NURSING CARE PLAN

Patient Name: Juan Carlos Enrique Tejada Age: 25

D DIAGNOSIS GOALS INTERVENTION OF NURSING FUNDAMENTAL EVALUATION

OF NURSING NURSING (NIC) (NOC)

Willingness to Patient will lead - Responsibilities

To encourage the patient
a healthier life, of own care for
improve health Give you confidence
with a balanced treatment
management, diet, adequate Support him at all times It consists of stabilizing the patient enough to ensure an
exercise. He will adequate airway, effective breathing and circulation, and
expressed by Give you more information
also have more Justification of the
being able to carefully identify the injuries involved.
Expressing a energy. therapeutic
regimen-
desire to improve
behavior to Description of the
effects expected
prevent
from the treatment
infectious
diseases
DIAGNOSIS DAY GOALS I INTERVENTION OF NURSING FUNDAMENTAL E EVALUATION
OF NURSING (NIC) (NOC)

NURSING

Nutritional Nutritional
Patient will Managing eating disorders
status: food and
imbalance: intake increase his Nutrition management liquid intake
less than needs. food intake, Nutritional
Help to gain weight
Will not It involves eating a variety of foods that give you the status: nutrient
Related by Fluid/electrolyte
express intake
management nutrients you need to stay healthy, feel good, and have
Psychological refusal to eat Weight control
energy. These nutrients include proteins, carbohydrates, Knowledge: diet
factors. Nutritional advice fats, water, vitamins and minerals.
Manifested by
Refusal to eat,
➢ Kiwi ➢ Apple ➢ Broccoli ➢ Carrot ➢ Brown rice ➢
Diarrhea, Beans ➢ Salmon ➢ Sardines
abdominal
noises
 DIAGNOSIS GOALS INTERVENTION OF NURSING FUNDAMENTAL EVALUATION (NOC)
OF NURSING NURSING (NIC)

intestinal
Diarrhea management Bowel movements with very liquid stools are generally elimination
Diarrhea related Patient did not Water balance
Nutrition management caused by gastrointestinal infections caused by viruses,
to anxiety, high present diarrhea Hydration
Fluid/electrolyte bacteria or parasites.
degree of stress Therapeutic
manifested by management behavior: illness
Washing hands before and after cooking and eating, and or injury
intestinal Liquid handling after using the toilet, changing diapers, taking out the
sounds, trash, touching animals, or sneezing or blowing your
liquid stools nose.
Be careful with food safety
Do not drink unpasteurized milk or foods made with it
Wash fruit and vegetables well before eating them.
Cook eggs, meat and seafood thoroughly before eating
them.
Keep surfaces clean
 DIAGNOSIS GOALS INTERVENTION OF NURSING FUNDAMENTAL EVALUATION
OF NURSING NURSING (NIC) (NOC)

Ambulation: walk
Energy management . active joint
Impaired
Patient will be Promotion of exercise movement
ambulation
able to move Bodies or objects in motion are called mobile. If an object Mobility level
related to pain Exercise therapy: ambulation
without pain is not changing position over time, with respect to a muscle function
manifested by
Exercise therapy: muscle certain reference point, we say that said object is at rest. Personal care:
Impaired ability
Patient will control activities of daily
to navigate
improve his . It is a term that means that a joint or part of the body living
obstacles, Pain management
mood cannot move through its normal range of motion. Personal care:
uneven surfaces
Helps self-care instrumental
activities of daily
Teaching: prescribed living
activity/exercise Safety Behavior:
Fall Prevention
Comfort level
Pain level
DIAGNOSIS GOALS INTERVENTION OF NURSING FUNDAMENTAL EVALUATION
OF NURSING NURSING (NIC) (NOC)

Distribute
responsibilities
Maintenance of family among members
Willingness to processes
You will share It is the conscious action of exchanging information
improve
your anecdotes, Efficient communication between two or more participants in order to transmit or - Adapts to
communication
you will have development
manifested by receive different information or opinions.
better speaking changes
Expressing Source or Sender (Sender): Device that generates the
fluency, you will
feelings, data to be transmitted, for example telephones or
relate much
expressing personal computers.
better.
satisfaction at Transmitter : Transforms and encodes information,
being able to generating electromagnetic signals that can be sent
share ideas with
through some transmission system.
others, sharing
information,
expressing
thoughts
 DIAGNOSIS GOALS INTERVENTION OF NURSING FUNDAMENTAL EVALUATION
OF NURSING NURSING (NIC) (NOC)

It is the opinion that a person has about himself, which

Efficient has a value judgment associated with it. It should be - Adapts to
Willingness to communication
active, social noted that self-concept is not the same as self-esteem, development
improve self-
person who however their relationship is very close and one could not changes
concept
expresses
manifested by be understood without the presence of the other.
confidence in
accepting one's
abilities,
limitations, Three essential characteristics stand out:
expresses
strengths,
satisfaction with
confidence in It is innate: the self-concept is formed with experience
his or her
one's abilities, and the image projected or perceived in others. It also
personal
satisfaction with
identity, depends on the symbolic language.
one's body
patient with It is an organized whole: the individual tends to ignore
image,
great the variables that he perceives about himself that do not
satisfaction with
confidence fit the whole and has his own hierarchy of attributes to
one's thoughts
value.
It is dynamic: it can be modified with new data, coming
from a reinterpretation of one's own personality or from
external judgments.
DIAGNOSIS GOALS INTERVENTION OF NURSING FUNDAMENTAL EVALUATION
OF NURSING (NIC) (NOC)

NURSING

It is a reciprocal interaction between two or more people.

Family visit These are social relations that, as such, are regulated by Patient already
Willingness to
good Proper communication the laws and institutions of social interaction. relates adequately
improve the
communication Communication intervenes in every interpersonal
relationship
with his
manifested by relationship, which is the ability of people to obtain
Brothers,
the components information about their environment and share it with the
cousins and his
of the couple rest of the people.
family and
demonstrate
social
mutual respect, People having interpersonal relationships
environment.
support, People having interpersonal relationships
understanding,
Human relationships occur between different social
express
groups, such as family, friends, acquaintances...
satisfaction by
pleasing the
physical and
emotional needs
of their partner.
 DIAGNOSIS GOALS INTERVENTION OF NURSING FUNDAMENTAL EVALUATION
OF NURSING NURSING (NIC) (NOC)

Stress is considered the mechanism that is set in motion

when a person is involved in an excess of situations that Emotional
Risk of transfer
You will no Facilitate self-responsibility exceed their resources. balance
stress syndrome
longer present Help to control anger Overcoming
related to the
stress related to Increase coping problems
expression of :
the expression Advice Psychosocial
helplessness,
of helplessness Emotional Support adaptation: life
Lack of an
Give hope change
adequate support
Increase support systems Anxiety control
system
Discharge planning
 DIAGNOSIS GOALS INTERVENTION OF NURSING FUNDAMENTAL EVALUATION
OF NURSING NURSING (NIC) (NOC)

• Willingness to
improve It is the state of mind in which an individual assumes the
religiosity related Encourage the patient knowledge or experience he or she has about an event Positive future
to the illness I will already Spend some time with the or thing to be true;1 when objectified, the content of the orientation
manifested by practice patient belief presents a logical proposition, and can be
Expressing religiosity with Expression of
Encourage the expression of expressed through a linguistic statement. as an trust,
emotional great devotion
suffering due to feelings affirmation.2 Basically believing means "taking something Will to live,
separation from for granted, without having evidence of it." reasons for living,
their religious optimism,
community, complete faith
expressing the
need to re-enter
contact with
previous
customs
 DIAGNOSIS GOALS INTERVENTION OF NURSING FUNDAMENTAL EVALUATION
OF NURSING NURSING (NIC) (NOC)

It is an annoying sensation that limits a person's ability

and ability to perform daily activities. Sometimes it acts
Relieve pain Application of heat or cold as an initial warning sign that something is not working Pain control
Acute pain related to Pain: harmful
Pain management well in the body.
related to harmful harmful agents effects
agents Analgesic administration Pain level
manifested by Medication management
Pain is an annoying sensation and some people go to
Posture to avoid
Increase coping great lengths to try to relieve it. If we couldn't feel pain,
pain, expresses
Environmental management: we would be unable to avoid injuring ourselves again and
pain
comfort again or causing permanent damage to our body.