NURSING CARE PLAN

PRE-OPERATIVE NCP

ASSESSMENT NURSING PLANNING INTERVENTION RATIONALE NURSING VINCENTIAN EVALUATION

DIAGNOSIS THEORY CORE VALUES
Subjective Short term: Independent: Carl Roger’s Commitment GOAL
data: Acute Pain to Vincentian PARTIALLY
related to After 8 hours of 1.  Provide - It is Theory of Self Excellence MET
“Gapang hugot multinodular nursing measures to preferable to Concept in
kag masakit nontoxic intervention the relieve pain provide an Mental Health Compassionat After the
akon tutunlan. goiter. client will be before it analgesic Nursing e Service nursing
Indi ako kakaon able to: becomes severe. before the interventions
insakto” as onset of pain or “It highlights Co- the client was
verbalized by 1. Report pain before it the need of Responsibility able to have
the client. of being becomes severe nurses to be rest and sleep
controlled. when a larger aware of their with the pain
Objective dose may be own self when scale of 3 out of
data: 2. Appear required. working with 10 post
relaxed and able clients, a state operatively.
2. Acknowledge
*Pain Scale of 9 to rest/sleep. - Nurses have that can only be
and accept the
out of 10 the duty to ask achieved if the
client’s pain.
*Dysphagia their clients nurses
*Restlessness Long term: about their pain themselves
*(+) and believe have adequate
Hoarseness of After 2 days of their reports of clinical
voice nursing pain. supervision and
*(+) Throat intervention the Challenging or an environment
tightness client will be undermining which is
*(+) Guarding able to: their pain supportive of
behavior reports results such work.”
*(+) Facial 1. Displays in an
grimaces improved well- unhealthy  thera
*(+) Swelling in being and peutic Margaret Jean
the anterior describes relationship  tha Watson’s
neck satisfactory pain t may hinder
*(+) control at a pain Philosophy and
Tenderness level less than 3 management Science of
upon palpation on a rating scale 3. Pain and deteriorate Caring
*CR: 81, RR: of 0 to 10. assessments rapport.
21, BP: 140/70 “Her theory
must be initiated stresses
- Pain
by the nurse. humanistic
*(+)Enlarged responses are
isthmus with a unique from aspects of
solid mass in each person, nursing as they
the right and some intertwine with
extremity clients may be scientific
reluctant to knowledge and
Right lobe of report or voice nursing
the thyroid out their pain practice.”
gland with solid unless asked
mass 4. Investigate about it.
signs and
Normal sized symptoms
left lobe of the related to pain. - Bringing
thyroid gland attention to
with: associated signs
 Solid and symptoms
massess may help the
 Calcified nurse in
nodule evaluating the
pain. In some
instances, the
 existence of
5. Determine the pain is
patient’s disregarded by
anticipation for the patient.
pain relief.
- Some patients
may be satisfied
when pain is no
longer intense;
others will
demand
complete
elimination of
pain. This
influences the
perceptions of
the
effectiveness of
the treatment
modality and
6. Determine their eagerness
factors that to engage in
alleviate pain. further
treatments.

- Ask clients to
describe
anything they
have done to
alleviate the
pain. These
may include, for
 example,
meditation,
deep breathing
exercises,
praying, etc.
Information on
7. Evaluate what
these alleviating
the pain
activities can be
suggests to the
integrated into
patient.
planning for
optimal pain
management.

Dependent: - The meaning

of pain will
1. Paracetamol directly
(Ifimol) IV given as determine the
ordered. patient’s
response.

2. Tramadol
(Dolright) 50mg - Analgesics are
slow IVTT given as given for short
ordered. term treatment
of moderate
pain.

- Management
for pain

ASSESSMENT NURSING PLANNING INTERVENTIO RATIONALE NURSING VINCENTIAN EVALUATION

 DIAGNOSIS N THEORY CORE VALUES
Subjective Short term: Independent: Carl Roger’s Commitment GOAL MET
data: Moderate to Vincentian
Anxiety After 3 hours 1. Validate source - Identification of Theory of Self Excellence After 3 hours of
“ Nakinulbaan related to of nursing of fear. Provide specific fear Concept in nursing
ako” as unfamiliarity intervention accurate factual helps patient Mental Health Compassionate intervention the
verbalized by with the the client will information. deal realistically Nursing Service client was able
the client. surgical be able to: with it. Patient to manage her
procedure as may have “It highlights Co- fear by
Objective evidenced by 1. Report misinterpreted the need of Responsibility verbalizing
data: increased heart decreased fear preoperative nurses to be readiness for
rate and anxiety information or aware of their the upcoming
*Diaphoresis reduced to a have own self when surgical
*Restlessness manageable misinformation working with procedure.
*Heart rate: level regarding clients, a state
105 bpm surgery. Fears that can only
*Respiratory 2. Can regarding be achieved if
rate: verbalize her previous the nurses
21 bpm readiness for experiences of themselves
the upcoming self or family have adequate
surgical may be resolved. clinical
procedure supervision and
2. Provide - Can provide an environment
preoperative reassurance and which is
education such alleviate patient’s supportive of
as deep anxiety. such work.”
breathing
exercises. - Provides for
 positive Margaret Jean
3. Compare identification, Watson’s
surgery schedule, reducing fear
patient that wrong Philosophy and
identification procedure may Science of
band, chart, and be done. Caring
signed operative
consent for “Her theory
surgical stresses
procedure. humanistic
- Establishes aspects of
4. Introduce staff rapport and nursing as they
at time of psychological intertwine with
transfer to comfort. scientific
operating suite. knowledge and
nursing
Dependent: practice.”

1. - May be
Metoclopramide provided in
10mg IV given as preoperative
ordered. holding area to
reduce
nervousness and
provide comfort.

ASSESSMENT NURSING PLANNING INTERVENTION RATIONALE NURSING VINCENTI EVALUATIO

DIAGNOSIS THEORY AN CORE N
 VALUES
Subjective data: Short term: Independent: Carl Roger’s Commitme GOAL MET
Deficient nt to
“Ano ang ubrahon Knowledge After 3 hours of 1. Assess - Facilitates Theory of Vincentian After 3 hours
sakon ma’am” as related to nursing patient’s level of planning of Self Excellence of nursing
verbalized by the information intervention the understanding. preoperative Concept in intervention
client. misinterpretation client will be able teaching Mental Compassio the client was
as evidenced by to: program, Health nate able to:
Objective data: inaccurate follow- identifies Nursing Service
through of 1. Verbalize content needs. 1. Fully
 Inaccurate instructions/devel understanding of “It Co- understand
follow through disease 2. Review specific - Provides highlights Responsibi about the
opment of
of instructions process/perioperati pathology and knowledge the need of lity perioperative
preventable
 Lack of recall ve process and anticipated base from nurses to be processes and
complications.
 Repeated postoperative surgical which patient aware of able to comply
questioning expectations. procedure. Verify can make their own with the
 Information that appropriate informed self when medical and
misinterpretati 2. Initiate consent has been therapy working treatment
on necessary lifestyle signed. choices and with clients, regimens.
 Non- changes and consent for a state that
compliance participate in procedure, and can only be
with the treatment presents achieved if
prescribed regimen. opportunity to the nurses
therapy Implement clarify themselves
 Expressing individualized misconception. have
psychological preoperative adequate
alterations teaching clinical
(anxiety) supervision
program: and an
environmen
3. Preoperative or t which is
postoperative - Enhances supportive
procedures and patient’s of such
expectations, understanding work.”
urinary and bowel or control and
changes, dietary can relieve
considerations, stress related Margaret
activity levels/ to the Jean
transfers, unknown or Watson’s
respiratory/ unexpected.
cardiovascular Philosophy
exercises; and Science
anticipated IV of Caring
lines and Penrose
drain. “Her theory
stresses
4. Preoperative humanistic
instructions: NPO aspects of
- Helps reduce
time, shower or nursing as
the possibility
skin preparation, they
of
which routine intertwine
postoperative
medications to with
complications
take and hold, scientific
and promotes
prophylactic antibi knowledge
a rapid return
otics, and nursing
to normal body
or anticoagulants,  practice.”
anesthesia preme function. 
dication.

5. Intraoperative
patient safety: -Reduced risk
not crossing legs of
during procedures complications
performed under or untoward
general outcomes,
anesthesia. such as injury
to the perineal
and tibial
nerves with
postoperative
pain in the
calves and
6. Inform patient feet.
or SO about
itinerary, -Logistical
physician/SO information
communications. about
operating room
(OR) schedule
and locations
(recovery
room,
postoperative
room
 assignment),
as well as
where and
when the
surgeon will
communicate
with SO
relieves stress
and mis-
communication
s,
preventing con
fusion  and
7. Discuss doubt over
individual patient’s well-
postoperative being.
pain management
plan. Identify -Increases
misconceptions likelihood of
patient may have successful pain
and provide management.
appropriate Some patients
information. may expect to
be pain-free
or fear becomi
8. Provide ng addicted to
opportunity to narcotic
practice coughing, agents.
deep-breathing,
and muscular -Enhances
exercises. learning and
continuation of
activity
postoperatively
.
ASSESSMENT NURSING PLANNING INTERVENTION RATIONALE NURSING VINCENTIAN EVALUATION
DIAGNOSIS THEORY CORE VALUES
Subjective Short term: Independent: Carl Roger’s Commitment GOAL MET
data: Disturbed to Vincentian
Body Image After 6 hours of 1. Assess the - The patient’s Theory of Self Excellence After 6 hours of
“Nahuya na ako related to nursing patient’s level of attitude towards Concept in nursing
mag gwa kag multinodular intervention the acceptance.  their new Mental Health Compassionate intervention the
situations makes
pirme ko gina nontoxic goiter client will be Nursing Service client was able
a significant
tago akon liog as evidenced by able to: to:
difference.
kung my iban swelling of the “It highlights Co-
katawo” as anterior neck 2. Assess the - Family
the need of Responsibility 1. Establish
verbalized by 1. The client nurses to be rapport to the
patient’s support members and
the client. will use learned system.  caregivers can aware of their nurse and
coping make temporary own self when expresses her
Objective strategies to and permanent working with feelings.
data: adjust to a new changes much clients, a state
reality. more that can only 2. Accept about
* Increase manageable and be achieved if the physical
number and 2. The client predictable.  the nurses changes
sizes of thyroid will recognize themselves happened in her
self-sabotage 3. Encourage the - This is a form
nodules. have adequate body.
and accept patient to express of coping
* Enlarged clinical
help. feelings about strategy that
isthmus with a body changes.  starts the healing supervision and
solid mass in process. Sharing an environment
3. The client
the right their feelings which is
will identify
extremity provides supportive of
irrational beliefs
excellent insight such work.”
*Right lobe of and use new into the patient’s
the thyroid insecurities and
gland coping helps the nurse Margaret Jean
with solid mass strategies to in individualizing Watson’s
enhance care.
*Normal sized perception Philosophy and
about body 4. Praise the - Positive Science of
left lobe of the
patient every reinforcement
thyroid gland image.  Caring
time he or she is promotes self-
with: cooperative and esteem and
 Solid “Her theory
willing to motivates the
massess participate in patient to
stresses
 Calcified care.  continue care.  humanistic
nodule aspects of
- Patients may nursing as they
* Hiding of 5. Provide benefit from intertwine with
affected body resources, such as exchanging scientific
part. a list of support experiences, knowledge and
groups.  feelings, and nursing
thoughts with practice.”
* Change in
people going
social behavior
through the
(withdrawal).
same hardships. 

- This approach
6. Encourage the allows the
patient in self-care patient to
with a step-by-step become used to
approach.  the altered body
part or function
without
 overwhelming
the patient. 

- Coping
7. Assist the strategies that
patient in have worked in
identifying the past might
coping not be as
strategies.  effective
anymore. Finding
new coping
methods is
essential in the
transitioning
process. 

- Knowledge and
skills about the
8. Teach the care in the
patient about how altered body part
to care for the or function
changed body part increases
or function.  independence
and confidence. 

- Family and
caregivers have
9. Involve to be involved to
family members ensure proper
and caregivers in continuity of care
routine care.  after discharge. 

- Knowledge
about the altered
body part or
10. Encourage the function
patient and family promotes
to ask questions.  confidence in
family and
caregivers and
promotes safety. 
 NURSING CARE PLAN
POST-OPERATIVE NCP

ASSESSMENT NURSING PLANNING INTERVENTION RATIONALE NURSING VINCENTIAN EVALUATION

DIAGNOSIS THEORY CORE VALUES
Subjective: Independent: Faye Glenn Commitment GOAL MET
Risk for Short term: abdellah” 21 to Vincentian
” Medyo nabudlayan ko Ineffective 1. Monitor - Respirations Typology if Excellence After 2 hours of
maginhawa” as Airway After 2 respiratory rate, may remain nursing nursing
verbalized by the client. Clearance hours of depth, and work of somewhat problems” Compassionat intervention the
nursing breathing. rapid, but the e Service client was able
Objective: intervention development to maintain
the client of respiratory “ To Co- patent airway,
 Irritability will maintain distress is recognize the Responsibility with aspiration
 Restlessness patent indicative of psychological prevented.
 Difficulty of airway, with tracheal responses of
communicating aspiration compression the body to Vital sign taken:
 Vital signs: prevented. from edema or disease T:36.8°C
T:36.8°C hemorrhage conditions – CR:80 bpm
CR:80 bpm 2. Auscultate pathological, RR:18 bpm
RR:27 bpm -Rhonchi may physiological BP:110/80mmH
breath sounds,
BP:110/80mmHg indicate airway and g
noting the
O2 sat: 89 % obstruction compensatory O2 sat: 100 %
presence of
and
rhonchi.
accumulation
of copious Carl Roger’s
thick
 secretions. Theory of
Self Concept
3. Assess for - Indicators of in Mental
dyspnea, stridor, tracheal Health
“crowing,” and obstruction Nursing
cyanosis. Note and laryngeal
quality of voice. spasm, “It highlights
requiring the need of
prompt nurses to be
evaluation and aware of their
intervention own self
when working
4. Caution patient
-Reduces the with clients, a
to avoid bending
likelihood of state that can
neck; support head
tension on the only be
with pillows.
surgical achieved if
wound. the nurses
5. Assist with themselves
- Maintains have
repositioning, deep
clear airway adequate
breathing
and clinical
exercises, and/or
ventilation. supervision
coughing as
Although and an
indicated.
“routine” environment
coughing is which is
not supportive of
encouraged such work.”
and may be
 painful, it may
be needed to Margaret
clear Jean
6. Suction mouth secretions. Watson’s
and trachea as
indicated, noting -Edema and Philosophy
color and pain may and Science
characteristics of impair the of Caring
sputum. patient’s ability
to clear own “Her theory
7. Check dressing airway. stresses
frequently, humanistic
especially the - If bleeding aspects of
posterior portion. occurs, the nursing as
anterior they
dressing may intertwine
appear dry with scientific
because blood knowledge
pools and nursing
8. Investigate
dependently. practice.”
reports of difficulty
swallowing,
- May indicate
drooling of oral
edema or
secretions.
sequestered
bleeding in
tissues
surrounding
the operative
 9. Keep site.
tracheostomy tray
at the bedside. -Compromised
airway may
create a life-
threatening
situation
requiring an
emergency
10. Provide steam
procedure.
inhalation; humidify
room air. - Reduces the
discomfort of
sore throat
and tissue
edema and
promotes
Dependent: expectoration
of secretions.
1. Administere
d Oxygen
therapy as
ordered -Oxygen
reduces and
correct
hypoxemia
ASSESSMENT NURSING PLANNING INTERVENTION RATIONALE NURSING VINCENTIAN EVALUATION
DIAGNOSIS THEORY CORE VALUES
Subjective data: Short term: Independent: Faye Glenn Commitment GOAL MET
“ Masakit kung mag Acute Pain abdellah” 21 to Vincentian
tulon” as verbalized by related to After 6 hours 1. Assess - To have Typology if Excellence After 6 hours
the client. stimulation of of patient’s baseline data nursing of
nerve endings nursing condition and & to note any problems” Compassionate nursing
Objective data: secondary to intervention monitor vital changes in Service intervention
surgical the client will signs vital signs. the client was
 Pain on the neck procedure verbalize “ To recognize Co- able to
during (total relief of 2. Encourage - Reduces the Responsibility verbalize relief
swallowing due thyroidectomy) pain within patient to assume abdominal psychological of
to post total tolerable position of tension and responses of pain within
thyroidectomy level. comfort. promotes the body to tolerable
 Pain scale of sense of disease level.
7/10 control. conditions – Pain scale of
 Restlessness pathological, 3/10
 Vital signs: 3. Review factors - Helpful in physiological
T:36.8°C that aggravate or establishing and
PR:80bpm alleviate pain. diagnosis compensatory
RR:18cpm And
BP:110/80mmHg treatment
O2 sat: 96% needs Carl Roger’s
4. Note reports of
pain, including - Pain is not Theory of Self
location, always Concept in
duration, present, but if Mental Health
intensity present Nursing
(0–10 scale) should be
. compared “It highlights
 with patient’s the need of
previous pain nurses to be
symptoms. aware of their
Dependent: own self when
working with
1. Paracetamol clients, a state
(Ifimol) 1g IV that can only
drip given as be achieved if
ordered. the nurses
-Treatment
themselves
2. Tramadol for post-
have adequate
(Dolright) 50mg operative pain
clinical
slow ivtt given as
supervision
ordered
and an
environment
3. Celecoxib
which is
(Coxidia)
supportive of
200mg/cap given
such work.”
as ordered.

Margaret Jean
Watson’s

Philosophy and
Science of
Caring

“Her theory
 stresses
humanistic
aspects of
nursing as they
intertwine with
scientific
knowledge and
nursing
practice.”

ASSESSMENT NURSING PLANNING INTERVENTIO RATIONALE NURSING VINCENTIAN EVALUATION

 DIAGNOSIS N THEORY CORE VALUES
Subjective Data: Short Independent: Commitment GOAL MET
N/A Risk for term: Faye Glenn to Vincentian
Infection 1. Maintain strict - Aseptic abdellah” 21 Excellence After 3 hours of
Objective Data: related to After 3 asepsis for technique Typology if nursing
invasive hours of dressing decreases the nursing Compassionate intervention the
 Surgical Incision procedure nursing changes, wound chances of problems” Service client
site intervention care, intravenous transmitting or
 With Penrose the client: therapy, and spreading Co- 1. Was able to
drain drainage pathogens to or “ To Responsibility remain free of
 Vital signs: 1. Will handling. between recognize the infection.
T:37.1°C remain free patients. psychological (-) Foul odor
PR:80bpm of infection, Interrupting the responses of (-) Chills
CR:83bpm as chain of the body to
RR:18cpm evidenced infection is an disease Vital signs
BP:140/80mmHg by normal effective way to conditions – taken:
O2 sat: 96% vital signs prevent the pathological,
and absence spread of physiological T:36.3°C
of signs and infection. and PR:80bpm
symptoms compensatory CR:83bpm
2. Ensure that
of infection. any articles used -This reduces RR:18cpm
or eliminates BP:120/80mmHg
are properly
2. Client will germs. Carl Roger’s O2 sat: 96%
disinfected or
maintain or
sterilized before
restore Theory of
use.
defenses. Self Concept
in Mental
3. Wash hands or -Friction and Health
perform hand
hygiene before running water Nursing
having contact effectively
with the patient. remove “It highlights
Also, impart microorganisms the need of
these duties to from hands. nurses to be
the patient and Washing aware of their
their significant between own self
others and know procedures when working
the instances reduces the risk with clients, a
when to perform of transmitting state that can
hand hygiene or pathogens from only be
“5 moments for one area of the achieved if
hand hygiene”: body to the nurses
another. Wash themselves
A. Before hands with have
touching a antiseptic soap adequate
patient. and water for clinical
B. Before clean or at least 15 supervision
aseptic procedure seconds, and an
(wound dressing, followed by an environment
starting an IV, alcohol-based which is
etc.). hand rub. If supportive of
C After body fluid hands were not such work.”
exposure risk in contact with
D. After touching anyone or
a patient anything in the Margaret
E. After touching room, use an Jean
the patient’s alcohol-based Watson’s
surroundings. hand rub and
rub until dry. Philosophy
Plain soap is and Science
good at of Caring
reducing
bacterial “Her theory
counts, but stresses
antimicrobial humanistic
soap is better, aspects of
and alcohol- nursing as
based hand they
rubs are the intertwine
4. Educate clients best. with scientific
and SO knowledge
(significant other) -Knowledge of and nursing
about appropriate ways to reduce practice.”
cleaning, or eliminate
disinfecting, and germs reduces
sterilizing items. the likelihood of
transmission.
5. The following
methods help
break the chain -Measures to
of infection and break the chain
prevent of infection and
conditions that prevent
may be suitable infection
for microbial
growth:

*Change dressing
and bandages
that are soiled or
wet.
*Assist clients in
carrying out
appropriate skin
and oral hygiene.
*Dispose of
soiled linens
properly.
*Ensure all fluid
containers are
covered or
capped.
*Avoid talking,
coughing, or
sneezing over
open wounds or
sterile fields.
*Wear gloves
when handling
patient
secretions.
*Instruct clients
to perform hand
 hygiene when
handling food or
eating.

6. Promote nail
care by keeping -Rough edges
the client and the or hangnails
nurse‘s can harbor
fingernails short microorganisms
and clean. .

7. Limit visitors

- Restricting
visitation
reduces the
Dependent: transmission of
pathogens.
1. Ampicillin-
Sulbactam
(Silgram) 750mg -Prevention of
given as ordered. susceptible
infections.

ASSESSMENT NURSING PLANNING INTERVENTION RATIONALE NURSING VINCENT EVALUATION

DIAGNOSIS THEORY IAN
CORE
VALUES
Subjective Short term: Independent: Commitm GOAL MET
data: Impaired Verbal Faye Glenn ent to
--------------- Communication After 7 hours of 1. Maintain a clam - Individuals abdellah” 21 VincentiaAfter 7 hours of
related to nursing unhurried manner. with Typology if n nursing
Objective data: laryngeal nerve intervention Provide sufficient expressive nursing Excellencintervention the
damage the client will time for client to aphasia may problems” e client was able to
 Difficulty of secondary to be able to: respond. talk more communicate and
Forming thyroid removal as easily when Compassi express feelings
words or evidenced by 1. Establish they are “ To recognize onate using non-verbal
sentences inability of the methods of rested and the Service cues such as hand
 Use of patient to speak communication relaxed and psychological gestures and uses
in which needs
nonverbal when they responses of Co- writing materials.
can be
cues. expressed. are talking to the body to Responsi
one person disease bility
2. Demonstrate at a time. conditions –
congruent verbal 2. Keep pathological,
or non-verbal - This helps physiological
communication
communication. reduce the and
with the patient
demand for compensatory
short and simple.
the patient
Use questions
to speak and
answerable with a
helps him Carl Roger’s
yes or no.
rest his
voice. Theory of Self
3. Provide the
- Using these Concept in
patient alternative
measures Mental Health
means to
helps the Nursing
communicate such
as writing pads, patient
slate boards and communicate “It highlights
letter/picture his needs the need of
boards. more nurses to be
effectively, aware of their
reduces own self when
stress related working with
to having to clients, a state
use his voice that can only be
to speak and achieved if the
allows nurses
4. Anticipate the further rest. themselves
needs of the have adequate
- Anticipating clinical
patient by visiting
his needs supervision and
him often and
also an environment
being aware of
promotes which is
non-verbal cues.
relaxation supportive of
because such work.”
there is a
reduced
need to use Margaret Jean
5. Maintain a quiet his voice to Watson’s
environment. ask for
assistance. Philosophy and
- Enhances Science of
ability to Caring
hear
whispered “Her theory
communicati stresses
on and humanistic
reduces the aspects of
necessity for nursing as they
the patient intertwine with
to raise or scientific
strain voice knowledge and
to be heard. nursing
practice.”