NURSING CARE PLAN

ASSESSMENT NURSING DIAGNOSIS RATIONALE OBJECTIVES NURSING INTERVENTIONS RATIONALE EVALUATION

3. Acute Pain related to Abdominal pain, cramping, Gen. Objective: Independent:
hyperperistalsis, prolonged diarrhea, and borborygmi may occur Relieve/ Reduce/ 1. Encourage patient/ child to May try to tolerate pain rather
skin/ tissue irritation, perirectal from gas released from Eliminate pain. report pain. than seek treatments.
excoriation, fissures as evidenced by undigested food, irritation 2. Assess reports of abdominal Changes in pain characteristics
reports of cramping or abdominal of bowel mucosa, distention cramping or pain, noting location may indicate spread of disease/
pain, guarding/ distraction behaviors of the intestines. Specific Objectives: duration, intensity,. Investigate and developing complications.
restlessness. After the nursing report changes in pain Child's primary way ofconveying
REF.: Medical & Surgical interventions have been characteristics. (Be very sensitive pain is maybe thru crying.
Nursing Textbook by employed, with the childs mov't or actions
Black & Hawks the child will be able to: e.g. crying as this suggests pain
pp. 809 - 810 Vol. I 1. Appear relax and be or something irritating to the child).
able to sleep or rest 3. Note nonverbal cues, e.g. Body language/ non verbal cues
appropriately. restlessness, reluctance to move, may be both physiological and
2. Report pain is relieved abdominal guarding. psychological and maybe used in
controlled. Investigate dispcrepancies between conjunction with verbal cues to
verbal and nonverbal cues. determine extent/ severity of the
problem.
4. Review factors that aggravate May pinpoint precipitating or
or alleviate pain. aggravating factors ( such as
stressful events, food
intolerance), or identify developing
complications.
5. Encourage patient to assume Reduces abdominal tension,
position of comfort, and promotes sense of control.
e.g. knees flexed as assisted by
the mother.
6. Provide comfort measures Promotes relaxation, refocuses
and diversional activities ( repositionattention, and may enhance coping
play with the child, offer toy) abilities. Promotes nurse - child
relationship.
7. Cleanse rectal area with mild soapProtecting skin from bowel acids,
and water/ wipes after each stool & preventing excoriation.

obstruction from inflammation. cramping. pain. 2. lowers body temp. Collaborative: 1. due to fever. relieve spasmsof Gi tract & Antipyretics. provide skin care. Observe/ record abdominal May indicate developing intestinal distention. Implement prescribed dietary Complete bowel rest can reduce modification. (Seek assistance from mother) con. increased temperature. . Administer medications as indicated: Analgesics: For pain management. edema and scarring. Anticholinergics.t 8. .

Limit fiber/ bulk. ive weight gain toward daily weights. altered peristalsis. 2. Patient is in NPO. Encourage client to choose To stimulate appetite. 7. Assess the over all nutritional To determine any deviation form But could be given by body requirements realted to very essential since we can't demonstrate progress. 3. nutritional deficiencies & stasis of 3. aversion to eating & perceived (gas . intolerances/ gastric motility problems. showing expressions reported inadequate food intake lifestyle changes to foods that are appealing. Since they can lead to early satiety. healing. Demonstrate behaviors.status of the client by checking her previous data. Limiting fluids hours prior to So as not to cause early meal satiety. To monitor effectiveness of care. relaxing To stimulate proper appetite/ environment. hot & spicy) inability to digest food. nutritious intake. deep breathing. Provide info regarding individual needs & ways to meet these needs within financial constraints. and muscle mass. Avoid foods that causes So as not to cause intestinal situation. inability to ingest/ digest food or survive without the two. food "waray gana pagkaon. of infection 2. cotton water. Be free of signs to promote safe environment. chronic diseases. DISCHARGE PLANNING: 1. secretions. Cleanse insertion sites daily & To prevent sepsis. N & V. 6. Imbalanced nutrition: less than Food and water intake is 3. restless. Weigh weekly & prn. DISCHARGE PLANNING: 1."/ appropriate weight. coughing. position changes. pallor. Encourage early ambulation. RISK for infection related to Body weakness would 4. 5. lack of interest in regain and or maintain 3. prn with solution. 4. Explain the importance of proper . Achieve timely 1. 2. tissue integrity absorb nutrients. loss of appetite as evidenced by failure. of difficulty with her less than RDA. change in pH secretions. Patient will be able to 1. Promote pleasant. For mobilization of gastric body fluids. Emphasize importance of well balance. person. 4.forming foods. enhance intake. status & nasogastric suctioning & intake would lead to body of laboratory values. Demonstrate lifestyle changes For personal growth of the inadequately primary defenses further lead to infections. (weak body). Be afebrile. NPO Gradual decrease of food goal with normalization & presence of adequate body fat O: Patient is weak.

are suitable for the client. Reassure the client and To let the client feel secured. body. & irritation brought about by the defense mechanism of the manifestations of acknowledge that the unknown is that she is not alone. 5. Patient having deep. anxiety as evidenced of frightening. The client will express 1. touchi NGT tube attached. related to abdominal pain/ RR is 15 . fear of pain returning will happen next. anxiety/ decreased energy. Anxiety related to change in Anxiety is a vague feeling 6.tenderness as evidenced by RR 30 pattern as evidenced by 2.CN Student Nurse Clinical Instructor EVRMC . 6. R. rapport. Assist client in use of relaxation So as to relax the client from shallow. hygiene especially hand washing. removed. Assess the client's level of To determine what interventions "Tangala na ini na health status. Ineffective breathing pattern Normal range of value for 5. while To as to maintain and improve O: RR 30 bpm. RTRMF . NAME: ROOM & BED #: AGE/SEX: WARD: CHIEF COMPLAINT: ATTENDING PHYSICIAN: Prepared by: Submitted to: DONN ED MARTIN A. Allow significant others to she wants to be associated with remain with the client. techniques. fatigue. the NGT tube which displaying behavior 3. irregular bpm. O: Fatigue. coping behaviors.20 bpm. The client will maintain 1. relaxed respiratory effort suffering. S: Patient uttered. adi tak may irong. an effective breathing dealing with client to limit anxiety. ROBERT PONTIAN AGNER. Maintain calm attitude. Demonstrate approp." environment.N. the tension and anxiety she is breathing. ABRIL MR. RR within normal limits. It is a normal decreasing 2. relaxation. change in of apprehension as to what and demonstrate anxiety by listening and observing.

15-Nov-05 .