Nursing Care Plan

ASSESSMENT NURSING DIAGNOSIS OUTCOME PLANNING INTERVENTION EVALUATION

IDENTIFICATION RATIONALE
Subjective: Acute pain related to After 8 hours of nursing -Determine the - This will help to After 8 hours of nursing
“Ang sakit sakit ng ulo headache and intervention, the patient’s perception of determine what nursing intervention, the goal
ko, ang init init kase dehydration evidence patient will be able to pain. care will be given. was met. The patient
samin dahil walang by pain scale of 7/10, display comfort and verbalized comfort and
kuryente.” as verbalized dry mouth and lips, and describe satisfactory -Provide a calm and -To reduce the number described low pain
by the patient. exposed in high pain control. The quite environment. of stimuli that could level. The patient is also
temperature due to patient will also become worsen the patient's rehydrated.
Objective: power interruption rehydrated and have - Provide dim lights in condition.
-pain scale of 7/10 energy to do light task. patient’s room.
-facial grimacing -This will help a patient
-dry mouth and lips -Drink fluids at least to get feeling better
3000ml. because bright and
T: 37°C flickering lights can
BP: 110/80 -Administer trigger headache.
RR: 16 medications such as
PR: 96 analgesics like -To replenish losses
paracetamol. since dehydration can
cause headache.
-Practice relaxation and
offer massage. -To reduce the intensity
of pain signals to the
brain.

-This will help to

promote circulation of
blood in areas that lack
of blood flow that
contribute to pain.
Name: Flores, Freema Mae C. Date:
Year and Block: BSN 1-C
Problem: Fever
Nursing Care Plan

ASSESSMENT NURSING DIAGNOSIS OUTCOME PLANNING INTERVENTION EVALUATION

IDENTIFICATION RATIONALE
Subjective: Hyperthermia related to After 8 hours of nursing -Monitor the patient’s -It will serve as baseline After 8 hours of nursing
“Ang sama ng viral infection. intervention, the degree of body data to determine if intervention, goal was
pakiramdam ko, patient’s temperature temperature. there is other met. The patient’s body
nilalagnat ako.” as will subside from 38.5°C underlying condition. temperature subsided
verbalized by the to normal body -Administer regular to 37.2°C and verbalized
patient. temperature. The tepid sponge baths for -A non-pharmacological comfort.
patient will also display surface cooling until measure that allow
Objective: comfort. body temperature falls evaporative cooling.
-warm skin within normal range.
-restlessness -When skin is exposed
-teary eyed -Loosened the clothing to room air, it loses
of the patient. heat and generates
T: 38.5°C evaporative cooling.
BP: 100/80 -Provide nutritional
RR: 18 support. -Hyperthermia causes
PR: 95 higher energy demands
-Encourage adequate and a high metabolic
fluid intake. rate, which necessitates
the consumption of
-Monitor input and food. Since fever causes
output. a loss of appetite, the
food must be enticing
-Wash hands with anti- to the patient.
bacterial soap and
encourage proper -To maintain fluid
hygiene. balance and avoid
dehydration.
-Administer antipyretic
drug as prescribed by -To determine any fluid
the doctor. imbalances or shortfalls
that could lead to
complications, as well
as to promote
circulatory volume and
tissue circulation.

-To reduce cross

contamination and
prevent the spread of
infection.

-Antipyretics cause the

hypothalamus to
override a
prostaglandin-induced
increase in
temperature. The body
then works to lower the
temperature, which
results in a reduction in
fever.
Name: Flores, Freema Mae C. Date:
Year and Block: BSN 1-C
Problem: Diarrhea
Nursing Care Plan

ASSESSMENT NURSING DIAGNOSIS OUTCOME PLANNING INTERVENTION EVALUATION

IDENTIFICATION RATIONALE
Subjective: Diarrhea caused by After 8 hours of nursing -Observe for abdominal -Helps to differentiate After 8 hours of nursing
“Sumasakit ang tiyan contaminant exposure. intervention, the pain, cramps, disease and assess intervention, goal was
ko, madalas ang patient will reestablish frequency, pressure, severity of episode. met. The patient
pagdumi ko.” as and maintains a normal watery stools, and reestablished and
verbalized by the pattern of bowel bowel sensations that -This will help to maintained a normal
patient. functioning and are overly active. decrease metabolic rate bowel functioning and
verbalize lower pain that worsens diarrhea. verbalized lower pain
Objective: scale. -Advised bed rest. scale.
-pain scale of 8/10 -Diarrhea can cause
-squirming with -Determine hydration serious dehydration. An
abdominal pain status by assessing extended series of
- watery stool input and output. diarrhea can cause the
body to lose more fluid
T: 36.8°C -Encourage to eat than it can absorb. The
BP: 110/90 nutritional foods such result is dehydration,
RR:18 as banana and apple. which occurs when the
PR: 84 body lacks sufficient
-Avoid foods that are fluid to function
spicy oily and caffeine. properly.

-Encourage balance -Fruits high in pectin

fluid intake and oral and potassium help
rehydration solution. reduce diarrhea since
these foods have a
-Administer binding effect in
antidiarrheals as digestive system that
prescribed by the make stools bulkier.
doctor.
-These will worsen
diarrhea because it
makes the
gastrointestinal system
cramp up.
-Electrolytes help
balance the amount of
water in your body as
well as the pH level and
move nutrients and
waste into and out of
cells.

-It will help to reduce

gastrointestinal
peristalsis and
diminishes digestive
secretions to relieve
diarrhea.