Patient Initials: S.O.P.

Age: 19 years old Sex: Female

Chief complaint: Pain in the Left Chest due to Stabbing Date: October 4, 2023

Nursing Care Plan

Assessment Diagnosis Analysis Planning Intervention Rationale Evaluation

Subjective Data: Acute pain related The single stab At the end of the nursing Independent SHORT TERM:
“Napakasakit po ng to single stab wound to the left intervention, the pt will be - Assess reports of To provide base line After an hour of nursing
saksak sa akin” As wound to the left chest in the mid- able to: pain, including information. intervention, patient felt
verbalized by the pt. chest in the mid - axillary line presents location and more comfortable, less
axillaries line as an immediate risk of SHORT TERM: intensity (scale of Pain is unique to each agitated, and reported a
Objective Data: evidenced by impaired breathing After an hour of 0-10). patient. One may pain scale of 7/10.
-Facial Grimacing visible puncture and potential internal intervention, patient - Monitor vital encounter varying
-Agony site, agony, organ damage, would feel more signs every hour descriptions because of LONG TERM:
-Shortness of Breath shortness of including the lungs comfortable, less - Explore individualized After 8 hours of nursing
breath, and and diaphragm. agitated, and will report a alternative pain perceptions. Nonverbal interventions, the patient
subscapular pain. Nursing interventions pain scale of 7/10. relief measure cues may aid in was able to maintain
V/S taken as should focus on like relaxation evaluation of pain and adequate oxygen
follows: monitoring respiratory LONG TERM: technique, effectiveness of saturation. No further
Temperature: 37.2 ‘C status, assessing - Maintain breathing therapy. respiratory complications
HR: 91/min signs of distress, and Adequate techniques and arose.
RR: 26 ensuring adequate Oxygenation: guided imagery. Cognitive behavioral
O2 Sat: 98% after oxygenation. Wound The patient will - Provide a interventions may The patient reported a
oxygen mask was care, infection maintain oxygen peaceful reduce reliance on pain scale of 2/10.
placed prevention, and pain saturation within environment pharmacological
BP: 129/71 management are the target range - Monitor therapy and enhance GOALS MET
crucial. Collaboration and demonstrate respiratory rate, patient’s sense of
with the healthcare improved breath depth, and effort control.
team for diagnostic sounds. regularly.
imaging and potential - Prevent - Monitor for signs Reduces discomfort,
surgical interventions Respiratory of respiratory and risk for injury.
is vital for accurate Complications distress
assessment and related to - Monitor for signs Help reduce muscle
timely treatment. impaired gas of internal tension.
Emotional support exchange. bleeding, such as
and education for the - Manage Pain: abdominal pain, Prevents joint stiffness
patient and family are The patient will distention, or and possible
essential components report pain at a changes in vital contracture formation.
of the care plan. level of 3 or less signs. Report any
on a scale of 0- concerning .
10. findings promptly.

Dependent
- Administer drugs
as indicated like Analgesics reduces
analgesics and pain and promotes rest
antibiotics and comfort, while
- Administer antibiotics inhibits
oxygen as further bacterial
prescribed infection

Collaborative
- Assist with
diagnostic Being well-prepared
procedures and and informed reduces
surgeries as anxiety, promotes
needed, ensuring cooperation, and
the patient is enhances the overall
well-prepared patient experience,
and informed improving the
about the effectiveness of the
procedures. medical interventions..
- Gather laboratory
test results and
anticipate the
findings

Prepared by:
Eduard Vinzent Ma. C. Aquino, SN
Patient Initials: A.A.C. Age: 19 years old Sex: Female
Chief complaint: Left Chest Stabbing (Risk for Infection) Date: February 14, 2024

Nursing Care Plan

Assessment Diagnosis Analysis Planning Intervention Rationale Evaluation

Subjective Data: Risk for Infection The risk for infection At the end of the nursing Independent SHORT TERM:
“Nangangalay po ako related to open is high due to the intervention, the patient Assess reports of pain, To provide base line After an hour of
at sobrang sakit po wound secondary open wound resulting will be able to: including location and information. intervention, the patient
ng balikat ko ko” As to the stab injury, from the stab injury. intensity (scale of 0-10). feels more comfortable,
verbalized by the compromised skin Compromised skin SHORT TERM: Monitor vital signs every Pain is unique to each numbness lessens,
patient. integrity, and integrity and potential After an hour of hour patient. One may radiating pain
potential intra- intra-abdominal intervention, patient Monitor the wound for encounter varying decreases, and reports a
Objective Data: abdominal contamination would feel more signs of infection descriptions because of pain scale of 7/10.
-Facial Grimacing contamination, as increase comfortable, numbness (redness, swelling, individualized
-Agony evidenced by the susceptibility. The would lessen, radiating warmth, increased pain, perceptions. LONG TERM:
-Shortness of Breath presence of an presence of an open pain would decrease, or pus) during every After 8 hours of nursing
- Visual Stab wound open wound. wound provides a and will report a pain dressing change. Continuous monitoring interventions the patient
on the left chest portal of entry for scale of 7/10. Provide a peaceful of the wound is remains free from signs
pathogens. Vigilant environment essential to detect any and symptoms of
wound care, strict LONG TERM: Encourage early signs of infection infection, with the wound
V/S taken as aseptic techniques, - Prevent ambulation and mobility promptly. Early site showing no signs of
follows: and administration of Infection: The within the confines of detection allows for inflammation or infection.
Temperature: 37.2 ‘C prescribed antibiotics patient will remain medical safety. timely intervention,
HR: 78bpm are crucial free from signs Assist the patient with which can prevent the The patient remains free
RR: 26 interventions. Timely and symptoms of turning and repositioning infection from from signs and
O2 Sat: 98% after and appropriate infection, with the in bed to prevent worsening and promote symptoms of infection,
oxygen mask was measures are wound site pressure ulcers and wound healing. with the wound site
placed necessary to prevent showing no signs promote lung expansion. showing no signs of
BP: 110/60 infection and facilitate of inflammation or Encourage deep Reduces discomfort, inflammation or infection.
wound healing. infection. breathing exercises to and risk for injury.
- Promote Wound prevent respiratory The patient reports pain
Healing: The complications. Help reduce muscle at a level of 3 or less on
wound will show Assist the patient in tension. a scale of 0-10. he
 signs of healing, effective coughing patient maintains optimal
such as techniques to prevent Prevents joint stiffness mobility to prevent
decreased size, atelectasis and and possible complications associated
absence of pneumonia. contracture formation. with immobility.
necrotic tissue,
and presence of Dependent Early ambulation and GOALS MET
granulation Administer drugs as mobility prevent
tissue. indicated like analgesics complications
- Ensure Pain and antibiotics associated with
Management: Cleanse the wound site immobility, such as
The patient will using sterile technique, deep vein thrombosis
report pain at a mild antiseptic solution, and muscle atrophy. It
level of 3 or less and sterile saline. Dress also promotes
on a scale of 0- the wound according to circulation and lung
10. the physician's orders. expansion, aiding in
- Promote respiratory function.
Mobility: The
patient will Analgesics reduces
maintain optimal pain and promotes rest
mobility to and comfort, while
prevent antibiotics inhibits
complications further bacterial
associated with infection
immobility.
Adhering to aseptic
practices minimizes the
risk of introducing
harmful
microorganisms,
enhancing the overall
wound healing process.

Prepared by:
 Eduard Vinzent Ma. C. Aquino, SN

Patient Initials: S.O.P. Age: 50 Years old Sex: Female

Chief complaint: Fluid Retention/ Edema Date: February 14, 2024

Nursing Care Plan

Assessment Diagnosis Analysis Planning Intervention Rationale Evaluation

Subjective Data: Excess Fluid Fluid Volume Excess or After 8 hours of nursing Independent Independent SHORT TERM:
“Nahihirapan po ako Volume related to hypervolemia, refers to intervention, the patient Assess causative/ Identifying underlying After an hour of nursing
huminga” asfluid retention an isotonic expansion of will be able to: precipitating factors: causes to target intervention, patient felt
verbalized by the Pt secondary to the ECF due to an Note the presence of interventions effectively. more comfortable,
increase in total body
heart failure as SHORT TERM: medical conditions or Accurately assessing breathing pattern
sodium content and an
Objective Data: evidenced by increase in total body  After an hour of situations (e.g., heart fluid intake and normalizes, BP is
-Shortness of Breath Pedal edema water. This fluid intervention, failure,) that can nutritional factors to decreased, urine output
-Pedal Edema (BLE) (BLE), Shortness overload usually occurs patient would contribute to excess fluid guide fluid is increased. Patient
-Restlesness of Breath, weight from compromised have decreased intake or retention. management. verbalized
- 60 kg gain, elevated regulatory mechanisms BP, RR would Determine or estimate Monitoring weight, vital understanding of the
BP, and for sodium and water as return to normal, the amount of fluid signs, and signs of fluid importance of fluid
V/S taken as decreased urine seen commonly in heart Pt will display intake from all sources overload to evaluate restrictions. Patient
follows: output. failure (CHF), kidney fail normal fluid Review nutritional issues response to treatment. verbalized how to
Temperature: 37.2 ‘C ure, and liver failure. volume as Compare current weight Placing patients in monitor for excess fluid
Excessive intake of
HR: 98 bpm evidenced by with admission and/or semi-Fowler's position volume
sodium from foods,
RR: 26 medications, IV balanced intake previously stated weight. to promote respiratory
O2 Sat: 98% solutions, is also and output. Weigh daily or on a function and reduce LONG TERM:
BP: 130/80 considered the cause of  Patient verbalizes regular schedule, as dependent fluid pooling. Pt have no signs of
FVE. Other medical understanding of indicated edema. Pt presents with
Urine Output conditions that could the importance of Measure vital signs and Dependent clear breath sounds and
- 150 mL for the contribute are fluid restrictions if invasive hemodynamic Administering diuretics a normal respiratory rate
past 8 hrs via hemodialysis, peritoneal ordered. parameters and oxygen therapy to
urinary cath dialysis, and myocardial  Patient verbalizes Note the presence of manage fluid overload
infarction. Restriction of how to monitor for tachycardia, irregular and improve cardiac
sodium and water intake
excess fluid rhythms function. GOALS MET
is vital for the treatment
in order to return the volume. Assess for the presence Restricting fluid intake
extracellular of neck vein distention as necessary to prevent
compartment to normal. LONG TERM: Note the presence and further accumulation
Dialysis may be  Patient will location of edema and optimize
required for acute display no signs Measure and record I&O cardiovascular function.
cases. of edema or accurately
sudden weight Place in semi-Fowler’s Collaborative
gain position when at bedrest, Physical therapy to
 Patient will as appropriate promote mobility and
present with clear venous return, reducing
breath sounds Dependent fluid stasis.
and a normal Administer drugs as Assisting with
respiratory rate indicated like diuretics procedures such as
and cardiotonic dialysis or ventilation to
Facilitate oxygen manage fluid overload.
administration as Consulting a dietitian to
prescribed optimize nutritional
Restrict fluid intake as interventions for fluid
indicated and sodium
Provide for sodium management.
restrictions if needed
These interventions
collectively address the
Collaborative multifaceted aspects of
Promote early excess fluid volume,
ambulation through aiming to alleviate
physical therapist symptoms, prevent
Prepare for and assist complications, and
with procedures as optimize patient
indicated (e.g., outcomes.
peritoneal or
hemodialysis,
ultrafiltration; mechanical
ventilation, cardiac
resynchronization
therapy [CRT])
Consult dietitian as
needed

Prepared by:
 Eduard Vinzent Ma. C. Aquino, SN

Patient Initials: J.P.V. Age: 37 Years old Sex: Male

Chief complaint: Fever and Pruritus Date: February 14, 2024

Nursing Care Plan

Assessment Diagnosis Analysis Planning Intervention Rationale Evaluation

Subjective Data: Impaired Skin The human body has a After 8 hours of nursing Independent Independent SHORT TERM:
“Nangangati po yung Integrity related to well-maintained intervention, the patient Identify underlying interventions After hours of nursing
mga braso at binti ko” fever and protection system will be able to: condition or pathology emphasize the intervention, patient felt
increased against all external involved. importance of more comfortable, free
threats. A major part of
Objective Data: metabolic SHORT TERM: Assess skin, noting thoroughly assessing from pruritus. Risk
this system is made up
-Facial Grimacing demand, as of the skin, the largest  After an hour of type(s) of disruption and and addressing factors factors and underlying
-Visual Redness BUE evidenced by organ of the human intervention, general health of skin contributing to impaired causes identified. Patient
& BLE erythema, body. It protects the patient would be Determine client’s age skin integrity. This displayed timely healing
-Bleeding on some warmth, body from injuries, free from pruritus and developmental includes identifying of skin lesions, wounds,
spots tenderness, and infections, heat, light,  Will Identify factors or ability to care underlying conditions, or pressure sores
-Skin is warm to risk factors such pollutants, etc. When individual risk for self. assessing skin health, without complications.
touch as prolonged the skin is compromised factors. Review with client/ considering age and Body temperature
bedrest and due to injuries like cuts,  Patient will significant other (SO) developmental factors, decreased.
V/S taken as decreased rashes, abrasions, the display timely history of past skin reviewing past skin
integrity of the skin layer
follows: mobility. healing of skin problems (e.g., allergic issues, evaluating skin LONG TERM:
is compromised. This is
Temperature: 38.6 ‘C called having impaired lesions, wounds, reactions, rashes, easy care practices, Pt’s skin appearance
HR: 102 bpm skin integrity. or pressure sores bruising or skin tears) determining nutritional improved. Red spots are
RR: 24 As aging occurs, without Evaluate client’s skin status, and assessing gone and has never
O2 Sat: 99% the skin layer naturally complication. care practices and blood supply and complained of itchiness
BP: 120/80 thins, making the skin hygiene issues sensation. These in the past shift.
more prone to damage. LONG TERM: Determine nutritional interventions aim to
- Furthermore, there is  Patient would status and potential for tailor care to the
also a loss of natural have better skin delayed healing or tissue individual's needs,
moisturizing factors, appearance injury exacerbated by promote skin health, GOALS MET
like hyaluronic acid,
 Future pruritus malnutrition and prevent further
from the skin. This
makes the skin more occurrences Assess blood supply injury.
would be (e.g., capillary return
dry, flaky, and prevented time, color, and warmth) Dependent
susceptible to damage. and sensation of skin interventions involve
Therefore, older adults surfaces and affected administering
are at a much higher area on a regular basis medications, assisting
risk for impaired skin
Dependent with wound
integrity.
This is a phenomenon Administer drugs as management
that may be accelerated indicated like diuretics procedures, and
by certain medications, and paracetamol for applying appropriate
sun exposure, or fever dressings to address
genetics. However, Assist with debridement underlying conditions
poor nutrition, certain or enzymatic therapy, as and promote wound
diseases, surgical indicated (e.g., burns, healing.
procedures, or severe pressure sores),
immobility (in comatose Use appropriate barrier Collaborative
patients or those with
dressings, wound interventions focus on
spinal cord injuries) can
also contribute to coverings, drainage leveraging
heightened impaired appliances, vacuum- interdisciplinary
skin integrity. assisted closure device collaboration to
optimize patient care.
Collaborative This includes reviewing
Review laboratory laboratory results,
results pertinent to obtaining wound
causative factors specimens,
Obtain specimen from encouraging early
draining wounds when ambulation, and
appropriate for culture consulting with a
and sensitivities or Gram dietitian to address
stain nutritional needs. These
Encourage early collaborative efforts aim
ambulation or to enhance treatment
mobilization outcomes and promote
Consult dietitian as overall well-being.
needed

Prepared by:
Eduard Vinzent Ma. C. Aquino, SN