NURSING CARE PLAN TEMPLATE (SCHOOL HEALTH and SAFETY NURSING ROTATION)
NCM107 – CARE OF MOTHER, CHILD AND ADOLESCENT (Well Client)
NCP A
Name of Patient: A.A
Diagnosis or Clinical Impression: Acute pain related to leg cramps
Date: April 24, 2021
ASSESSMENT
(Differentiate
OBJECTIVE from
SUBJECTIVE DATA)
Subjective:
The client verbalized,
“madalas akong nagigising
sa sobrang sakit”
The leg cramp was rated as
10 on a pain scale of 1-10,
with 1 as the lowest and 10
as the highest.
The patient reported that
she was not able to sleep
well due to leg cramps that
usually occur during her
bed time.
AMPONIN, ELISA JILLIAN E.
BSN 2B
NURSING DIAGNOSIS PLAN
(Actual or Potential with (Include Long and Short
complete parts) Term Goals plus at least
3 outcome criteria)
Acute pain related to leg NOC – Pain Level
cramps as evidenced by
verbal report. Short Term Goal:
The patient will be able to
provide evidence for
improved comfort
compared to baseline
within 24 hours
Long Term Goal:
After 3 days of nursing
interventions the client
should manifest a decrease
in the pain scale of 4/10 to
a manageable level of 1/10.
Outcomes:
The patient will be able to:
Civil Status: Single
Age: 16
INTERVENTIONS
(At least 5 and include
only the MOST
APPROPRIATE for
client’s context)
NIC- Pain Management
Perform an assessment on
its location, characteristics,
onset, duration, frequency
and severity of pain.
Observe for nonverbal
indicators of pain such
moaning, guarding, crying,
facial grimace.
Assess if the client
currently uses any
medications.
Sex: F
RATIONALE EVALUATION
(with scientific evidences (State whether met,
as needed) partially met or unmet
and the supporting
outcomes)
Short term goal:
• It helps ensure that
the patient receives Within 48 hours, the goal
effective pain relief. was met as evidenced by
verbal report of the patient
having minimal level of
pain.
• These behaviors
can help with
proper evaluation Long Term Goal:
of pain. After 3 days of nursing
interventions goals are met
as evident of the client
• Aids in planning decrease in pain scale from
and in obtaining 4/10 to 1/10 or with no
medication history. pain and discomfort and
positive verbal report of
 -Report minimal level of Recognize the need for • Early recognition the client during the
pain. pain management. can lead to a more evaluation.
Objective Data: effective pain
∅ -Reports pain management management.
methods relieve pain to a
satisfactory level. Use non-pharmacological • Some medications Outcomes:
pain relief methods are not of easy
-Reports ability to get (relaxation exercises, access, pain relief • The patient report
enough sleep and rest. breathing exercises, music methods are easily minimal level of
therapy). accessible and can pain.
be easily recalled. • The patient reports
pain management
methods
relieve pain to a
satisfactory level.
• The patient reports
ability to get
enough sleep and
rest.

The client learned

relaxation methods to
manage the level of pain

The patient reports getting

less interruptions during
her sleep.
Submitted by:

AMPONIN, ELISA JILLIAN E.

(Signature over Complete Name)

Evaluated by:

____________________________________
(Signature over Complete Name)
 NURSING CARE PLAN TEMPLATE (SCHOOL HEALTH and SAFETY NURSING ROTATION)
NCM107 – CARE OF MOTHER, CHILD AND ADOLESCENT (Well Client)

AMPONIN, ELISA JILLIAN E.

BSN 2B

NCP B
Name of Patient: A.A Civil Status: Single
Diagnosis or Clinical Impression: Disturbed sleeping pattern Age: 16 Sex: F
Date: April 24, 2021

ASSESSMENT NURSING DIAGNOSIS PLAN INTERVENTIONS RATIONALE EVALUATION

(Differentiate (Actual or Potential with (Include Long and Short (At least 5 and include (with scientific evidences (State whether met,
OBJECTIVE from complete parts) Term Goals plus at least only the MOST as needed) partially met or unmet
SUBJECTIVE DATA) 3 outcome criteria) APPROPRIATE for and the supporting
client’s context) outcomes)
SUBJECTIVE Disturbed sleeping pattern NOC: Disturbed Sleeping NIC: Sleep Enhancement
DATA: related to non- restorative Pattern Elimination
sleep pattern (e.g., due to Short term goal:
school activities and Short term goal: Evaluate the patient’s • The patient may After 2-3 hours of nursing
“Yung pagtulog ko hindi na responsibilities) as After 2-3 hours of nursing knowledge on the cause of have insights about intervention the client
katulad nung dati kasi evidenced by patient intervention the client will sleep problems. the existing understood the effects of
tinatapos ko muna ang mga stating “yung pagtulog ko be able to understand the lack of sleep to the well-
problems that may
school activites bago hindi maayos kasi tinatapos effects of lack of sleep to being
guide appropriate
matulog.”as verbalized by ko muna ang mga school the well-being
the patient. actions.
activities.”
She also, added that Long term goal:
“minsan nahihirapan na Long term goal: After 2-3 weeks of nursing
akong ibalik yung dating After 2-3 weeks of nursing intervention the client
pagtulog ko kasi parang intervention the client will • Consistent reported improvement in
nasasanay na ako na Instruct the patient to schedules facilitate sleep/rest pattern and
be able to report
ganon.” follow a consistent daily regulation of the increase sense of well-
improvement in sleep/rest
schedule for rest and sleep. being and feeling rested.
pattern and increase sense circadian rhythm
 of well-being and feeling
rested.
Outcomes:
Objective Data:
The patient will be able
Her conjunctivae are pale, verbalize understanding of
with dark circles around the importance of sleep to
the eyes. well -being.
The patient will be able to
verbalize the feeling of
being rested.
The patient will be able to
have adequate amount of
sleep and decrease
presence of dark circles
Encourage the client to
drink milk before sleeping
Encourage some light
physical activity during the
day. Make sure client stops
activity several hours
before bedtime, as
individually appropriate.
Introduce relaxing
activities such as warm
bath, calm music, reading a
book, and relaxation
exercises before bedtime.
Provide comfortable
bedding and some of own
possessions,
and decrease the
energy needed for Outcomes:
adaptation to
changes. The patient verbalized
• L-tryptophan is a understanding of the
component of milk importance of sleep to well
-being.
which promotes
sleep.
The patient verbalized the
• Daytime activity feeling of being rested.
can help client
expend energy and The patient had adequate
be ready for amount of sleep and
nighttime sleep; decrease presence of dark
however, circles
continuation of
activity close to
bedtime may act as
a stimulant,
delaying sleep.
• These activities
provide relaxation
and distraction to
prepare mind and
body for sleep.
• Increases comfort
for sleep; provides
physiological and
such as a pillow or an psychological
afghan. support.

Advice the patient to take • Taking naps will

naps if needed only.
compensate the
lack of sleep but
too much of it can
also disrupt normal
sleep pattern.

Instruct in relaxation
• Helps induce sleep.
measures.

Reduce noise and light.

• Provides
atmosphere
conducive to sleep.
Submitted by:

AMPONIN, ELISA JILLIAN E.

(Signature over Complete Name)

Evaluated by:

____________________________________
(Signature over Complete Name)