Advincula NCP

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MCN Form 016

Lyceum of the Philippines University


College of Nursing

NURSING CARE PLAN


ASSESSMENT DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATION
Subjective: Impaired comfort related to After of 4 hours of nursing -Note for the location, - To promote comfort and -After 4hours of nursing
“Masakit ang ulo ko” as headache interventions patient’s scale, intensity, and onset relaxation. interventions, goal was
verbalized by the patient. perception of altered of pain. met. The patient verbalized
comfort/pain will be - To add comfort to the being relieved of pain and
Objective: decreased; - Maintain a calm and quiet patient. there are no non-verbal
Pain scale of 5/10 environment. indicators of
With facial grimace The patient will be able to - They serve as non- pain/discomfort present.
verbalize relief of pain - Use relaxation pharmacological methods
techniques such as deep for reducing
breathing exercises pain/promoting comfort.

-To determine the nursing


care to be given to the
patient.
MCN Form 016

Lyceum of the Philippines University


College of Nursing

NURSING CARE PLAN


ASSESSMENT DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATION
-Subjective: - Fatigue related to side -After 8 hours of nursing -Assist patient with self- - Adequate intake of -After 8 hours of nursing
effects of medications, and interventions, the patient care needs. Keep the bed in nutrients is necessary to interventions, the patient
“Nanghihina ako, chemotherapy. will report an improved a low position and assist meet energy needs and was able to report an
pakiramdam ko lagi akong sense of energy. with ambulation. build energy reserves for improved sense of energy
pagod.” as verbalized by   activity.
the patient. -Encourage nutritional
intake. - increases strength and
-Objective: allows the patient to
- Encourage the patient to become more active
V/S taken as follows: take whatever possible without being overly tired
T: 36.8 action and to improve their out.
PR: 68 exercise level as tolerated.
RR: 20 - Frequent rest periods or
BP: 90/60 naps are needed to restore
or conserve energy.

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