VISION MISSION

A premier university in Republic of the Philippines Cavite State University shall provide
historic Cavite recognized CAVITE STATE UNIVERSITY excellent, equitable and relevant
for excellence in the Don Severino Delas Alas Campus educational opportunities in the arts,
development of morally Indang, Cavite science and technology through quality
upright and globally instruction and relevant research and
competitive individuals. development activities. It shall produce
College of Nursing
professional, skilled and morally upright

NURSING CARE PLAN

Name of Patient (initial): _YZB_____ Date of Admission: _________________________

Age: _43___ Diagnosis: _________________________________
Sex:__F___ Surgery (if any): ____________________________

ASSESSMENT NURSING OBJECTIVES OF NURSING INTERVENTIONS RATIONALE EVALUATION

DIAGNOSIS CARE SCHEME
Subjective Cues: 1. Acute pain Short term: Independent:
- experiencing related to chemical - The nurse will assess These data can be Goal met. After
stomach ache, pain burn -After 2 hours of pain used to identify the 4 hours of
of gastric
scale of 7 out of 10 mucosa nursing characteristics(quality, extent of the pain as nursing
intervention, the severity, location, well as serve as a interventions,
and easily exhausted
patient will be able onset, duration, baseline information. the patient
- the client precipitating and verbalized relief
to discuss the pain
relieving factors). from pain and
verbalized felt by the client.
rated it as 2/10
“Kadalasan
Long term: - The nurse will observe Some people deny from 7/10.
sumasakit tiyan ko or monitor signs and the experience of
tuwing makatapos - After 4 hours of symptoms associated pain when it is
kumain, sa bandang doing the nursing with pain, such as BP, present. Attention to
baba at kaliwa. heart rate, associated signs may
interventions, the
Siguro 7/10 sa pain temperature, color help the nurse in
patient will and ability to focus. evaluating pain.
scale. ” verbalize relief
Objective Cues: from pain and rate
it as 2/10 from - The nurse will assess
- Restless 7/10. patient’s knowledge
- Pacing of or preference for
 - Wrinkled the array of pain-relief Different etiological
nose strategies available. factors respond
- Rigid better to different
therapies.
- Rated pain as
Some patients may
7/10 in a be unaware of the
pain scale of effectiveness of
0-10 nonpharmacological
methods and may be
willing to try them,
either with or instead
of traditional
analgesic
medications. Often a
combination of
therapies (e.g., mild
analgesics with
distraction or heat)
may prove most
Dependent: effective.
- The nurse will
administer analgesic
for relief of pain (e.g.
morphine sulfate) Reduces abdominal
tension and
promotes
sense of control
- The nurse will
administer antacids
(e.g. Magnesium
Hydroxide Aluminum Relieves abdominal
Hydroxide) pain by reducing the
peristaltic activity.

Subjective Cues: 2. Acute pain Short term goal: Goal met. After
The client related to Tissue After 2 hours of Justify and clarify cause of Provides opportunity 4 hours of
verbalized, “Napo- trauma. Evidenced nursing pain and the need of for timely nursing
provoke ‘yung sakit by restlessness and intervention, the notifying caregivers of administration of interventions,
kapag nakain ako ng changes in pain occurrence analgesia (helpful in the patient
facial mask of pain. client will be able
foods na maraming and characteristics. enhancing patient’s reported and
to report and
preservatives, e hilig coping ability and demonstrated
ko pa naman ‘yon.” demonstrate may reduce anxiety) behaviors signaling
behaviors signaling and alerts caregivers a relief or control of
Objective Cues: a relief or control of to possibility of pain and appeared
- Restlessness pain. passing of stone and relaxed, was able to
- Facial mask of pain developing rest appropriately.
complications.
Sudden cessation of
Long term goal: pain usually indicates
stone passage.
After 3 hours of
doing the nursing
interventions client
will appear relaxed, Implement comfort measures Promotes relaxation,
able to sleep/rest (back rub, restful reduces muscle
appropriately environment). tension, and
enhances coping.

Assist with frequent Renal colic can be

ambulation as indicated and
increased fluid intake of at
least 3–4 L a day within
cardiac tolerance.
worse in the supine
position. Vigorous
hydration promotes
passing of stone,
prevents urinary
stasis, and aids in
prevention of further
stone formation.

Document reports of
increased and persistent Complete obstruction
abdominal pain. of ureter can cause
 perforation and
extravasation of
urine into perirenal
space. This
represents an acute
surgical emergency.
Apply warm compresses to
back. Relieves muscle
tension and may
reduce reflex spasms.

Subjective Cues: - Allow the patient to - The patient’s Goal met. After
The patient 3. Fatigue Short term: express feelings about point of view 4 hours of
verbalized, “Mabilis related to lack of fatigue. can give nursing
akong mapagod After 2 hours of interventions,
sleep, and stress valuable
kaya nahihirapan nursing the patient was
evidenced by insight into
ako minsan tapusin intervention, the able to name the
increase need of his or her
ang mga ginagawa patient will be able causes of fatigue,
sleep and rest, and awareness
ko. Nagsimula ‘to to name the causes name factors that
nung lagi akong having hard time and worsen and
of fatigue . The
stress.”. finishing activities motivation to improve symptoms
patient will name
and weakness. improve of fatigue , was able
Objective Cues: factors that worsen to show increased
and improve fatigue
- Having hard engagement in
time finishing symptoms of symptoms. daily activities,
activities fatigue. - Encourage the patient - Keeping track verbalized
- Weakness to keep a log of of activities increased energy,
- Increased Long term: activities along with with emotions described energy-
need for the energy level at the and energy conserving
sleep and After 3 hours of time. techniques.
level helps the
rest nursing
patient
intervention, the
become more
patient will
aware of
verbalize increased
contributing
energy. The patient
factors to
will show increased
engagement in their fatigue.
daily activities and Nurses can
will describe use this
energy-conserving information
techniques. to develop
strategies
with the
patient to
reduce
situations that
increase
fatigue.

- Planning daily
- Assist in developing a
activities and rest
schedule that
supports the most periods might reduce
energetic hours of the anxiety. Planning
day and allows for small increments
rest when needed. might promote
motivation and help
complete daily tasks.
Tasks can be decided
between several
days, such as
housework.

- It takes less energy

- Provide small to consume several
frequent meals with a small portions than
soft texture. three full meals. Soft
foods require less
chewing and
 conserve energy.

- Certain medications
- Collaborate with the such as sleep
attending physician medications,
about optimizing sedatives, pain
medications.
medications, and
others can contribute
to fatigue.
Adjustments in
frequency and dosing
could improve
symptoms of fatigue.

- Teach family - Regular checks of

members and vital signs and an
caregivers signs of
overall observation of
overexertion.
the patient’s general
appearance will
reveal their activity
level.

Submitted By: _BUQUID, JULLIENE IVES Z.____________________ Submitted To: _Prof. Mary Antoniette Viray__
Year/Section/Group: _2______________________ Date: _10/29/21________________________