St.

Anthony’s College
Nursing Department

NURSING CARE PLAN

Name of patient: Mrs. Jones Attending Physician: Dr. Robinson

Age: 42 years old Impression Diagnosis: Colon cancer/colostomy
Gender: Female

Clustered Cues Nursing Rationale Outcome Criteria Nursing Interventions Rationale Evaluation
Diagnosis
Subjective: After 2 hours of Independent: Independent: After 2hrs of nursing
Acute pain Acute pain is unpleasant nursing intervention, A. Monitor pain, noting A. To monitor the client’s intervention the goals was
“ My surgical site is related to the sensory and emotional the patient will be location, characteristics, response to the treatment met as evidenced by:
really painful and I want disruption of experience associated able to report relieve intensity (0–10 scale). and helps evaluate the
to request morphine to skin secondary with disruption of skin from pain as evidence degree of discomfort or
relieve this” as verbalized to surgical due to colostomy or by: may reveal developing
by the patient. procedure as after surgical procedure complications.
evidence by which could also results “ My pain in surgical site
Objective: for the patient to exhibit “ My pain in surgical B. Observe or monitor other B. This create a baseline set of is now controlled or
other signs and site is now controlled associated signs and observations to the patient. relieved because I was
pain score of 8
- Pain score is 8 from symptoms associated to or relieved because I symptoms such as heart rate provided a medication for
out of 0-10
scale of 0-10 this problem (Vera, was provided a and BP which I had requested” as
2019). medication for which verbalized by the patient.
BP-
VS: I had requested” as C. Reposition the patient in C. Promotes relaxation,
130/90mmHg
BP: 130/90mmHg verbalize by the her comfortable or preferred prevent associated BP is within the normal
HR: 106 bpm patient. position.  Assure patient that discomfort and may range( from130/90mmH
HR - 106 bpm
position change will not injure enhance coping abilities. g to 120/80 mmHg)
- irritable BP is within the stoma.
Being irritable
- guarding behavior normal D. Note nonverbal cues D. Body language or HR is within the normal
range( from130/90m (abdominal guarding, nonverbal cues may be both range ( from 106bpm to
Guarding
mHg to 120/80 irritability).  physiological and 100 bpm)
behavior mmHg) psychological to determine
extent and severity of the Patient appeared
HR is within the E. Encourage use of relaxation problem. comfortable and relaxed
normal range ( from techniques, e.g., guided E. Helps patient rest more
106bpm to 100 bpm) imagery, visualization and effectively and refocuses Responsive
 Patient will appear deep breathing techniques.
comfortable and
relax F. Encourage verbalization of
feelings about the pain.
Responsive
Dependent:
A. Administer pain
medication(morphine) as
prescribed.
Collaborative:
A. Refer the patient to pain
specialist.
Student’s Name: Cyril Joy N. Fernando BSN 3B References:
Clinical Instructor: Louwelyn Diasnes, RN
Doenges, et al. (2016). Nurse’s Pocket Guide. Diagnoses, Prioritized Interventions and Rationales. F.A Davis Company.
Vera (2019). 10 Ileostomy and Colostomy Nursing Care Plans. Nurseslabs. Retrieved from https://nurseslabs.com/10-ileostomy-
colostomy-nursing-care-plans/3/
attention, thereby reducing
pain and discomfort.
F. Patient may try to tolerate
pain rather than request
analgesics so it is essential
to encourage them to
promote comfort and early
treatment.
Dependent:
A. Used to decreased pain and
patient’s comfort.
Collaborative:
A. Helps to receive more
information and specialized care
on pain management if needed.
 
 St. Anthony’s College
Nursing Department

DRUG STUDY

Name of patient: Mrs. Jones Attending Physician: Dr. Robinson

Age: 42 years old Impression Diagnosis: Colon cancer/colostomy
Gender: Female

Name of Drug Dosage, Route, Mechanism of Action Indication Side Effects: Special Precautions Nursing Responsibilities
Freq., Timing

Generic: Dosage: Binds with opioid Moderate to severe CNS: Drowsiness, dizziness, Avoid use in patient with - Check doctor orders.
receptors within CNS, pain confusion, headache, sedation, bowel impaction, abrupt
Morphine 2mg euphoria, insomnia Observe 14 rights of
inhibiting ascending discontinuation, addictive
medication administration.
pain pathways. CV: Palpitations, change in B/P, personality, renal/hepatic
chest pain, hyper/ hypotension, disease and avoid taking if - Assess pain: location, type,
Brand: Route: contraindicated
edema character, intensity; give dose
Infomorph PF IV Therapeutic outcome: before pain becomes extreme.
EENT: Blurred vision, miosis,
Decreased pain diplopia - Ensure safety precautions
such as fall precautions,
Frequency: ENDO: Gynecomastia
raising bed side rails and
GI: Nausea, vomiting, anorexia, assist in terms of ambulation.
q 2 hours constipation, cramps, biliary tract
pressure - Monitor I&O ratio; check
Timing:
for decreasing output; may
prn GU: Urinary retention, indicate urinary retention.
impotence, gonadal suppression - Monitor VS especially the
BP
INTEG: Rash, urticaria, bruising,
- Monitor serum sodium.
flushing, diaphoresis, pruritus
- Monitor CNS changes:
 Classification: Contraindications Adverse Reactions dizziness, drowsiness,
hallucinations, euphoria, pupil
Pharmacothera Hypersensitivity, CNS: Seizures reactions.
peutic: hemorrhage, - Monitor allergic reactions:
CV: Bradycardia, shock, cardiac
paralytic ileus, rash, urticaria
Opioid agonist arrest, tachycardia
hypovolemic shock, - Monitor vital signs 5–10
Clinical: increased ICP and HEMA: Thrombocytopenia min after IV administration.
bronchial asthma - Consult physician if pain
Opioid analgesic RESP: Respiratory depression, relief is not adequate.
respiratory arrest, apnea - Inform significant others not
Chemical: to leave the patient.
Alkaloid - Inform significant others to
caution patient to avoid tasks
that require alertness, motor
skills until response to drug is
established.
- Inform significant others to
change the patient’s position
slowly to avoid orthostatic
hypotension.

Student’s Name: Cyril Joy N. Fernando BSN 3B

References:
Jones & Bartlett Learning (2015). Nurse’s Drug Handbook.
Kizior & Hodgson (2019). Saunders Nursing Drug Handbook. Elsevier.
Skidmore-Roth (2015). Mosby’s Drug Guide for Nursing Students Eleventh Edition. Elsevier Mosby.