Nursing Care Plan

Name: Legaspi, Fatima Aira S. Section: 1YB-31 Date: March 22, 2022
Dorothy Grant

Assessment Diagnosis Planning Interventions Rationale Evaluation

Subjective Data: Chronic Pain After 1 to 3 days of Independent: After 1 to 3 days of

Patient reported that related to nursing intervention nursing intervention
she has severe severe patient will be able - Monitor patient patient is able to:
- Vital signs
throbbing pain in the headache as to: vital signs. can alleviate
right temporal region evidence by - Demonstrate
that started since she the patient - Demonstrate or altered
the use of
was 16. On a scale of reported that the use of during the
different
0 to 10 (with 10 being she had a different acute pain.
the worst), she rates long history relaxation relaxation
her pain as a 9. She of severe skills and - Perform a skills and
- Helps the
said she feels migraine diversional comprehensive diversional
nauseated but denies headaches. nurse in
activities. assessment of activities.
vomiting. She planning
described its pain. Determine optimal pain
- Report pain - Report pain
beginning with loss of at a level the location, management
her central field of characteristics, at a level
less than 3 strategies.
vision, followed by to 4 on a 0 onset, duration, less than 3
flashing lights and to 10 rating frequency, to 4 on a 0
then "orange and blue scale. quality, and to 10 rating
triangles moving from scale.
severity of pain
left to right" across her - Verbalize
visual field. About an acceptable via assessment.
- Verbalized
hour later, she level of pain
experienced the pain. - Observe acceptable
relief and - Observations
She also stated that ability to nonverbal cues level of pain
may not be
engage in relief and
 Nursing Care Plan
she is feeling "a little desired and pain congruent ability to
lightheaded." activities. behaviors (e.g. with verbal engage in
how client reports or desired
Objective Data: - Engage in
walks, hold may be an activities.
desire
Height: 162.5 cm activities body sits; facial indicator
Weight: 63.5 kg without an expression) present when - Engaged in
PR: 78 bpm increase in client is desire
RR: 24 bpm pain level. unable to activities
BP: 128/74 mmHg without an
verbalize.
Temp: 37.1 °C increase in
pain level.
- Provide or
Physical Assessment: promote non- - To distract
 Voice trembles pharmacological the patient to
slightly when pain any painful
speaking management sensation
 Head & face such as quiet
are round; environment,
symmetric
calm activities,
 Head is in
central position comfort
 Trachea is in measure, use of
midline relaxation
 Thyroid gland, exercise (e.g.
Cervical, & focus on
Supraclavicular breathing etc.)
Lymph Nodes and distractions
are non-
activities (e.g.
palpable and
non-tender watching TV
 Temporal area listening to calm
is tender music etc.)
 Nursing Care Plan
 Temporal
artery is
palpated Dependent:
 Cranial Nerves
Test Result:
- Provide - To alleviate
Normal
pharmacological the pain or to
pain maintain
management as “acceptable”
ordered by the level of pain.
physician Notify the
physician if
the regimen
is inadequate
to meet the
pain control
goal.
 Nursing Care Plan
Name: Legaspi, Fatima Aira S. Section: 1YB-31 Date: March 22, 2022
Mrs. Hira

Assessment Diagnosis Planning Interventions Rationale Evaluation

Subjective Data: Ineffective After 3-5 days of Independent: After 3-5 days of
Patient reported dry eye self- nursing nursing intervention,
changes in her vision management - Provides a the patient:
intervention, the - Assess the
as “blurring that seems related to
patient will be able patient’s ability baseline for
to be getting worse” blurred determination - Maintained
vision as to: to see and
and a halo effect at of changes
evidence by perform a safe
night when she looks affecting the
at lights. the patient - Maintain a activities. environment
reported she patient’s with no
safe
is having visual acuity. injury noted.
Physical Assessment: environment
changes in
 No lid lag with no
her vision
 Extraocular that seems
injury noted.
- Provide - Knows how
- Helps elderly
muscles are to be getting sufficient to deal with
people as
intact worse. - Learn how lighting for the they need the lights at
 Visual fields
to deal with patient to carry more light night
are equal to
the lights at out activities.
examiner’s
 No excessive night
- Learned
tearing or - Provide foods - Essential for about proper
blinking - Have a good vision
rich in Vitamin eye self-
knowledge
 Conjunctivae A since it is a management
about proper
are smooth, component of
eye self-
without redness management the protein
 Pupils are rhodopsin,
bilaterally which allows
 Nursing Care Plan
round, equal in the retina to
size, reactive to work
light & properly
accommodation
 No nystagmus - Encourage the - Can monitor
OD: 20/40 patient to visit a any
OS: 20/40 specialist for complications
the eyes. if there is any

Collaborative:

- Refer to an - To ensure the

ophthalmologist best
for examination examination
and treatment
that they can
give