NURSING CARE PLAN

Patient’s Name:
Problem: Acute Pain
Date: January 08, 2011

Assessment Nursing Planning Intervention Rationale Evaluation

Diagnosis
Subjective:
 “Nasakit jay Acute pain r/t  The patient Independent: Goal met.
pangak” as incision site to will be After 30 min - 1
verbalized by surgical procedure. able to  Monitors v/s.  Serves as hour of nursing
the pt. demonstrate  Assess for pain baseline data. intervention the
 Pain scale of pain scale scale.  Serve as a patient was able to
6/10 from 6 to 1  Encourage pain scale demonstrate
scale after 30 verbalization of rate from 1 to painscale from 6-1
Objective mins to 1 hour feeling about the 10. scale.
 Irritable of nursing pain.  To lessen
 Crying intervention. anxiety.
 Grimacing face Dependent:
 To prevent
V/s as follows:  Encourage fatigue.
T – 36.3 OC adequate rest
PR – 100 period.  To facilitate
RR-23  Administers fast recovery.
BP-100/60 antibiotics as
prescribed by the
physician.
 NURSING CARE PLAN

Patient’s Name:
Problem: Hyperthermia
Date: January 05, 2011

Assessment Nursing Planning Intervention Rationale Evaluation

Diagnosis
Subjective: Hyperthermia  After 2 hrs of Independent: Goal met
 “Nabara ti r/t dehydration. nursing  Monitor vital  Serves as After 2 hours of
panagriknak” as intervention signs. baseline data. nursing intervention
verbalized by the the patient  Record all  To monitor the patient was able
pt. will maintain sources of fluid fluid and to maintain core
core temp. loss such as electrolytes temp. within
Objective: within urine, vomiting losses. normal range.
 Flushed skin, normal and diarrhea.  To decrease
warm to touch range.  Promote surface temp.
 Restlessness cooling by
 V/s taken as mean of TSB
follows: dependant
T – 38.4 Dependent:
P-100  Instructed to  To replace
R-23 fluid intake. fluid loss.
 Administer
antipyretics as  To facilitate
prescribed by fast recovery.
the physician.
 NURSING CARE PLAN

Patient’s Name:
Problem: Sleep disturbance
Date: January 05, 2011

Assessment Nursing Planning Intervention Rationale Evaluation

Diagnosis

Subjective: Sleep disturbance r/t  At the end of Independent:  To promote Goal met.
 “Saanak nga uncomfortable sleep the shift the  Provide quite comfort and At the end of the
makaturog ” environment as patient will and to reduce shift the patient will
as verbalized by manifested by pain, be able to comfortable excessive be able to sleep.
the pt. restlessness, guarding sleep. environment stimulation.
behavior and grimace by closing
face. doors to
Objective: prevent noise
 Discomfort from the
 Irritable outside.
 V/s taken as
follows:
T- 36.3
P-100
R-23
 NURSING CARE PLAN

Patient’s Name:
Problem: Impaired swallowing
Date: January 05, 2011

Assessment Nursing Planning Intervention Rationale Evaluation

Diagnosis

Subjective: Impaired  At the end Independent: Goal met

 “Marigatanak swallowing r/t of the shift  Monitor vital  Serve as partially met. At
agalimun” upper airways the patient signs. baseline data. the end of the shift
as verbalized by anomalies. will be able  Provide  To provide the pt. was able to
the pt. to pass food comfort to comfort. pass fluid fro mouth
and fluid provide  To prevent to stomach.
from mouth measures such fatigue.
Objective: to stomach as providing a
 Facial grimace safely. calm and quite
 Dysphagia environment.
 V/s taken as  Encourage rest
follows: periods to
T- 36.3 prevent fatigue.
P-100 Dependent
R-23  Increased fluid
intake.
 To replace
fluid loss.