NURSING CARE PLAN

ASSESSMENT DIAGNOSIS PLANNING IMPLEMENTATION RATIONALE EVALUATION

SUBJECTIVE: Acute pain related to Within 3hrs. of nursing Independent: -To obtain baseline and assess Goal partially met, after
The client complains of occipital headache interventions, the patient’s -Monitor vital signs and assess preliminary possible areas of immediate 3hrs. of nursing
headaches at the lower pain scale due to occipital assessment. intervention. interventions, the
back of her head. headache will be alleviated patient’s pain scale was
from 8/10 to 5/10 and the -Note for the location, scale, intensity and lessened from 8/10 to
OBJECTIVE: patient will be able to onset of pain. -To determine the nursing care to be 1/10 and the patient
-Temperature- 36.6 ℃ verbalize the relief of pain. . given to the patient. verbalized being
-RR- 28 cpm -Provide comfort measures such as relieved of pain.
-BP- 154/86 mmHg repositioning the patient in a comfortable -To allow non-pharmacological pain
-PR- 78 bpm position by elevating the head of the relief and promote good circulation to
-Urine Sample: 1,9443 patient and provide a hot or cold compress. the brain and decrease
mg/dl of microalbumin vasoconstriction.
-Hemoglobin A1c of74%
-Occipital Headaches -Provide a dim and light but providing -To add comfort to the patient.
-Polyuria and Polydipsia good ventilation.
-Pain Scale: 8/10
-Maintain a calm and quiet environment. -To minimize stimulus that could
aggravate the condition of the patient.

-Encourage and maintain bed rest - Minimizes stimulation and

during acute phase. promotes relaxation.

Dependent:
-Administer pain medication as prescribed
by the physician.
 ASSESSMENT DIAGNOSIS PLANNING IMPLEMENTATION RATIONALE EVALUATION
SUBJECTIVE: Difficulty of Within 30mins. of nursing Independent: Goal partially met, after
The client complains of breathing due to interventions, the patient -Position the patient in semi-Fowler’s -Positioning helps maximize lung 30mins. of nursing
difficulty of breathing. hypertension as will be able to maintain an position. expansions. interventions, the
evidenced by fast effective breathing pattern, patient was able to
OBJECTIVE: breathing as evidenced by relaxed - Evaluate skin color, temperature, - Lack of oxygen will cause maintain an effective
-Temperature- 36.6 ℃ breathing at normal rate capillary refill, observe central versus blue/cyanosis coloring to the lips, breathing pattern, as
-RR- 28 cpm and depth and absence of peripheral cyanosis. tongue, and fingers. Cyanosis to the evidenced by relaxed
-BP- 154/86 mmHg tachypnea. inside of the mouth is a medical breathing at normal rate
-PR- 78 bpm emergency. and depth and absence
-Urine Sample: 1,9443 - Encourage deep breathing exercise. of tachypnea.
mg/dl of microalbumin
- To promote chest expansion.
-Hemoglobin A1c of74%
-Occipital Headaches
-Polyuria and Polydipsia
-Pain Scale: 8/10 Dependent:
-Administer oxygen at lowest
concentration as indicated. -To help patient in breathing.

-Administer prescribed medication as

ordered.
 ASSESSMENT DIAGNOSIS PLANNING IMPLEMENTATION RATIONALE EVALUATION
SUBJECTIVE: Risk for fall related Within 30mins. of nursing Independent: Goal partially met, after
“Nahihilo ako at medyo to impaired balance interventions, the patient -Raise side rails of the bed. -Reducing the risk of patients falling 30mins. of nursing
nanlalabo paningin ko” as evidenced by will be free from falls. out of bed. interventions, the
dizziness. patient was able to
OBJECTIVE: -Instruct the patient to call for assistance -To prevent the patient from falling in decrease the risk of
-Temperature- 36.6 ℃ when moving. bed. falling through
-RR- 28 cpm implementation of
-BP- 154/86 mmHg -Assess the patient ability to ambulate -It is helpful to determine the client’s safety measures such as
-PR- 78 bpm safely with or without assistive device functional abilities to plan for ways of raising the side rails of
-Urine Sample: 1,9443 improving the problem areas. the bed, assisting the
mg/dl of microalbumin patient when moving
-Hemoglobin A1c of74% -Thoroughly orient the patient to -For the client to familiarize the and keeping the area a
-Occipital Headaches environment. surroundings. well-lighted
-Polyuria and Polydipsia environment.
-Pain Scale: 8/10 -Assess vision and provide adequate -To provide well-lighted environment
lighting to clearly see the pathway. and avoid the occurrence of injury.

-Evaluate the client’s current
disorder/conditions that could enhance risk
potential for falls.
-Acute, even short term situations can
affect any client, such as sudden
dizziness, positional blood pressure
changes, new medications, change in
glasses prescription, recent use of
alcohol/other drugs, and so on.

-Assess the client’s cognitive status (brain -This affects the client’s ability to
injury, neurological disorders/depression). perceive his/her own limitation or
recognize danger.
-Ascertain the client’s/significant other’s -This may reveal a lack of
level of knowledge about and attendance to understanding, insufficient resources,
safety needs. or simple disregard for personal
safety.