St.

Michael’s College
College of Nursing
Iligan City

NURSING CARE PLAN FORM

Group: A Date/Shift: FEB 3, 2021 / 7:00- 3:00PM

Area: STATION I

Pt Initials: Age: Sex: Civil Status: Ward: Room/Bed No

G.L.L 50YRS OLD FEMALE MARRIED FEMALE WARD- RM # 23

Date Admitted: JANUARY 27, 2021 Chief Complaint: SWELLING RIGHT MAXILLARY
Attending Physician: DR. MARK YU Admitting Diagnosis/Impression: MAXILLARY INFECTION

Significant Medical and Nursing History:

POOR APPETITE, SWELLING OF RIGHT MAXILLARY OF FACE, RIGHT EYE SWELLING

Prepared by: GERLYN L. GINGOYON Supervised by: _MAE F. CABIGON

Student Nurse Clinical Instructor

Trace/write the pathophysiology or psychosocial explanation/consequences of the nursing diagnosis at the back of this form.
1
ASSESSMENT NURSING DIAGNOSIS PLANNING/ Goals: IMPLEMENTATION RATIONALE EVALUATION:
(Indicate the time the
outcome was met.)

Subjective: Short-term: Independent:

Acute Pain Related to At the end of 8 hours of
“ aki tang akong toong Maxillary Infection duty patient will:
aping” as verbalized by - Report pain is
patient relieved and
controlled
- Lessen bad
gesture and
guarding behavior
Objective: - Follow prescribed
- Observed pharmacological
evidence of pain at regimen
the right side of pt.
face.
- Guarding behavior Long-term:
- Protective gesture During my 4 days of duty
- Thick, yellow and the patient will:
greenish - Verbalize
discharges from nonpharmacologic
the nose-noted al methods that
- With nasal provide relief.
congestion - Demonstrate use
- With tenderness, of relaxation skills
and swelling and diversional
around the eyes, activities, as
cheeks, and nose . indicated for
- Sore throat noted individual situation
-interact client to report - To Verbalized pain After 8 hrs of my care
any improvement that can create other patient will be able to ;
/exacerbation to pain problems such as
experience. anger, anxiety, Report pain is relived
immobility, respiratory and controlled
problems and delay in
healing Follow prescribed
pharmacological
-encourage verbalization of - Only the client can regimen.
feelings about the pain . judge the level of
distress of pain; pain
management should
be a term approach
that includes the client
vary few people lie
about pain.
Dependent/Collaborative:
- Administer medication - Necessary for
particularly analgesic as treatment of the
prescribed by the underlying cause
physician
- Assist with laboratory/ - To determine changes
diagnostic studies as indicative of healing/
indicated infection/ complication
and to identify
causative and
precipitating factors