang
kinakain ko,
tulad ng ubas at
orange.”

20.  According to
his daughter, he
eats only
1/2cup of rice
and refuses to
eat more
because of the
discomfort that
he feels.
 Lack of interest
in food
 Prefers eating
fruits rather
than a meal
Elimination The client’s The client The client Urinary
bowel defecates regularly defecates elimination is
elimination is and urinates regularly, and essential to health,
urinates and voiding can be
regular and normally and is
without postponed for only
normal with no wearing diaper. He difficulty and so long before the
difficulties or usually consumes 4 pain. urge normally
any discomforts diapers each day. becomes too great
as well as to his according to his He uses to control.
urination daughter, “ minsan, approximately Although people’s
pattern. kahit hindi pa 4 diapers a day, patterns of
urination are
naman puno ang which is
highly individual,
kanyang diaper, replaced even if most people void
pinapatanggal na it is not yet full, about 5 to 6 times
niya kasi naiirita because the a day.
daw siya. Kaya patient feels
pinapalitan na lang irritated The frequency of
naming agad ng wearing the defecation I highly
individual, varying
bago kapag gusto diaper.
from several times
na niyang palitan.” per day to two or
three times per
week. The amount
defecated also
varies from person
to person.
(Kozier,
Fundamentals of

21. Nursing, 8th
edition)
Exercise The client’s The client’s The patients To exercise
exercise activities are exercise is regularly is to keep
includes limited since he limited because one’s body to its
needs bed rest for best optimal state.
walking.He said, of the need for
his recovery. Exercising could
“madalang lan However, proper bed rest. But to make a person feel
ako mag positioning maintain good rejuvenated and
exercise medyo (usually every 2 blood give more energy.
busy din kasi hours) is advised circulation, he This is a part of
talaga sa as well as range of is advised to do Maslow’s
trabaho, at pag motion exercises to range of motion Physiologic Needs.
maintain good
di naman ako and change of
blood circulation. Limitations to
busy mas gusto position every 2 movement may be
kong makasama The client hours. medically
ang pamilya ko.” verbalized: prescribed for
 nahihirapan some health
akong problems. Bed rest
gumalaw-galaw may be the
ngayon dahil therapeutic choice
nanghihina ang for certain clients.
katawan ko (Kozier,
tsaka medyo Fundamentals of
masakit kapag Nursing, 8th
ginagalaw ko edition)
ang mga paa ko.
Kapag
nagpapalit ako
ng posisyon,
dahan dahan
lang ang galaw
ko tsaka
tinutulungan
naman ako ng
anak ko o kaya
yung nurse
dito.”
 Limited range
of motion
 Limited ability
to perform
gross motor

22. skills
Slowed movement
Hygiene The client takes Since the client is During Personal hygiene is
a bath every day on complete bed hospitalization, the self-care by
and practice rest, bathing which the patient is which people
attend to such
good hygiene requires sufficient not able to take
functions as
practices mobility is a bath. But to bathing, toieting,
restricted. maintain his general body
However, his hygiene, his hygiene, and
daughter or other family does grooming. Hygiene
family members do sponge bath on is a highly personal
sponge bath to him him. matter determined
by individual
regularly.
values and
practices.
(Kozier,
Fundamentals of
Nursing, 8th
edition)
Substance The client’s has Not applicable The client does Any substance
Use no bad vices. since the client is not use any abused by a person
hospitalized and substance. could trigger an
illness of a client.
continuous
Maslow said that
monitoring of her overuse of any
condition is substance makes a
necessary. person susceptible
to the agents
around that could
cause disease.
(Kozier,
Fundamentals of
Nursing, 8th
edition)
Sleep and The client’s Because of some The client;s Sleep is a basic
Rest sleeping pattern factors like lighting sleeping human need; it is a
is good. He and health care pattern was universal
providers coming biological process
usually sleeps change because
in and out for their common to all
6-8 hours, continuous nursing of being people. We require
continuous and care to the patient, confined in the sleep for many

23. with no his sleep pattern is hospital. He is reasons: to cope
interruptions or usually interrupted disturbed by with daily stresses,
difficulties. He and disturbed. He the lights in the to prevent fatigue,
sleeps for only 3-5 to conserve
verbalized, room and
hours. He energy, to restore
“maayos ang verbalized, “ hindi monitoring of the mind and body,
pagtulog ko maayos ang the nurses. ad to enjoy life
noon. Tuloy- pagtulog ko dito more fully. It is
tuloy siya tsaka kasi minsan vital for not only
di naman ako nasisilaw ako sa optimal
pagising-gising ilaw. Kaya hindi psychological
ako nakakatulog ng functioning as the
o naiistorbo.”
maayos.” rate of healing of
damaged tissue is
 Restless greatest during
 Low and sleep.
slowed voice
 Slightly The absence of
lethargic usual stimuli or the
presence of
unfamiliar stimuli
can prevent people
from sleeping.
Hospital
evironments can
be quite noisy, and
special care needs
to be taken to
reduce noise in the
hallways and
nursing care units.
(Kozier, B. et.al.,
Fundamentals of
Nursing, 8th
edition)
II. Nursing care plan
a. Problem identification
Nursing Problems Cues Justification
Identified
Impaired physical S> ABC: The problem affects the

24. mobility related to The client verbalized: airway, breathing and circulation.
decreased muscle  nahihirapan akongMaslow’s Hierarchy of needs: The
strength, gumalaw-galaw ngayon problem affects the physiologic
pain/discomfort as dahil nanghihina ang needs specifically the need for bed
manifested by report katawan ko tsaka medyo rest as well as the safety and
of pain/discomfort masakit kapag ginagalaw security since the client has
on movement, ko ang mga paa ko. Kapagdecreased muscle strength.
limited range of nagpapalit ako ngUrgency: The problem is not a life
motion, slowed posisyon, dahan dahan threatening situation, however,
movement lang ang galaw ko tsaka supportive care and assistance
tinutulungan naman ako from the family members and the
Suggested Functional ng anak ko o kaya yung health care providers specially the
Level Classification: nurse dito.” physical therapists are necessary
and of great help so that the patient
2- Requires help O> will be able to have good
from another person  Limited range of motion circulation, restore her muscle
for assistance  Limited ability to perform strength, improve muscle tone and
gross motor skills prevent further complications or
Slowed movement injury. Proper positioning usually
every 2 hours is also indicated for
the patient in order to promote
good circulation to the body as well
as to prevent bed sores.
(Client)
Resources: Money is needed for
maintaining his medications and
treatments such as physical
therapist that will assist him in
range of motion and leg exercises.
Time: The time is needed for the
patient will personally engaged him
in doing these exercises and
therapies.
Manpower: This is also needed if
the patient needs assistance, for
example, by a family member.
(Nurse)
Skills: Available
Knowledge: Available
Time: Available
Sleep deprivation S> ABC: The problem does not affect
related to  The client admitted that the airway, breathing and
uncomfortable sleep because of some factors circulation.
environment as like lighting and health Maslow’s Hierarchy of needs: The
manifested by care providers coming in problem affects the physiologic

25. restlessness and out for continuous needs specifically the need for rest
nursing care, his sleep and sleep.
pattern is usually Urgency: The problem is not a life
interrupted and threatening situation, however,
disturbed. He sleeps for sufficient and adequate sleep is
only 3-5 hours. He needed in order for the client to
uttered, “hindi maayos acquire complete rest that is
ang pagtulog ko dito kasi necessary for maintaining good
minsan nasisilaw ako sa health.
ilaw. Kaya hindi ako (Client)
nakakatulog ng maayos.” Resources: Money is not needed;
however, proper environmental
O> conditions should be
 Restless altered/improved in order for the
 Low and slowed voice client to acquire good sleep.
 Slightly lethargic Lighting and ventilation should be
improved since these are factors
that somehow affect the sleeping
pattern of the client.
Time: Adequate time is needed
since the client should gain an
enough hours of sleep.
Man power: N/A
(Nurse)
Skills- Available
Knowledge- Available
Time- Available
Imbalanced S> ABC: The problem does not affect
Nutrition: less than The client verbalized: the airway, breathing and
body requirements  “konti lang ang kinakain circulation.
related to inability to ko kasi sumasakit ang Maslow’s Hierarchy of needs: The
digest food/absorb tiyan ko at kapag madami problem affects the physiologic
nutrients as ako kinain, sinusuka ko needs specifically the need for food
manifested by lack of naman. Kaya konti lang and water.
interest in food; ang sinusubo ko kasi Urgency: The problem is not a life
perceived inability to madali akong masuka. threatening situation; however, the
digest food; tsaka kung minsan wala client needs to attend to his needs
abdominal pain; akong ganang kumain. by following the doctor’s order
weakness of muscles Medyo hirap ding akong including the type of diet. He
required for lumunok at ngumuya should eat the right type and
swallowing or kaya madalas puro prutas amount of foods in order for him to
mastication na lang ang kinakain ko, maintain good health and be able to
tulad ng ubas at orange.” regain his strength.
 According to his (Client)
daughter, he eats only Resources: Money is needed for

26. 1/2cup of rice and his continuous medication and
refuses to eat more hospitalization that includes the
because of the discomfort different interventions done to him
that he feels. by his health care providers.
 He said he prefers to eat Time: Time is needed in order to
fruits rather than eating a acquire the full willingness of the
meal (consisting of rice, client to cooperate with the health
fish and veggies) care team and follow their advices.
especially after taking his Man power: The client needs other
medications because he is people (example, a family member)
easily irritated by the to assist him in eating his foods;
medications. especially since he is resting on
bed.
O> (Nurse)
 Lack of interest in food Skills- Available
 Prefers eating fruits Knowledge- Available
rather than a meal Time- Available
b. Nursing care plan
NURSING GOAL/ EVALUA-
CUES ANALY-SIS NURSING INTERVENTIONS RATIONALE
DIAGNOSIS OBJECTIVE TION
S: Impaired Limitat Goal: Instruct in use of side For position Goal
The physical ion in After 8 rails, overhead changes was
client mobility indepe hours trapeze, roller pads. /transfers. met.
verbali related of Client
ndent,
zed: to nursing Support affected To maintain was
nahihir decrease purpos interve body part/joints position of able to
apan d muscle eful ntion, using pillows/rolls, function and demons
akong strength, physic the foot supports/shoes, reduce risk of trate
gumala pain/dis al client air mattress, water pressure behavio
w- comfort movem will be bed, etc. ulcers. rs that
galaw as ent of able to enable
ngayon manifest demons Provide regular skin To maintain resump
the
dahil ed by trate care. skin integrity. tion of
nanghi report of body behavio activitie
hina pain/dis or of rs that Observe movement To note any s.
ang comfort one or enable when client is incongruencie
katawa on more resump unaware of s with reports
n ko moveme extrem tion of observation. of abilities.
tsaka nt, ities. activitie
medyo limited s. Administer To permit Goal

27. masaki range of medications prior to maximal was
t kapag motion, Objecti activity as needed for effort/involve met.
ginagal slowed ves: pain relief. ment in Client
aw ko moveme After 30 activity. was
ang nt minutes able to
mga of Schedule activities To reduce identify
paa ko. Suggeste health with adequate rest fatigue. ways on
Kapag d teachin periods during the how to
nagpap Function g, the day. prevent
alit ako al Level client further
ng Classifica will be Identify energy- Limits fatigue, complic
posisy tion: able to: conserving maximizing ations.
on, - techniques for ADLs. participation. Goal
dahan 2- Identify was
dahan Requires ways on met.
lang help how to Consult with To develop Client
ang prevent physical/occupation individual was
from
galaw further al therapist, as exercise/mobi able to
ko another complic indicated. lity program identify
tsaka person ations. and identify and
tinutul for - appropriate demons
ungan assistanc Identify mobility trate
naman e and devices. therape
ako ng demons utic
anak trate Encourage adequate Promotes well- ways
ko o therape intake of being and that
kaya utic fluids/nutritious maximizes will
yung techniq foods. energy help
nurse ues that production. alleviat
dito.” will e
help conditio
O: alleviat Note Feelings of n.
Limite e emotional/behaviora frustration/po Goal
d conditio l responses to werlessness was
range n. problems of may impede met.
of - immobility. attainment of
Client
motion Verbali goals.
Limite ze was
d appreci able to
ability ation Encourage Enhances self- verbaliz
to and participation in self- concept and e
perfor willingn care, sense of appreci
m ess to occupational/diversi independence. ation
gross coopera onal/recreational
and
motor te with activities.
willingn

28. skills the ess to
Slowed nterven Encourage client’s Enhances coopera
move tion. involvement in commitment te with
ment decision making as to plan,
the
much as possible. optimizing
outcomes. interve
ntion.
c. Discharge planning
Medications The client should be closely monitored in complying in his
therapy and medications which are:
Ketosteril 1tab TID
Melatonin 3mg 1cap at hs
Digoxin 0.25mg 1tab OD
Folic acid 1cap OD
Lozacar 1tab OD
Sulodexide 250g 1 tab BID
Exercise Deep breathing exercise sitting up in bed, supported by
pillows or out in a chair. Take a deep breath in through the
nose, hold for at least 3-5 seconds and then exhale the air
to a pursed lip.
Walking to improve circulation
When in bed rest, practices turning the client in different
position/side at least every 2 hours. And try to exercise the
extremities by simply moving/lifting it.
Treatment Treatment of the underlying disorders may help
prevent or delay development of chronic renal
failure. Diabetics should control blood sugar and
blood pressure closely and should refrain from
smoking.
Blood transfusions or medications such as iron and
erythropoietin supplements may be needed to
control anemia.
Dialysis or kidney transplant may eventually be
needed.
Health Teachings Urinate when the urge occurs or at least every 2-4
hours during the day.

29. It is advisable to have an output of 2.5 to 3 liter/day
by appropriate increase in water intake if the
patient can tolerate it.
Avoid strenuous activity to reduce fatigue.
Out-patient As an outpatient, medications that are given should be
taken regularly for treatment even when advised to be
home.
Follow-up checkups must be needed depends on the
physicians advice.
Diet
Sodium--Salt has to be restricted if edema,
congestive cardiac failure and hypertension are
present
Potassium intake has to be restricted in order to
avoid hyperkalemia. (Certain fruits, chocolate, milk,
vegetable and salt are rich sources of potassium)
Adequate calories have to be provided by a diet
containing carbohydrate and fat.
Hyper phosphatemia can be prevented by giving
diet low in phosphate. Milk and dairy products,
which are rich in phosphorus, are to be avoided.
Dietary supplement of calcium together with
vitamin D have to be given to elevate calcium level
and abolish symptoms of hypocalcaemia.
Spiritual Advise Encourage the patient to pray for his fast recovery.