Professional Documents
Culture Documents
Nursing Care Plans
Nursing Care Plans
Nursing Care Plans
SUBJECTIVE: Pain related to After 4 hours Change the position Pain is sometimes After 4 hours
“Masakit ang tahi tissue trauma of nursing of the patient due to the position of of nursing
ko” as verbalized by and incisional intervention the patient intervention
the 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 To reduce anxiety
grimace Relay on the patient felt by the patient
Increased report of pain To divert the
respiration Encoura attention from pain to
RR=26 bpm ge divertional activities
Pain scale = activities Usually altered in
7: pain Monitor pain.
scaling of 1- vital sign To
10 where 1 Administer maintain
is the least analgesic as ordered acceptable level
painful and by the AP of pain.
10 is the
most painful
Impaired
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