NURSING CARE PLAN

DIAGNOSIS: Acute Gastritis, T/C adrenal crisis, COPD

NURSING PLANNED
CUES / DIAGNOSIS OBJECTIVE OF RATIONALE EVALUATION
EVIDENCES CARE INTERVENTION

Subjective Alteration At the end of 8 hrs of  Forsee the need for Preventing the pain is one thing that a At the end of 8 hrs of
Verbalized, and giving patient care, pain relief patient experiencing it can consider. giving patient care,
“Sakit akong discomfort patient will: Early intervention may decrease the patient:
likod, labi na related to total amount of analgesic required.
 describe  described
kung maglihok” possible  Provide rest periods Pain may result to fatigue. A peaceful
satisfactory pain satisfactory pain
-lower back adrenal crisis to promote relief, environment may facilitate rest
control at a level control at a level
pain relaxation and sleep
less than 3 to 4 less than 3 to 4 on
-Pain scale of  Allow the patient to Pain is subjective. Patient can only
on a rating scale a rating scale of 0
6/10 assume position of determine which position he’s
of 0 to 10 to 10
Objective comfort comfortable and that lessens pain.
 verbalize pain is  verbalized pain is
-facial mask of  Feeding and For fast healing
relieved/controlle relieved/controlled
pain when he nutrition appropriate
d  verbalized method
moves for patient’s
 verbalize method that provides relief
-limited condition
that provides  displayed relaxed
movement  Encourage To divert patient’s attention from pain
relief manner: able to
Vital signs diversional activities
 display relaxed participate in
T – 36.7°C  Encourage Works by increasing the release of
manner: able to activities,
P – 100bpm breathing exercises endorphins, boosting the therapeutic
participate in sleep/rest
R – 24 cpm effects of pain relief medications.
activities, appropriately
BP – 130/70 sleep/rest
appropriately  Provide a quiet Additional stressors can intensify the

environment. patient’s perception and tolerance of

pain.

 Provide optimal Various types of pain require different

pain relief by analgesic approaches.

administering
prescribed pain
relief medication.
 Evaluate It helps the entire healthcare team

effectiveness of evaluate their pain management

drugs given strategy.

NURSING CARE PLAN

DIAGNOSIS: Acute Gastritis, T/C adrenal crisis, COPD

NURSING
CUES / DIAGNOSIS OBJECTIVE OF PLANNED RATIONALE EVALUATION
EVIDENCES CARE INTERVENTION

Subjective Disturbed At the end of 8 hrs  Render bedtime Facilitates relaxation and promote onset of At the end of 8 hrs of
Verbalized sleep pattern of giving patient nursing care such sleep giving patient care,
“wala koy related to care, patient will: as back rub and patient:
tarong tlog aging aging other relaxation
kay gamata- and techniques Obtained optimal
 obtain optimal
mata ko” environmenta  Encourage patient Milk has a component that promotes sleep amounts of sleep as
amounts of
-Hours of l variation to drink milk This will refrain the patient from going to evidenced by rested
sleep as
sleep is less the bathroom in between sleep appearance,
evidenced by
than the  Remind the Research shows that 60 to 90 minutes verbalization of
rested
usual patient to avoid one sleep cycle and that completion of an feeling rested and
appearance,
taking large entire sleep cycle is beneficial improvement of sleep
verbalization of
Objective amount of fluids Meals before bedtime may produce pattern
feeling rested
before bedtime gastrointestinal upset and hinder sleep
 presence and
onset.
of improvement
 Attempt to allow Coffee contains caffeine that interferes
eyebags of sleep
for sleep cycles at ability to relax and fall asleep
 looks pattern
least 90 minutes
sleepy
 Misconceptions about sleep will be
 Encourage the
Vital signs corrected.
patient on proper
T – 36.7°C
food and fluid
P – 100bpm
intake such as
R – 24 cpm
avoiding heavy
BP – 130/70
meals, and
drinking coffee
before bedtime
 Help the patient To promote minimal interruption
in sleep or rest.
understand the
main cause of
sleeping
difficulties

 Organize nursing
care
NURSING CARE PLAN

DIAGNOSIS: Acute Gastritis, T/C adrenal crisis, COPD

NURSING
CUES / DIAGNOS OBJECTIVE OF PLANNED INTERVENTION RATIONALE EVALUATION
EVIDENCES IS CARE

Subjective: Imbalanced At the end of 8 hrs of giving  Encourage/educate about good Oral hygiene has a positive effect on At the end of 8 hrs of giving
Verbalized “wala nutrition, patient care, patient will: oral hygiene appetite and on the taste of food. patient care, patient:
koy gana magkaon” less than  Explain to the patient and   It will give a better understanding on
 Understand the
body significant others the the need of meeting the daily
significance of nutrition  Understood the
Objective: requirement importance of maintaining nutritional requirements of the body.
to healing process and significance of nutrition
s related to proper nutrition
 Dry skin general health to healing process and
inadequate  Discourage caffeinated or Beverages will decrease hunger and
 Documented  Verbalize and general health
intake of carbonated beverages lead to early satiety
inadequate demonstrates selection  Verbalized and
nutrients  Encourage patient to have It will enhance the appetite and will
caloric intake of food or meals that will demonstrates selection
small, frequent feedings have better digestion of food intake
 Patient has accomplish the of food or meals that
 Provide a pleasant A pleasing atmosphere helps in
mispercetion termination of weight will accomplish the
environment decreasing stress and is more
about foods loss termination of weight
favorable to eating
 Take adequate amount loss
 Discuss eating habits including Appeals to client task and enhances
of calories or nutrients  Took adequate amount
food preference intake
of calories or nutrients