University of San Agustin

General Luna St., 5000 Iloilo City, Philippines

www.usa.edu.ph

COLLEGE OF HEALTH AND ALLIED MEDICAL PROFESSIONS - DEPARTMENT OF NURSING

NAME: CARLOS MIGUEL S. DE LA GENTE YEAR/SECTION:BSN 1-H

Case Application - Nursing Care Plan

Construct a Nursing Care Plan for Mr. Roman & Ms. Perez:

1. Mr. Roman, 25 years of age, presents to the triage nurse at the local emergency department,
complaining of severe generalized abdominal pain. She describes it as sharp and
intermittent. He states, “Over the last 4 days, I haven’t been able to have a bowel movement.”
He states that he is able to drink liquids and urinating without difficulty. Bowel sounds are
present in all 4 quadrants, however, they are hypoactive (decreased or quiet peristalsis).
Abdomen is distended and firm to touch. He states, “Two weeks ago I feel that my back hurts.
My doctor gave me a prescription of Tylenol #3 & I have been taking it every 6 hours for
pain.” He denies pain at the present time. Abdominal x-ray reveals a large amount of stool in his
lower colon. All other diagnostic tests are unremarkable. He was prescribed with Dulcolax 1
tablet once a day.

Diagnosis Goal Intervention Rationale Evaluation

Acute Abdominal Within 8 Independent: Independent: Short term:
Pain R/T pressure hours of  Examine  To The goal was
from distended receiving the daily promote achieved. After 4
abdomen as nursing care, routine of a patient hours of nursing
evidenced by: the patient patient. cooperatio interventions, the
will be able to n. patient reported
Subjective: express relief  Obtain the  Helpful in that the pain was
 He states, from patient’s assessing relieved/controlle
“Two gastrointestin vital signs. the need d, that he
weeks al distress and for followed the
ago I feel maintain a  Provide a interventio prescribed
that my stable stool quiet n pharmaceutical
back passage at environmen  To help regimen to relieve
hurts. regular t and assess pain, that he
intervals. reduce what could verbalized non-
 He also stimuli have been pharmacologic
states, (e.g., noise, the factor ways that give
"Over the lightning, affecting relief, and that he
last 4 constant the patient was able to relax
days, I interruption in his daily and sleep/rest
haven’t s) routine. correctly.
been able
to have a  List all the Dependent:
bowel patient’s
movemen current  Used to
t. prescription help
s. relieve

Email: cn@usa.edu.ph | Tel. No.: 0999-997-1485 | Fax No.: (033) 337-4403

 University of San Agustin
General Luna St., 5000 Iloilo City, Philippines
www.usa.edu.ph

COLLEGE OF HEALTH AND ALLIED MEDICAL PROFESSIONS - DEPARTMENT OF NURSING

mild to
moderate
Objective: Dependent: pain.
Abdomen is 1. Dulcolax 1  It works
distended and tab, once a directly on
firm to touch. day the colon
2. laxative to produce
such as a bowel
Dulcolax 1- movement
tab qd .
Interdependent:
 Suction to
relieve
buildup of
gas and
liquid
 Surgery

2. Mrs. Perez, 48 years old, is admitted to the nursing unit 2 hours after undergoing a right
surgical removal of her breast (mastectomy). The floor nurse receives a report from the
post anesthesia care unit (PACU) nurse that includes the patient’s admitting diagnosis of
breast cancer, latest vital signs, focused assessment, medication & intravenous (IV)
orders, pain level & the time she was last medicated for pain & status of the surgical
dressing. Initially, Mrs. Perez appears to be comfortable, dozing occasionally between
short conversations with her husband, who is at her side. When she was fully awake 3
hours after, she complains of sharp, constant pain on the right side of her chest. She
rates her pain at 8 / 10 on the pain scale. She is grimacing and appears tense. The RN
took her vital signs - T = 36.5 "C; BP = 130/100 mmHg; RR = 20 bpm; PR = 80
beats/min. She inspected the surgical wound, at the right breast and reveals that the
dressing is slightly soaked with blood and intact, no pus & slightly swelling noted.

Diagnosis Goal Intervention Rationale Evaluation

Mastectomy R/T After 1 Independent: Independent: Short Term:
impaired skin hour of  Establish  This could Goal met. After
integrity related nurse- Rapport serve as 1hour of nurse
to surgery to patient baseline data patient
breast removal interaction  Avoid sudden  Sudden interactionwithi
as evidenced by: over an 8- movement movement n an 8 hour shift,
hour shift, can cause the patient was
Subjective: the patient  Access mode damage to able to verbalize
She complains of will be able coping the healing and demonstrate
sharp constant to know, abilities and tissues on the theright
pain on the right pronounce, personality surgical measures
side of her chest. and show styles wound intaking of her

Email: cn@usa.edu.ph | Tel. No.: 0999-997-1485 | Fax No.: (033) 337-4403

 University of San Agustin
General Luna St., 5000 Iloilo City, Philippines
www.usa.edu.ph

COLLEGE OF HEALTH AND ALLIED MEDICAL PROFESSIONS - DEPARTMENT OF NURSING

the proper  To enhance post- surgical
Objective: precaution  Consider the self- esteem skin.
 She rates s and post- importance of and sense of
her pain surgical post-surgery self- worth.
at 8 / 10 skin care to rehabilitation  The client
on the prevent . stands to
pain infection. accommodat
scale e the change
Dependent: in the center
 She is Tylenol 1 tab PRN of gravity by
grimacin Advil 1 cap TID leaning to the
g and side.
appears
tense.

Email: cn@usa.edu.ph | Tel. No.: 0999-997-1485 | Fax No.: (033) 337-4403