NURSING CARE PLAN

ASSESSMENT DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATION

Objective: Acute pain r/t injury of Patient will express relief Assess for the referred To help determine Goal met. The patient
Guarding behavior biological agents; from pain within 30 pain possibility of underlying was able to express
Facial Mask Hydrogen in minutes of medication Obtain clients condition or organ relief from pain within 30
Expressive behavior accumulation and in administration assessment of pain to dysfunction requiring minutes of medication
increase in HCl include location, treatment administration.
characteristics, To rule out worsening of
onset/duration, underlying condition or
frequency, quality, develop of complication
intensity and When are usually altered
precipitating/aggravating in acute pain
Monitor skin color, To medicate
temperature and vital prophylactically as
signs appropriate
Note when pain occurs To promote
provide comfort nonpharmachological
measures, quiet pain management
environment and calm To maintain acceptable
activities level of pain
Administering analgesic, To prevent fatigue
as indicated, to Promote active, non-
maximum dosage as passive, role and
needed enhance sense of control
encourage rest periods
Provide for individualize
physical therapy/exercise
program that can be
continued by the client
after discharge
 ASSESSMENT DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATION
Activity in tolerance r/t Patient will participate in Monitor vital signs This can be cause Goal met. Patient was
Subjective: weakness physical activity with before and after by a temporary able to participate in
"nanghihina ako at appropriate changes in any activity, insufficiency of physical activity with
indi ko parang indi heart rate, blood noting any blood supply appropriate vital
ako masyado pressure and respiration abnormal changes Pain restricts the changes. Her vital signs
makagalaw" as within 3 days. Assess pain client from were checked before and
verbalized by the Pt. activity achieving a after activity and there
Obtain assistive maximal activity were indication of
devices or level and if often unstable vital sign.
equipment needed exacerbated by
Objective: before assisting in movement
Fatigue or weakness ambulation To increase
Lack of interest in Increase exercise mobility by
activity or activity levels helping the client
gradually overcome
Promote comfort limitation
measures and To conserve
provide for relief energy To reduce
of pain fatigue
Encourage client To enhance ability
to maintain to participate in
positive attitude; activities
suggest use of To enhance sense
relaxation of well-being
techniques such
as visualization or
guided imagery
 ASSESSMENT DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATION
Subjective: High risk of seizures in After 8 hr shift , no seizures - Monitor blood - The pressure over Goal Met, after hour shift
"baka pregnant women related to will occur. pressure every 4 110 mmHg diastole no seizure occured.
magkaimpeksyon ang decreased organ function hours and systole 160 or
(vasospasm and increased more an indication
tahi ko" as verbalized blood pressure). of PIH.
by the pt - The decline of
- Record the
patient's level of consciousness as
Objective: consciousness an indication of
-Guarding behavior decreased cerebral
-facial mask of pain blood flow.
- Assess signs of - The symptoms are
eclampsia (hyper a manifestation of
active, the patellar changes in the
reflexes, decreased brain, kidney, heart
pulse and and lung that
respiration, precedes seizure
epigastric pain and status.
oliguria)

-Monitor - Seizures will

for signs and increase the
symptoms of labor sensitivity of the
or uterine uterus which will
contractions. allow the delivery.

- Collaboration with - Collaboration with

the medical team in the medical team in
the provision of anti- the provision of anti-
hypertension hypertension
 ASSESSMENT DIAGNOSIS PLANNING INTEREVENTION RATIONALE EVALUATION
Subjective : Disturbed sleep Within 8 hours of Keep Excessive noise After 8 hours o9f
" hindi ako makatulog" as verbalized by r/t pain as duty the patient Environment causes sleep promoting nursing
the patient manifested by will be able to fall quite depletion interventions, the
restlesness adn asleep without Teach Relation and patient was able to
Objective : irritablity difficulty and the relaxation imaginary sleep without
Restlessness patient will wake techniques, induce sleep difficulty and
Yawning Inability to sleep up at night less pain relief wakeup less
Irritability frequently measures of frequently
imaginary
before sleep
 ASSESSMENT
Subjective :
"indi ako komportable" as verbalized
by the patient
Objective :
Observed evidence of pain
Guarding behavior
Expressive behavior
Change in muscle tone
Distracted behavior
DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATION
Impaired sense of After 8 hours, the - Assess the patient's - The threshold of Goal Met, patient was
comfort (pain) related patient will report pain intensity level pain everyone is able to verbalize
to uterine pain is decreased/ different, thus will be reduced pain
contractions reduced able to determine
appropriate action
treatment with the
patient's response to
- Explain the causes of pain.
pain - Pregnant women
can understand the
causes of pain
-teach the
pregnant woman with - With a deep breath
the breath in to relax the muscles,
anticipation of pain there was
arise vasodilatation of
blood vessels,
optimal lung
expansion, so that the
oxygen demand on
the tisue are met.
- .Help the
pregnant woman by
- To distract the
rubbing / massage on
patient.
the painful part