SAINT PAUL UNIVERSITY DUMAGUETE

COLLEGE OF NURSING
NURSING CARE PLAN FORM

IN PARTIAL FULLFILMENT OF THE REQUIREMENT IN

NCM 102

SUBMITTED TO:
Mrs. Rochel Ignacio RN, MAN

SUBMITTED BY:
Mary Rose S. Gargar

DATE:

March 14, 2019

Patient’s Name (Initials): J.B.D Admitting Diagnosis/Medical Diagnosis/CC: Sepsis sec to breast CA w/ abcess, right w/ palpable liver mets; pneumonia in immune compromised host,, anemia of malignancy
 SAINT PAUL UNIVERSITY DUMAGUETE
COLLEGE OF NURSING
NURSING CARE PLAN FORM

Age: 41 yrs. old Sex: Female Physician (Initials): Dr. Nervez

Room No: Diet: DAT
SUBJECTIVE OBJECTIVE NURSING SCIENTIFIC ANALYSIS PLANNING INTERVENTIONS RATIONALE EXPECTED OUTCOME
DIAGNOSIS
Independent
“Mo sakit akong totoy -patience face in Acute pain Unpleasant sensory and emotional After 6 hours of nursing Provide Promotes relaxation After 6 hours of nursing
kung dili ma grimace. related to experience arising from actual or intervention patient will nonpharmacological and helps refocus intervention patient was
dressingan” as -presence of foul compression/des potential tissue damage or described in be able to verbalized pain comfort measures attention. able to verbalized pain
verbalized by the odor truction of nerve terms of such damage; sudden or slow scale from 0 as the lowest (massage, scale from 0 as the
patient. -destruction of tissue. onset of any intensity from mild to to 10 as the highest. repositioning, lowest to 10 as the
nerve tissue severe with anticipated or predictable backrub) and highest.
end and a duration of <6 months. diversional activities
(music, television)
VS:
T- 36.7 Encourage use of Enables patient to
RR- 20cpm stress management participate actively in
PR- 82bpm skills or nondrug treatment of
BP- 90/60mmhg References: Reference: complementary pain and enhances
References: https://nurseslabs.com/cancer-nursing- therapies (relaxation sense of control. Pain
Doenges, M.E. , care-plans/3/ techniques, produces stress and,
Moorhouse, M. F visualization, guided in conjunction with
, & Murr, A. C imagery, biofeedback, muscle tension and
(2010) Nurse’s laughter, music, internal stressors,
pocket guide: aromatherapy, and increases patient’s
Diagnosis, therapeutic touch). focus on self, which in EVALUATION
prioritized , turn increases the
interventions level of pain.
and rationales.
F.A. Davis. Evaluate pain relief Goal is maximum pain
Philadelphia and control at regular control with minimum
intervals. Adjust interference with
medication regimen as ADLs.
necessary.

Assess for referred To help determine

pain, as appropriate. possibility of
underlying condition
or organ dysfunction
SAINT PAUL UNIVERSITY DUMAGUETE
COLLEGE OF NURSING
NURSING CARE PLAN FORM

requiring treatment.
Evaluate pain Use pain rating scale
characteristics and appropriate for age
intensity. and cognition.

Collaborative
Provide for Promotes active,
individualize physical rather than passive,
therapy or exercise role and enhances
program that can be sense of control.
continued by the
client after discharge.

Discuss with SO(s) Family members/SO

ways in which they may provide
can assist client with assistance by
pain management. transporting client to
prevent walking long
distances, or by taking
on clients strenuous
chores supporting
timely pain control,
encouraging eating
nutritious meal to
enhance wellness.
SAINT PAUL UNIVERSITY DUMAGUETE
COLLEGE OF NURSING
NURSING CARE PLAN FORM
SAINT PAUL UNIVERSITY DUMAGUETE
COLLEGE OF NURSING
NURSING CARE PLAN FORM
SAINT PAUL UNIVERSITY DUMAGUETE
COLLEGE OF NURSING
NURSING CARE PLAN FORM
SAINT PAUL UNIVERSITY DUMAGUETE
COLLEGE OF NURSING
NURSING CARE PLAN FORM
SAINT PAUL UNIVERSITY DUMAGUETE
COLLEGE OF NURSING
NURSING CARE PLAN FORM
SAINT PAUL UNIVERSITY DUMAGUETE
COLLEGE OF NURSING
NURSING CARE PLAN FORM
SAINT PAUL UNIVERSITY DUMAGUETE
COLLEGE OF NURSING
NURSING CARE PLAN FORM