College of Nursing

Nursing Care Management Plan

Name of Student: Jessa Mae M. Pagobo Year and Section: 4B

Level Outcome: At the end of the fourth year, given groups of clients (individuals, families, population groups, and communities) with health problems and special needs, the
learners demonstrate safe, appropriate, and holistic care utilizing the nursing process and can assume first-level entry positions in any field of nursing.
Medical Diagnosis: Multinodular Colloid Goiter
Clinical Floor: Surgical Ward (1st floor) Shift: Afternoon Shift (3 PM - 11 PM)
Dates of Assignment: April 3-4 (Monday Afternoon and Tuesday Afternoon)

Assessment Nursing Diagnosis Goals of Care Nursing Interventions Rationale Evaluation

SUBJECTIVE DATA: Risk for infection After 4 hours of nursing  Adress the importance of  Reduces the risk of After 4 hours of nursing
“Ngol-ngol pa ang gi related to surgical intervention, the personal hygiene, especially spreading the foreign intervention, the patient
operahan dapit” incisions. patient will be free of hand hygiene organisms was not infected as
infection as manifested manifested in her normal
OBJECTIVE DATA: by timely wound  Rendered bed bath with  To promote hygiene as vital signs and reduced
 Facial Grimace healing and normal warm water. well as pain relief. pain scale to 8 out of 10.
 Vital Signs vital signs and will
-BP = 110/80 identify interventions
-T = 36.2 to prevent and reduce  Change the bed linens  To prevent contamination.
-R = 21 the risk for infection. regularly.
-P = 95
-Spo2 =98  Clean the wound and  To promote healing of the
change the dressing. incision and reduce the
risk of infection.
 Document  For baseline data.
 University of Cebu – LapuLapu and Mandaue
College of Nursing
Drug Study

Patient’s Initials: S.R.A Age: 25

Medical Diagnosis: Multinodular Colloid Goiter
Allergies: None

Contraindications &
Generic/ Brand Name & Dose Strength & Indication/ Mechanism of
Adverse/ Side Effects of Nursing Responsibilities Rationale
Classification Formulation Drug Action
Drug Interaction
Generic: Ordered: Indication: Contraindications:  Monitor vital signs  Baseline data
Paracetamol Paracetamol 1 tab BID PO Temporary reduction of  Contraindicated  Obtain a history of the  To avoid drug-to-
fever, temporary relief of with allergy to patient’s previous drug interactions.
Brand: Timing: minor aches ad pains acetaminophen medication
Tylenol Twice a day (BID) caused by common cold  Use cautiously  Monitor blood  To monitor any
and influenza, headache, with impaired pressure while remarkable
Classification: Duration: sore throat, toothache, hepatic function, adjusting the dosage, change since
Analgesics(nonopioidid) 7 days backache, menstrual chronic especially in patients blood pressure
Antipyretic cramps, etc. alcoholism, with heart failure or provides essential
Another form: pregnancy, severe aortic stenosis information to aid
Tablets: 600mg Mechanism of action lactation diagnosis and
Antipyretic: Reduces fever  Educate to monitoring.
by acting directly o the Adverse effects/side immediately notify  Patient education
hypothalamic heat- effects: the prescriber o helps chronic
regulating center to cause  CNS: headache dizziness, arm or disease
vasodilation and sweating,  CV: chest pain, leg swelling, management by
which helps dissipate heat. dyspnea, difficulty informing and
myocardial breathing, hives, involving patients
damage or rash. in care instructions
 GI: hepatic toxicity and lifestyle
and failure, changes.
jaundice.