7.

NURSING CARE PLAN

1. ACTUAL PROBLEM: Acute Pain

Problem Goals Interventions Evaluation

Subjective Data: Short Term: Nursing Interventions:

 Patient  After 1-2  Instructed  Patient
verbalize hours of patient to reported
d pain at rendering assume minimal relief
the Right appropriate comfortable from pain
Upper nursing position
Quadrant interventions  Provided quiet
with a , the patient and calm
scale will report environment
ranging relief from  Advised patient
from pain with a to divert
6/10 to scale of 1/10 attention by
8/10 to 3/10 conversing with
relatives or do
Objective Data: meditation
 Guarding
behavior Pharmacological
at the Interventions:
RUQ  Administered  Verbalization
PRN medications of relief from
as ordered: pain
1. Paracetam
ol 500
mg/tab 1
tab per
orem
2. Dolcet tab
Long Term Goal: 1 tab per
 Treatment of orem
underlying
etiology: Medical-Surgical
Hepatic Management:
Abscess  UTZ guided  Drained
drainage of 300cc grayish
hepatic abscess pasty
(02-23-19) material
 Insertion of  Output
drainage ranging from
catheter (pigtail) 10-150cc
 Flushing of pigtail  Mass
as ordered decreased in
size from
7.6x7.9x7.5c
m to
4.4x6.2x5.3c
m (03-02-19)
 Pharmacological
Management:
 Administered
antibiotics as
ordered:
1. Piperacillin-
Tazobactam
4.5 g
intravenousl
y every 8
hours (02-16-
19)
2.Metronidazol
e 500mg
intravenously
every 8 hours
3. Meropenem
1g
intravenously
every 8 hours
GOAL IS MET

2. ACTUAL PROBLEM: Unstable Blood Glucose Level

Problem Goals Interventions Evaluation

Subjective Data: After 2-3 weeks of Nursing Interventions:

 Hba1c rendering  Instructed  Patient
result: 6.90% appropriate nursing patient to became
 CBG levels interventions, the report signs of more
ranging from patient will manifest rebound compliant to
131 mg/dL a stable blood sugar hypoglycemia treatments
to 528 level within normal such as:
mg/dL range 60-120 mg/dL weakness,
dizziness,
blurred vision
 Discuss to
patient the
action of
antidiabetic
medications
and it’s
importance

Medical-
Pharmacological
Interventions:
 Capillary Blood  CBG level:
Glucose 131-528
monitoring
three times a
day as ordered
(2-13-19)
 Strict
adherence to
diet: on 1200
kcal renal diet,
 1.2 g Na, 1.2 g
K, 800 mg
Phosphorous,
1.5g/kg/day
CHON divided
in 3 meals and
2 snacks +
6500 mg
Ensure in 1
glass H2O
 Administered
Insulin as
ordered:
1. Lantus 14  FBS: 97
units once mg/dL (03-
a day 04-19)
2. Apidra 6  FBS: 106
units SC mg/dL (03-
defer for 08-19)
CBG <100  CBG: 85-115
mg/dL mg/dL
three
times a
day
antecebum
3. Linagliptin
(Trajenta)
5 mg/tab
once a day

GOAL IS MET

3. ACTUAL PROBLEM: Hyperthermia

Problem Goals Intervention Evaluation

Objective Data: Short Term: Nursing Interventions:

 Body  After 1-2  Have the patient  Patient
temperatur hours of wear lose reported
e ranging rendering clothing feeling of
from 37.7 appropriate relief
degree nursing  Performed Tepid
Celsius to intervention Sponge Bath
38.6 degree s, patient
Celsius will have a  Advised patient
 Skin warm body to increase fluid
to touch temperature intake
within
normal
range 36.5- Pharmacologic
37.5 degree Interventions:
Celsius  Administered  Body
Paracetamol 300 Temperature
mg intravenously of 36.0
as ordered degree
Celsius
 IV Fluid
regulation
 increased as
ordered

Long Term: Medical-Surgical

 Treat Management:
underlying  UTZ guided  Drained
etiology: drainage of 300cc grayish
Hepatic hepatic abscess pasty
Abscess (02-23-19) material
 Insertion of  Output
drainage catheter ranging from
(pigtail) 10-150cc
 Flushing of pigtail  Mass
as ordered decreased in
size from
7.6x7.9x7.5c
m to
4.4x6.2x5.3c
m (03-02-19)

Pharmacological
Management:
 Administered  No
antibiotics as episodes
ordered: of fever
1. Piperacillin-
Tazobactam
4.5 g
intravenously
every 8 hours
(02-16-19)
2. Metronidazol
e 500mg
intravenously
every 8 hours
3. Meropenem
1g
intravenously
every 8 hours
GOAL IS MET

4. ACTUAL PROBLEM: Acute Pain

Problem Goals Intervention Evaluation

Subjective Data: After 2-3 days of Nursing

 Verbalized rendering Interventions:
pain in the appropriate nursing  Instructed to
abdomen interventions, patient increase
with a scale will be able to: mobility at
ranging 5- (1) verbalize least turning
8/10 relief of from side to
abdominal side or
pain and ambulating
 (-) Bowel (2) reports (+)  Advised to
movement Bowel increase fluid
for 5 days movement intake
 Instructed to
add and
consume
fiber rich
foods

Pharmacological
Interventions:
 Administered  Reports 3
Lactulose Bowel
30cc once a movement
day at hours (02-26-19)
of sleep as  No
ordered occurrence
of abdominal
pain

GOAL IS MET