Nursing Care Plan

Patients name: Joemel Relloso Assessment Nursing Diagnosi s

Ineffective breathing pattern related to acute pain.

Age: 12y7m/0 Planning Intervention Rationale Evaluation

Inference

Subjective: Masakit dibdib ko, nahihirapan akong huminga lalo na pag nakahiga as verbalized by the patient Masakit din yong tiyan ko as mentioned also by the patient Objective: dyspnea chest pain V/S taken as follows: RR: 22 Temp.:36.5 PR: 83 BP: 110/70

The ineffective breathing is manifested by increase or decrease in rate and/or pattern from what's normal for that patient

Goal: IN Independent: Pain is Established reduced/ controlled/ rapport lost Surgical procedure/ prognosis, therapeutic regimen Obtained and possible resting vital signs complications understood. Appear relaxed, able to sleep and rest appropriately. Outcomes: After 4 hours of nursing interventions, the patient will demonstrate use of relaxation skills, other methods to promote comfort. Assess the Scale of pain(0-10), location,duration, pain characteristics (dull, sharp, constant)and report changes accordingly. Encourage early ambulation. Rapport is important to gain patients cooperation and reduce anxiety. Baseline data is important to help determine patients current health status and evaluate efficacy of nursing interventions rendered. Useful in the supervision and efficient medicine, healing progress, changes and characteristics of pain. Promotes organization of organ function. Reducing abdominal Goal met. Patient exhibits a normal sleep and rest pattern as evidenced by absence of pain. Surgical procedure/ prognosis, therapeutic regimen and possible complications understood by the patient. After 4 hours of nursing interventions, the patient was able to demonstrate use of relaxation skills, other methods to promote comfort.

 Provide comfort measure like back rubs, deep breathing.

Reduces abdominal distention,thereby reduces tension. Reduces muscle tension or guarding, which may help to minimize the pain of movement. Promotes relaxation and may enhance patients coping abilities by refocusingattention.

Instruct in relaxation or visualization exercises.

Provide diversional activities.

Collaborative: Administer analgesics as prescribed.

Relief of pain facilitates cooperation with other therapeutic interventions such as ambulation.

Presented to: Maam Domine Presented by: Dienifpher Isa B. Ballesteros Yr. and Sec.: II- B