NURSING CARE PLAN

ASSESSMENT DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATION

Subjective: Acute Pain related to Goal:  Perform a  Pain is a subjective After implementing
-According to the pus in the urine as After 1 hour the client comprehensive the care plan,
client she only manifested by will report relieve assessment of pain experience and
reassessment of the
urinates 1-2 times a verbalization of pain from pain to include location, must be described client shows the
day. upon urination characteristics,
by the client in following result:
Objective: onset, duration,
After 5 minutes the frequency, quality, order to plan
-The client also said,
client will report less intensity or  The client will rate
“pa konti-konti lang effective treatment her pain between
pain perception; rate severity, and
yung pagihi ko kahit the pain (2-5) precipitating the rate of 2-5
feeling ko puno na factors of pain.
ang pantog ko.”  Teach the use of  The use of
nonpharmacologic noninvasive pain
-the client verbalize techniques (e.g., relief measures can
“ang sakit kapag relaxation, increase the re-
umiihi” guided imagery, lease of endorphins
music therapy, and enhance the
Objective: distraction, and therapeutic effects
- Client rate the massage) before, of painrelief
pain 7 (1 lowest- after, and if medications.
10 highest) possible during
- Urinalysis painful activities;
 Pus cell- over before pain occurs
50 HPF or
RBC- 25-30HPF increases; and
along with other
pain relief
measures.
 Provide the  To relieve the pain
prescribed pharmacologicaly
analgesic
 ASSESSMENT DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATION
Subjective: Disturbed sleep Goal: Independent: After implementing
-the client verbalize pattern related After 2 days the client  Provide comfort  Soothes and the care plan,
“iniisip ko yung mga unfamiliar will have an measure (back relaxes the client reassessment of the
anak ko kaya hindi environment as improvement in her rub) client shows the
ako makatulog saka manifested by quality of sleep  Recommend limit  Caffeine inhibits following result:
ang hindi ako sanay noticeable dark intake of caffeine sleep
matulog dito.” circles around the Obectives:
 the client will
eyes. After 1 hour of
state
Objective: intervention the
interventions that
-dark circles around client will state 2
will improve her
the eyes ways of improving
sleep
-frequent yawning sleep