NURSING CARE PLAN

Submitted by: Anthony B. Taquiqui Nov. 19, 2010

BSN – A405 Grp. 4A
Submitted to: Mrs. Wayne Pascual, RN, MAN
Clinical Instructor

ASSESSMENT DIAGNOSIS PLANNING NURSING INTERVENTIONS EVALUATION

INTERVENTIONS RATIONALE

SUBJECTIVE: Pain related to After 4 hours  Change the position  Pain is sometimes After 4 hours
“Masakit ang tahi ko” tissue trauma of nursing of the patient due to the position of nursing
as verbalized by the and incisional intervention of the patient intervention
patient. discomfort as patient’s pain  Provide comfort  To reduce the the patient
manifested by evidenced by measures discomfort reported pain
OBJECTIVE: grimace and pain scale =7  Assist patient in  To assist in muscle was lessened
 Restlessness pain scale =7. be reduced to breathing and generalized to pain scale
 Irritability 3. techniques relaxation =3.
 With cold  For patient
clammy skin  Provide quiet comfortabili-ty and
 Excessive environment lessen the
perspiration discomfort.
 Facial grimace  To reduce anxiety
 Increased  Relay on the patient felt by the patient
respiration report of pain  To divert the
RR=26 bpm  Encoura attention from pain
 Pain scale = 7: ge divertional to activities
pain scaling of activities  Usually altered in
1-10 where 1 is  Monitor pain.
the least painful vital sign  To
and 10 is the  Administer maintain
most painful analgesic as acceptable level
 Impaired ordered by the AP of pain.
 thought

ASSESSMENT DIAGNOSIS PLANNING NURSING INTERVENTIONS EVALUATION

INTERVENTIONS RATIONALE

OBJECTIVE: Fluid volume After 8 hours  Change  To protect the skin After 8 hours
 Poor skin deficit related of nursing dressings and monitor losses of nursing
turgor to the risk of intervention frequently intervention,
 Dry lips post-operative the patient  To prevent injury the patient
 Weak in hemorrhage as will maintain  Provide frequent from dryness was
appearance manifested by fluid at a oral care maintained
 Pale looking poor skin functional  Helps maintaining fluid as
 v/s of: turgor, dry level.  Measure input fluid in the body manifested by
BP = 100/80 lips. and output good skin
PR = 64  To monitor fluids in turgor
RR = 26 the body
 T = 37.8  Monitor v/s
 To assess the patient
and it serve as base
 Administer IV line data
fluids as  To reduce blood loss
indicated

 Give
medications as
ordered by the
attending
physician
 ASSESSMENT DIAGNOSIS PLANNING NURSING INTERVENTIONS EVALUATION
INTERVENTIONS RATIONALE
SUBJECTIVE:
“Hindi ako Impaired After 8 hours  Provide  To reduce the After 8 hours
makagalaw ng mobility of nursing activities with fatigue of nursing
ayos” as verbalized related to intervention adequate rest intervention,
by the patient. decreased the patient period. the patient
muscle will be able was able to
OBJECTIVE: strength as move safety move safely
 Impaired manifested by and  Encouraged  Promotes well and
ability to limited ROM. independently. adequate intake being and independently.
turn side to of fluids maximize energy
side. production
 Cannot eat
without
support  Advise to move  To
 Slowed hands and legs exercise/mobiliza
movement slowly tion of body parts
 Irritable and develop
 Limited muscle strength
ROM

 Encourage  Enhances self

participation in concept and
self care sense of
independence