CHAPTER VIII

NURSING CARE PLAN

ACTUAL Nursing Care Plan

ASSESSMENT

DIAGNOSIS

PLANNING

INTERVENTION

RATIONALE

EVALUATION

Acute pain

After 30

Independent:

Goal met, as

related to

minutes of

>Maintain

manifested by

bowel

nursing

immobilization of

>Relieves pain and

distension

intervention

affected part by

prevents bone

secondary to

the patient

Objectives:

means of bed

displacement/extension

disease

will have a

rest, cast, splint,

of tissue injury.

>Pain scale of

condition

pain scale of

traction.

4/10 or less.

>Identify

Subjective:
Nasakit nu aggaraw nak..

6/10
>Grimacing

diversional

face

activities

>Prevents boredom,
reduces muscle tension,

patients scale
of 3/10.

>Limited
movements

appropriate for
patient age,
physical abilities,

>Body malaise

and personal

and can increase muscle

strength; may enhance
coping abilities.

>Guarding

preferences.

behavior

>Elevate and

>Promotes venous

facial grimaces

support injured

return, decreases edema,

extremity.

and may reduce pain.

>BP- 120/90
mmHg
RR- 19 bpm

Dependent:

PR- 64bpm

>Administer

To- 36.4C

medication as
per doctors
order.
Ketorolac 30mg
IV q 8

>Given to reduce pain

and/or muscle spasms

ACTUAL Nursing Care Plan

ASSESSMEN

DIAGNOSI

PLANNING

INTERVENTION

T
Objectives:

S
Anxiety

Short

BP- 130/90

related to

Term:

Establish

mmHg

lack of

After 1

rapport

RR- 19 bpm

knowledge

hourof

PR- 64bpm

about the

Nursing

RATIONALE

Independent:

EVALUATION
Short Term:

To gain clients

Goal Met:

trust and

The patient

participation

had identified
ways to

To- 36.4C

disease

Intervention

condition

s the patient

Assess pts
condition

To obtain
baseline data

will be able
to identify

reduce
anxiety after
1 hour of

Assess for

In order to

ways to

level of

know the

reduce

anxiety

manageability

anxiety.

of anxiety and
provide
appropriate
intervention

Limited
Explain to the

knowledge of

patient, what

the unknown

to expect

results may
cause anxiety to
the patient

Deep breathing

nursing
intervention.

 Teach the pt
proper

exercises can
reduce tension

breathing
exercises

To divert focus
to other things

Instruct the
patient to do

Collaboration

diversional

promotes the

activities

best long range

plan to attain

Collaborate

success for the

with other

health of the

professionals

patient

Helps to relax
the patient if
necessary and
uncontrollable

 Administer
anti anxiety
drugs as
ordered