NURSING CARE PLAN

Name: Patient C.P Sex: Female Room No. 1223

Cues Nursing Rationale Goals and Intervention Rationale Evaluation

Diagnosis Objectives

Subjective: Acute pain Acute pain Short Term: Independent: Independent: Goal Met.
“Di ako related to is the state After 8 hours 1. Vital signs 1. Alterations Short Term:
makagalaw operative in which of nursing were from After 8 hours
ng maayos procedure as an intervention, monitored normal may of nursing
kasi masakit evidenced individual the patient will every 4 be signs of intervention,
yung opera by experience be able to: hours until infection the patient
ko”. grimacing, s and ● Have a stable was able to:
verbalizatio reports the Pain Scale
“Hinihintay n of pain, presence from 8/10 2. Assess 2. To establish ● Had a
ko lang din and pain of severe to 3/10 quality, baseline Pain
dumating scale 8/10 discomfort during rest characteris data for Scale
yung gamot, or an periods and tics and comparison from 8/10
kasi uncomfort during severity of in making to 3/10
sumasakit”. able movement pain evaluation. during
sensation rest
“Nagpapatu lasting 3. Maintain a 3. To periods
long ako sa from 1 ● Demonstrat calm and minimize and
kasama ko second to e relaxation quiet stimulus during
kapag less than 6 techniques environme that could movemen
gagalaw months to decrease nt aggravate t
ako, para (Nanda, pain the
hindi 2018). Due condition of ● Demonstr
kumirot”. to surgical the patient. ated
trauma ● Verbalizes relaxation
“Sumasakit with an minimized 4. Check the 4. Moistened technique
yung inflammat or wound dressings s to
bandang ory controlled dressing are decrease
likod ko” reaction feeling of favorable pain
and pain site for
Objective: initiation microorgani ● Verbalize
● Facial of an sm to d
Grimace afferent culture. minimize
● Positioni neuronal d or
ng to barrage. 5. Provide 5. Reduces controlled
ease position of pressure, feeling of
pain comfort providing pain
● Pain some
Scale: measure of
8/10 comfort and
pain relief.
6. Instructed 6. Deep
to do breathing
activities facilitates
such as maximum
deep expansion
breathing of the lungs
exercise. and smaller
airways.

7. Inform to 7. To prevent
avoid complicatio
weight ns on the
bearing incision
until site,
allowed activities
that may
extend the
cut must be
avoided.

8. Advise to 8. Allowing
rest and oxygen and
sleep nutrients to
be utilized
for tissue
growth,
healing,and
regeneratio
n

Dependent: Dependent:
1. Administe 1. To relieve
r the pain.
Paracetam
ol as
ordered by
physician

2. Provide 2. Fluids are

supplemen required to
tal fluids replace
losses and
aid in
mobilizatio
n of
secretions
 NURSING CARE PLAN

Name: Patient R.C Sex: Male Room No. 1225

Cues Nursing Rationale Goals and Intervention Rationale Evaluation

Diagnosis Objectives

Subjective: Disturbed Disturbed Goal: Independent: Independent: Goal met.

“Ang dami sleep pattern sleep pattern To improve ● Assess ● To establish Improved
kasing related to is defined as patient patient’s a baseline patient
nakakabit environmental the sleeping sleep data for the sleeping
sa kamay barrier and time-limited pattern and pattern and plan of care pattern and
ko na abdominal interruption relieve pain frequency and relieved pain
tinutusok pain as of sleep before and associate
ng nurse evidenced by amount and Short Term: after correction Short Term:
tas tunog frequent alarm quality due After 8 hours admission of sleep After 8 hours
pa ng tunog from infusion to external of nursing to the disturbance of nursing
kaya hirap pump and factors intervention: hospital intervention:
na ako pain scale of (NANDA,
makatulog 6/10 2018). Sleep ● The patient ● Identify ● To identify ● The patient
at kung is required will report other causative or had reported
ano-anong to provide feeling related contributing feeling
pwesto na energy for rested as factors factors that rested as
lang physical and evidenced contributing will be evidenced
ginawa ko mental by rested to sleep incorporated by rested
para activity. The appearance deprivation in the plan appearance
mawala amount of ● The pain of care ● The pain
yung sakit” sleep that will subside had subside
individuals from 6/10 ● Position the ● To alleviate from 6/10 to
“Madalas require to 3/10 client in a discomfort 3/10
nanonood varies with ● The patient comfortable on the ● The patient
nalang ako age and will lying abdominal achieved
ng TV kasi personal achieve position area optimal
di talaga characteristi optimal amount of
ako cs. Sleep amount of ● Advice the ● To sleep for 7
makatulog” patterns can sleep for 7 patient to compensate to 8 hours
be affected to 8 hours take naps from the per day
“Kung by the ● Decrease lack of sleep ● Decreased
makatulog environment the presence of
man laging , especially presence of ● Ensure that ● One of the eyebags
putol-putol in hospital eyebags infusion safety ● Decreased
kasi bukod care units. ● Decrease pump with features of presence of
sa maingay These the medication, infusion dark circles
ang sakit patient presence of IV fluid, or pumps is under the
pa ng tiyan experience dark circles parenteral alarms that eyes
ko” sleep under the feedings are are intended
 disturbance eyes properly to activate
Objective: secondary to administere in event of a
● Weakness the frequent d to the problem
● Restless noise from patient (ex. Air or
● Dark infusion blockage in
circle pump the tubing)
under the
eyes ● Continuousl ● To prevent
● Yawning y monitor it from
● Presence Circadian the infusion having
of clock system pump every problems
eyebags (responsible 4 hours which
● Pain for disturbs the
scale: regulating sleep of the
6/10 sleep-wake patient
cycle) caused by
↓ frequent
Sleep alarms
homeostasis
↓ ● Instruct the ● To enhance
Alteration of relative to the sleep
circadian provide pattern in
timekeeping with relation to
system comfortable good and
and/or bed linens conditioned
misalignmen and pillows environment
t between
endogenous ● Ensure ● External
circadian environmen stimuli
rhythm and t is quiet aside from
exogenous and has a frequent
factor that comfortable alarm from
affect sleep temperature infusion
timing as per pump can
(frequent patient interfere the
alarm of desire sleep and
infusion increases
pump and awakening
abdominal
pain) ● Provide ● To distract
↓ comfort attention on
Disturbance measure pain, reduce
in sleep through tension, and
wake therapeutic to promote
generating touch non-pharma
or timing cological
mechanisms pain
↓ managemen
 Disturbed t
sleep pattern
Dependent: Dependent:
● Administer ● Paracetamo
paracetamol l is a mild
as analgesic
prescribed and
antipyretic,
and is
recommen
ded for the
treatment
of most
painful and
febrile
conditions
 NURSING CARE PLAN

Name: Patient J.H.G II Age: 55 years old Sex: Male Room No. 1222

Cues Nursing Rationale Goals and Intervention Rationale Evaluation

Diagnosis Objectives

Subjective: Activity Activity Goal: Independent: Independent: Goal Met.

“I don’t do Intolerance intolerance To increase ● Asses ● Accurate Increased
any exercise related to bed is activity patient information activity
or activity rest insufficient tolerance medical required in tolerance
aside from secondary to physiologic history planning
going to the headache al or Short Term: activities Short Term:
comfort psychologic After 8 hours related to After 8 hours
room” al energy to of nursing activity of nursing
endure or intervention: intolerance intervention:
“Sometimes complete
when I get required or ● The patient ● Assess ● Provides ● The patient
out of the desired will regain client’s comparative regained his
bed I daily his strength ability to baseline and strength to
experience activities to perform perform provides perform
mild (NANDA, activity as normal task information activity as
headache 2018). Due evidenced and ADL’s about evidenced
but not all to headache by absence needed by absence
the time as activity are or reduced education to or reduced
compared being headache maintain headache
before” restricted to pain quality of pain
prevent the ● The life ● The
Objective: risk of fall headache headache
● Pain scale: associated pain will ● Identify ● To identify pain
6/10 with injury subside other related causative or subsides
● Prolonged from 6/10 factors contributing from 6/10 to
lying on to 3/10 contributing factors that 3/10
bed ● The patient to activity will be ● The patient
will be able intolerance incorporate performed
to perform d in the plan previous
previous of care activity as
activity as evidenced
evidenced ● Monitor the ● To provide by absence
by absence vital signs baseline of headache
of headache every 4 data ● The patient
● The patient hours because performed
will be able pain activity
to perform associated without
activity with assistance
without headache
assistance increase the
vital signs

● Note ● May
changes in indicate
balance / neurologic
gait changes

● Provide ● Positive
positive atmosphere
atmosphere minimizes
while frustration
acknowledgi and
ng patients re-channel
situation energy

● Promote ● To enhance
comfort sense of
measures well-being
and provide and
relief of pain expectation
of return to
usual
activities

● Assist ● To prevent
patient in orthostatic
gradual hypotension
change of and to give
position the body the
a.Elevate the chance to
head of the adjust in the
bed 30 effects of
degrees gravity on
b.Elevate the circulation
head of the in an
bed 60 upright
degrees posture
c.Elevate the
head of the
bed 90
degree
d.Let the
patient sit
on the
edge of the
bed
e.Dangle the
 patient leg
f. Let the
patient
assume
and
upright
posture

● Alternate ● Rest
activity with between
periods of activities
rest provides
time for
energy
conservatio
n and
recovery
from
headache
pain

● Inform the ● To prevent

patient to the risk of
request fall which
assistance can
when needed associate
for daily the patient
activities to injury

● Let the ● Provides

patient normalcy
perform and will
range of help reduce
motion complicatio
(ROM) ns
exercise associated
with
immobility

● Plan activity ● Promotes

progression gradual
with client return to
day per day normal
activity
level and
improved
muscle tone
or stamina
 without
headache

● Educate the ● Constipatio

patient that n occurs
decrease when bowel
activity movement
causes become less
constipation frequent
and stools
become
difficult to
pass

Dependent: Dependent:
● Administer ● Myonal is
Myonal as used to treat
prescribed aches and
pains.
 NURSING CARE PLAN

Name: Patient S.M Sex: Male Room No. 1227

Cues Nursing Rationale Goals and Intervention Rationale Evaluation

Diagnosis Objectives

Subjective: Readiness Readiness Short Term: Independent: Independent: Goal Met.

● “Sumasa for self-care for After 8 1. Examine 1. Provide Short Term:
kit kasi or self-care or hours of the opportunit After 8 hours
yung knowledge knowledge nursing patient’s y to of nursing
opera sa related to involves intervention, current assure intervention,
akin, anopost helping the the patient knowledge accuracy the patient will
ba pwede surgery as patient deal will be able about and be able to:
kong evidenced with to: post-surger completen ● Learned
gawin?” by verbal sequence of y care ess of the 5
report of cognitive ● Learn 5 knowledg methods to
● “Kapag wanting to information methods e base for be
may nag know more related to a to be future practiced
rounds na about after particular practiced learning. in order to
nurse, care of topic or in order decrease
tinatanon surgery learning to 2. Encourage 2. Questions pain.
g ko din acquisition decrease patient to can help
sila kung to pain. ask for open ● Assumed
paano health-relat questions communic responsibil
hindi ed ● Assume or ation ity for
sumakit.” objectives responsi clarificatio between managing
and can be bility for ns healthcare treatment
● “Kailang reinforced managin profession regimen
an ko (NANDA, g als and
lang pala 2018). treatment patients ● Verbalized
inumin regimen and methods
yung confirm that
gamot ko ● Verbalize comprehe provide
at hindi methods nsion of relief
itigil that the
hangga’t provide informatio
di ko siya relief n
kino provided.
konsulta
sa 3. Inform the 3. Helps to
doctor.” patient reduce
about anxiety by
post-surgic preparing
Objective: al care, and the patient
● Patient the need for for what
 shows medical to expect,
positivity follow-up. facilitatin
towards Report for g
the any complianc
treatment problems or e, and
● Pain critical providing
Scale: signs and informatio
5/10 symptoms n about
probable
complicati
ons.

4. Encourage 4. To
the patient prevent
to check infection
the wound and for a
and faster
dressing healing
from time process.
to time.

5. Instruct the 5. To control

patient to surgical
take pain and
medication help the
s at the body heal
right time
and dose as
prescribed.

Dependent: Dependent:
1. Administer 1. To
analgesics relieve
as ordered pain
by the
physician.
Submitted to:

.
Ion Dominguez Gregorio, RN, MAN

Prepared by:

.
Anabelle S. Rico, Student Nurse Maria Pauline Antoinette Sy, Student Nurse