DAVAO DOCTOR’S COLLEGE

General Malvar St., Davao City

Nursing Program
NURSING CARE PLAN

Name of Patient: Patient N. Date of Admission: October 7, 2022 Room: RM 213

Age: 65 y.o Sex: _Male Civil Status: Married Chief Complaint: unexplained weight loss, weakness, and breathlessness
Religion: Attending Physician: Dr. Claude

DATE & TIME CUES NURSING DIAGNOSIS
October 7, 2022 Subjective: After 8 hours of nursing
@7am Acute pain related to intervention the patient will 1. Perform a thorough pain The patient in pain is the most
“Masakit ang tiyan abdominal distention be able to:
ko.” As verbalized by secondary to chronic
the patient. lymphocytic leukemia
Objective: Scientific basis
According to NANDA 11 th
➢ Epigastric Pain with
edition (2019), Acute pain
a pain scale of 6/10refers to a state in which
➢ Feeling of fullness an individual feels and
➢ Mild abdominal reports the presence of
distention upon significant discomfort or
percussion an unpleasant sensation
lasting from one second
to less than six months.
When leukemia cells
collect in and around the
spleen, causing it to
enlarge, Chronic
lymphocytic leukemia can
cause abdominal pain.
REFERENCES: Herdman,
H. T., & Kamitsuru, S.
(2019). Supplement to
NANDA International
Nursing Diagnoses:
Definitions and
Classification, 2018–2020
(11th Edition): New things
you need to know (1st ed.).
GOALS/OBJECTIVES NURSING
INTERVENTIONS
INDEPENDENT
assessment. Assess for
• Report relief from provoking factors,
pain as evidenced Quality/Characteristics,
by a pain scale of Location, Severity, and
less than 3 Onset duration frequency pain evaluation since they can
• Demonstrate the by asking questions to the
use of relaxation patient.
skills and
diversional
activities, as
indicated, for the
patient’s situation.
• Verbalize
nonpharmacological 2. Assess the patient's vital
method that signs on a regular basis.
provides relief.
3. Assist the patient in a
comfortable and tolerable and stress throughout the
position once every two
hours.
4. Assist the patient
manage his pain or
discomfort by providing
comfort therapy such as
distraction tactics or
techniques which include
deep breathing exercises
RATIONALE EVALUATION
October 7, 2022 @3pm
“GOAL MET”
dependable source of
information concerning their After 8 hours of nursing
discomfort. Their self-report of intervention the patient
pain is the gold standard in was able to:
• Report relief from
pain as evidenced
describe the location,
by a pain scale of
intensity, and duration. Thus,
2/10
pain evaluation through an
• Showed
interview assists the nurse in appropriate use of
developing appropriate pain relaxation methods
treatment measures. and diversional
To provide baseline data of activities for the
patient's condition
the patient.
• Verbalized
The comfortable position of nonpharmacologica
the patient reduces tension l method that
provides relief.
body which makes the patient
free from the abdominal strain
that he is feeling and boosts
sensation.
Non-pharmacologic therapies,
notably comfort measures,
help people feel better. It also
aids in the patient's ability to
refocus his thoughts and cope
with the stress of pain.

To prevent the fatigue that

5. Encourage adequate can impair the ability to
rest periods for the patient manage or cope with the
patient’s pain
Throughout the course of the
6. Encourage the patient to day, the patient tends to lose
drink adequate amounts of water through breathing and
water. sweating. To avoid
dehydration and keep the GI
tract working normally,
restoring water is important.
Intaking of proper adequate of
water also helps lessen the
pain
 DEPENDENT
7. Administer medications
as prescribed by the Tramadol is used to treat or
physician. (Tramadol) alleviate moderate to severely
pain.

COLLABORATIVE
8. Consult with a dietician To create a diet plan and
as needed determine which items should
be avoided. Additionally,
patients may need additional
instruction and treatments
from a trained dietician if they
are unable to maintain healthy
diets or limits.

Jevee Jean P. Better

BBN/DTS/2020 NAME OF STUDENT
References:
Herdman, H. T., & Kamitsuru, S. (2019). Supplement to NANDA International Nursing Diagnoses: Definitions and Classification, 2018–2020 (11th Edition)
 DAVAO DOCTOR’S COLLEGE

General Malvar St., Davao City

Nursing Program

FDAR

Name of Patient: Patient N. Date of Admission: October 7,2022 Room: RM 213

Age: 65 Sex: _M Civil Status: Married Chief Complaint: unexplained weight loss, weakness, and breathlessness
Religion: N/A Attending Physician: Dr. Claude

DATE TIME FOCUS/NURSING DATA ACTION RESPONSE

DIAGNOSIS

October 7, 9:30 am Acute pain Subjective: 1. Establish rapport with the ● Report relief from
2022 “Masakit ang tiyan ko.” patient and his or her pain as evidenced by
As verbalized by the relatives. a pain scale of 2/10
10:30 am patient. 2. Assess the patient's vital ● The verbalized
signs on a regular basis. nonpharmacological
11:00 am Objective: 3. Perform a thorough pain method provides
➢ Epigastric Pain with assessment. Assess for relief.
provoking factors, ● The patient was
a pain scale of 6/10
Quality/Characteristics, able to verbalize
➢ Feeling of fullness
Location, Severity, and Onset understanding of the
➢ Mild abdominal duration frequency by asking treatment.
11:30 am distention upon questions to the patient. ● The patient was
percussion 4. Assist the patient in a able to demonstrate
comfortable and tolerable behavior to alleviate
position once every two hours. pain such as
12:00nn 5. Assist the patient manage his breathing exercises
pain or discomfort by
providing comfort therapy
such as distraction tactics or
techniques which include
deep breathing exercises
1:00pm 6. Administer medications as
prescribed by the physician.
(Tramadol)
EVALUATION:
□Fully Met
■Partially Met
□Unmet