Zeff Klyde Pascual

BSN1-E
Fundamentals of Nursing Final Requirement - Nursing Care Plan

A 40 year old woman appears at the A & E with complaints of pain in her ankle. She suffered a
trauma to her ankle in which she fell down in a hole. Her examination reveals a fracture and she
will need casting but in the meantime she
is in need of pain management. Her temp is 37.8°C, Pulse is 105 bpm, Respiration is 22 cpm
and B/P of 116/70 mmHg.

Assessment Nursing Dx Planning Intervention Rationale Evaluation

- 40 year Acute Pain - The patient 1. Administer 1. Analgesics - The patient

old female related to will report a analgesics as help to reported a
with ankle ankle fracture decrease in ordered. reduce pain decrease in
pain as evidenced pain level 2. Elevate the and pain level
- History of by patient's within 30 affected leg discomfort. within 30
trauma to reports of minutes of to reduce 2. Elevating minutes of
ankle from pain. intervention. swelling. the affected intervention.
falling in a - The patient 3. Apply ice leg helps to - The
hole will receive packs to the reduce patient
- appropriate affected area swelling and received
Examination pain for 20 pain. appropriate
reveals management. minutes at a 3. Ice packs pain
fracture - The patient time. help to management
requiring will 4. Educate reduce - The
casting understand the patient on swelling and patient
- Vital signs: the the pain. understood
Temperature importance of importance of 4.. Educating the
of 37.8°C, adhering to adhering to the patient on importance of
Pulse of 105 pain the pain the adhering to
bpm, management management importance of the pain
Respirations plan. plan. adhering to management
of 22cpm, 5. Assess the pain plan.
and Blood pain level management
Pressure of regularly and plan can help
116/70 adjust pain to ensure
mmHg. management effective pain
plan as relief.
needed. 5. Regular
assessment
of pain level
and
adjustment of
pain
management
plan can help
to ensure
 effective pain
relief.

A 26 year old female is in her Day 3 of Postpartum care from delivering a healthy baby girl via
Cesarean section. She reports to you that she has not had a bowel movement for 5 days. She
says that she has been "straining" and having difficulty passing stool and when she does it is a
“very hard small ball." In addition, she feels "a lot of pressure” in her rectum and is having pain
from hemorrhoids that she developed in the last trimester of pregnancy, She says that she is
afraid to have a bowel movement because of the pain caused by the hemorrhoids." The patient
received many narcotics during and after the delivery. Her vital signs are as follows:
Temperature of 101.9 degrees Fahrenheit, oral pulse rate of 85 bpm, oxygen saturation of 98%
at room air, blood pressure of 150/80 mmHg and Respirations of 22 cpm.

Assessment Nursing Dx Planning Intervention Rationale Evaluation

- 26-year-old Constipation - The patient 1. Administer 1. Stool

female in related to will have a stool softeners
postpartum post-operativ bowel softeners or help to soften
care after a e pain, movement mild laxatives stool and
Caesarian immobility, within 24 as make it
section and opioid hours. prescribed. easier to
delivery of a use as - The patient - Monitor pass.
healthy baby evidenced by will report the patient's 2. Increased
girl straining, decreased response to fluid intake
- Complaints difficulty pain and the helps to
of not having passing stool, discomfort medication soften stool
a bowel and hard related to and assess and prevent
movement for small balls. hemorrhoids. for any constipation.
5 days, - The patient adverse 3. Ambulation
experiencing will effects. and physical
difficulty and demonstrate - Provide activity help
straining, proper education on to stimulate
passing hard technique for the proper bowel
small stool preventing use and movements
- Reports constipation. potential side and prevent
feeling effects of the constipation.
pressure in prescribed 4. Proper
the rectum medication. technique for
and pain from 2. Encourage preventing
hemorrhoids increased constipation
developed fluid intake can help to
during the and a alleviate
last trimester high-fiber symptoms
of pregnancy diet. and prevent
- History of - Offer future
receiving water or episodes.
narcotics other 5. Ice packs
during and hydrating and topical
after delivery fluids
- Vital signs: regularly.
temperature - Suggest
of 101.9 foods rich in
degrees fiber, such as
Fahrenheit, fruits,
oral pulse vegetables,
rate of 85 whole grains,
bpm, oxygen and legumes.
saturation of 3. Provide
98% at room education on
air, blood proper bowel
pressure of movement
150/80 techniques.
mmHg, and - Instruct
respiratory the patient to
rate of 22 avoid
cpm straining and
to use
relaxation
techniques
while on the
toilet.
-
Encourage
the patient to
establish a
regular
toileting
schedule.
4. Assist with
sitz baths
and
application of
topical
analgesics or
creams.
- Provide
instructions
on the correct
procedure for
sitz baths.
- Educate
the patient on
the proper
application
and usage of
topical
analgesics or
creams.