NURSING CARE PLAN
ASSESSMENT NURSING PLANNING INTERVENTION/ RATIONALE EVALUATION
DIAGNOSIS IMPLEMENTATION
Subjective: Impaired of After 4 hours Independent: Manifestati After 4 hours
gas of nursing on of of nursing
‘Nahihirapan Assess respiratory
exchange intervention respiratory interventions
akong rate depth and
r/t the patient distress is , the patient
huminga’ as ease.
collection will achieve dependent will achieve
verbalized by
of timely Monitor Body on timely
the patient
secretions resolution of Temperature. indicative of resolution of
Objective: affecting current the degree current
Elevate head of
oxygen infection of lung infection
-Dyspnea the bed and
exchange without involvemen without
change position
-Tachycardia across Implications. t and complication.
frequently.
alveolar underlying
Vs.
membrane. Limit visitors as general
Temp. 37.7 indicated. status.
PR. 125 Institute isolation High fever
precaution. greatly
RR. 50
increase
metabolic
demand
and oxygen
consumptio
n and alters
cellular
oxygenation
.
Promotes
expectorati
on clearing
of Infection
pathogens.
Isolation
technique
may be
desired to
prevent
NURSING CARE PLAN
ASSESSME NURSING PLANNING INTERVENTION/ RATIONALE EVALUATION
NT DIAGNOSIS IMPLEMENTATION
Subjective: Acute pain After series Assess the To Identify the After series of
“sumasakit related to of client pain intensity, onset, nursing
ang akin post intervention scale and duration, quality, interventions
tyan” as surgical as the client perception and quality of the goals are met
verbalized manifested should pain as evident of
Encourage
by the by facial manifest a the clients
verbal report Pain is highly
patient grimace, decrease in decrease on
during and subjective and to
guarding the pain scale pain scale
Objective: after the identify the
behaviour of 5/10 to from 5/10 to
nursing effectiveness of
-With facial and verbal manageable 0/10 or with
intervention. the interventions.
grimace report of level of 0/10 no pain and
pain felt in Monitor V/S Obtain baseline discomfort and
-Verbal
the lower and Pain V/S, V/S changes positive verbal
report of
abdominal Scale. during onset of report of the
acute pain
region. pain for future client during
Teach client
-Guarding comparison after the evaluation.
divertional
behaviour interventions
activities
on the left
To divert clients
lower Advise
attention from
extremity breathing
pain.
exercise
To allow proper
O2 supply in the
body, clients lend
to stop during
pain
NURSING CARE PLAN
ASSESSMENT NURSING PLANNING INTERVENTION/IMPLEMENTATION RATIONALE EVALUATION
DIAGNOSIN
Subjective: Acute pain -After 8 Investigate Helpful in After 8 hours
related to hours of report of pain, determining of nursing
“Agsakit
inflammatory nursing noting pain interventions,
likod ko “ as
process. intervention, characteristics management the patient
verbalized by
the patient , location, needs and will be able
the patient.
will be able intensity (0-10 effectiveness to
Objective: to scale) of the incorporate
incorporate program. relaxation
-Facial mask Apply warm
relaxation skills and
pain. or moist Heat
skills and diversional
compress on promotes
-Fatigue diversional activities into
the affected muscle
activities pain control
-V/S taken as area several relaxation
into pain program.
follows: times a day. and mobility,
control
decreases
Temp: 37.3 program. Provide gentle
pain and
massage.
PR: 80 relieves
morning
RR: 18
stiffness.
BP: 120/90
Promotes
relaxation
and reduces
muscle
tension.
NURSING CARE PLAN
ASSESSMENT NURSING PLANNING INTERVENTION/IMPLEMENTATION RATIONALE EVALUATION
DIAGNOSIS
Subjective: Risk for After 8 hours Suggest frequent position changes, Decrease After 8 hours
prone of nursing leg exercises when lying down. peripheral of nursing
“Agulaw
behaviour interventions venous intervention
ulaw nak” as
related to the patient pooling the patient
verbalized by
lack of will that may was able to
the patient.
knowledge verbalized be verbalize
Objective: about understandi potentiate understandi
disease. ng of the d by ng of the
-Agtated
disease vasodilator disease
behaviour.
process and s and process and
-V/S taken as treatment prolonged treatment
follows: regimen. sitting or regimen.
standing.
Temp: 37.2
PR: 84
RR: 18
BP: 180/110
NURSING CARE PLAN
ASSESSMENT NURSING PLANNING INTERVENTION/ RATIONAL EVALUATI
DIAGNOSIS IMPLEMENTATION E ON
Subjective: Hyperther After 4 Maintain bed rest. To reduce After 4
mia related hours of metabolic hours of
“Nabara ti Promote tepid sponge bath.
to nursing demands nursing
panagrikrikn
dehydratio interventio and interventi
ak” as
n. ns, the oxygen. on, the
verbalized by
patient will patient
the patient. To
maintain was able
decrease
Objective: core to
temperatu
temperatur maintain
-Warm to re
e within core
touch.
normal temperatu
-Restlessness range. re within
normal
-V/S taken as
range.
follows:
Temp: 38.1
PR: 70
RR: 19
BP:110/90
NURSING CARE PLAN
ASSESSMENT NURSING PLANNIN INTERVENTION/ RATIONAL EVALUATION
DIAGNOSIS G IMPLEMENTATION E
Subjective: Nutrition After 8 Measure abdominal Provides After 8 hours, Of
“Nagsarwasar imbalanced hours of girth. quantitativ nursing
wa nak as” less than nursing e evidence interventions, the
verbalized by body interven of changes client will be able to
the patient. requiremen tions the in gastric maintain usual
ts related to client will or weight.
Objective:
nausea and be able intestinal
-Pale vomiting. to distention.
maintain
-V/S taken as
usual
follows:
weight.
Temp: 36.6
PR: 98
RR: 18
BP: 110/90
NURSING CARE PLAN
ASSESSMENT NURSING PLANNING INTERVENTION/IMPLEMENTATION RATIONALE EVALUATION
DIAGNOSIS
Subjective: Ineffective After 8 Auscultate breath sounds. Note Some After 8 hours
airway hours of advenititious breath sounds like degree is of nursing
“Marigatan
clearance nursing wheezes and crackles. present interventions,
nak
related to intervention with the patient
aganges” as
increased the patient obstructions was able to
verbalized by
production will in airway demonstrate
the patient.
of demonstrate and may or behaviors to
Objective: secretions. behaviors to may not be improve
improve manifested airway
-abnormal
airway in clearance.
breath
clearance. adventitious
sounds.
sounds.
-V/S taken as
follows:
Temp: 37.3
PR: 82
RR: 25
BP: 110/80
NURSING CARE PLAN
ASSESSMENT NURSING PLANNING INTERVENTION/IMPLEMENTATION RATIONALE EVALUATION
DIAGNOSIS
Subjective: Acute pain After 30mins Perform pain assessment. To rule out The patient
related to of nursing worsening was able to
“Medyo Provide comfort measure like
inflammatory intervention of demonstrate
nasakit toy change in position.
process. the client underlying use of
likod ko nu
will be able condition. relaxation
agaraw
demonstrate skills and
garaw nak” Promotes
use of diversional
as verbalized relaxation
relaxation activities.
by the
skills and
patient.
diversional
Objective: activities.
-with pain
score of 7
out of 10.
-PR: 102
-RR: 31
-TEMP: 36.7
ASSESSMENT NURSING PLANNING INTERVENTION/IMPLEMENTATION RATIONALE EVALUATION
DIAGNOSIS
Subjective: Acute pain After 8 hours Investigate report of pain, noting Helpful to After8 hours
“agsakit sakit related to of nursing characteristics location, intensity determining of nursing
toy likod ko” inflammatory interventions, (0-10 scale). pain interventions,
as verbalized process. the patient management the patient
Provide firm mattress and small
by the will be able needs and will be able
pillows.
patient. to effectiveness to
incorporate Provide gentle massage. of the incorporate
Objective:
relaxation program. relaxation
-Facial mask skills and skills and
Soft or
of pain. diversional diversional
sagging
activities into activities into
-Fatigue mattress and
pain control pain control
large pillows
-V/S taken as program. program.
inhibits the
follows:
proper body
Temp: 37.3 alignment.
PR: 80 Promotes
relaxation
RR: 18
and reduces
BP:120/90 muscle
tension.
NURSING CARE PLAN
ASSESSMENT NURSING PLANNING INTERVENTION/IMPLEMENTATION RATIONALE EVALUATION
DIAGNOSIS
Subjective: Impaired After 8 -Assess or document size, color, -Provide After 8 hours
“nakagat nak skin hours of depth of wound and condition of baseline of nursing
ti aso” as integrity nursing surrounding skin. information intervention,
verbalized by related to intervention, about the the patient
-Keep skin free from pressure.
the patient. disruption the patient wound and was able to
of skin will achieve possible achieved
Objective:
surface timely clues about timely
-Facial with wound the blood wound
grimace destruction healing. circulation healing.
of skin in the
-Irritability
layers. affected
-V/S taken as area.
follows:
-To
Temp: 37.2 promote
circulation.
PR: 81
RR: 21
BP: 120/70
NURSING CARE PLAN
ASSESSMENT NURSING PLANNING INTERVENTION/IMPLEMENTATION RATIONALE EVALUATION
DIAGNOSIS
Subjective: Acute pain After series -Assess the clients pain scale and -To identify After series
“sumasakit related to of perception. the intensity, of nursing
ang aking post intervention onset, interventions
-Monitor V/S and pain scale.
tyan” as surgical as the client duration, goals are
verbalized by manifested should quality and met as
the patient. by facial manifest a quality of the evident of
grimace, decrease in pain. the clients
Objective:
guarding the pain decrease in
-Obtain
-with facial behaviour scale 5/10 pain scale
baseline V/S,
grimace. and verbal manageable from 5/10 to
V/S changes
report of level of 0/10 or with
-verbal during onset
pain felt in 0/10 no pain and
report of of pain, for
the lower discomfort
acute pain. future
abdominal and positive
comparison
region. verbal report
after
of the client
interventions.
during the
evaluation.
NURSING CARE PLAN
ASSESSMENT NURSING PLANNING INTERVENTION/IMPLEMENTATION RATIONALE EVALUATION
DIAGNOSIS
Subjective: Acute pain After 8 hours -Note reports of pain. Including -Pain is not Goal met,
“Sumasakit in r/t of nursing location, duration, intensity (0-10 always patient has
ang sikmura chemical interventions, scale). present, verbalized
ko burn of the patient but if relief of
pagkatapos gastric will verbalize present pain.
ko kumain.” mucosa. relief of pain. should be
As verbalized compared
by the with
patient. patient’s
previous
Objective:
pain
-Abdominal symptoms.
guarding
-Facial
grimacing
-Pain scale of
6 out of 10
-V/S taken as
follows:
Temp: 37.5
PR: 65
RR:14
BP: 110/80
NURSING CARE PLAN
ASSESSMENT NURSING PLANNING INTERVENTION/IMPLEMENTATION RATIONALE EVALUATION
DIAGNOSIS
Subjective: Anxiety Within 8 -Monitor vital signs. -To identify After 8 hours
related to hours of physical of nursing
“jak a
threat nursing responses interventions
makapagtrabaho
to/or interventions associated the patient
nga nalaing ta
change in the patient with both appeared
kastoy
health will appear medical relaxed and
marikriknak” as
status. related and and the level of
verbalized by
the level of emotional anxiety will
the patient.
anxiety will conditions. reduced to
Objective: reduced to manageable
manageable level.
-Vital Signs:
level.
Temp: 36.2
PR: 64
RR: 20
BP: 130/90
-Fatigue
NURSING CARE PLAN
ASSESSMENT NURSING PLANNING INTERVENTION/IMPLEMENTATION RATIONALE EVALUATION
DIAGNOSIS
Subjective: Decreased After 8 hours Provide calm, restful surroundings, Help to After 8 hours
“bigla na cardiac of nursing minimize environmental activity or reduce of nursing
lang bumigat output interventions, noise. sympathetic interventions
ang timbang related to the patient simulation, the patient
ko” as decreased will promotes was able to
verbalized by venous participate in relaxation. participate in
the patient. return. activities that activities
reduce blood that reduce
Objective:
pressure or blood
-Edema cardiac work pressure or
load. cardiac word
-V/S taken as
load.
follows:
Temp: 37.1
PR: 78
RR: 20
BP: 140/90
NURSING CARE PLAN
ASSESSMENT NURSING PLANNING INTERVENTION/IMPLEMENTATION RATIONALE EVALUATION
DIAGNOSIS
Subjective: Fear After 4 hours -Encourage patient to -Provides After 4 hours
related to of nursing acknowledge and express fears. opportunity of nursing
“Natatakot
change in interventions, for dealing interventions,
ako bigla na
health the patient with the patient
lang akong
status. will report concerns, was able to
dinugo” as
fear and clarifies report fear
verbalized by
anxiety are reality of and anxiety
the patient.
reduced to a fears, and are reduced
Objective: manageable reduces to a
level. anxiety to manageable
-
manageable level.
Restlessness
level.
-Increased
tension.
-V/S taken as
follows:
Temp: 37.2
PR: 90
RR: 18
BP: 110/80
