Nursing Care Plan

ASSSESSMENT DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATION

Subjective Data: Acute pain related After 30 minutes to Establish rapport To gain patient Goal Met: After 1
“Sobrang sakit ng to increased 1 hour of nursing trust and hour of nursing
tiyan ko sa may frequency or force intervention the cooperation intervention the
bandang kanan” of ureteral patient pain scale patient pain scale
contractions as will decreased into Monitor vital signs To have a baseline decreased from
Objective Data: evidenced by 4/10 data 8/10 into 4/10
- Pain Scale guarding behaviors,
8/10 body weakness Assess the client’s To assess the
- Guarding and facial grimace pain characteristics effectiveness of a
behavior pain-reduction
- Body intervention
weakness
- Facial Determine possible To become
grimace causes of pain knowledgeable
- Increased (inflammation, about causes and
respiratory fractures or treatment
rate 23 bpm surgery)

Accept patient For validation the

description of pain patient’s perception
of pain

Encourage patient To promote rest to

to have a rest and the patient
sleep

Provide comfort To recover quicker

and calm and have a better
environment health outcome

Administer pain To decrease the

medication as intensity of pain
ordered
 ASSESSMENT DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATION
Subjective Data: Impaired urinary After 2-3 days of Establish rapport To gain patient Goal Met: After 2
“Nahihirapan akongelimination related nursing intervention trust and hours of nursing
umihi” to anatomic the patient will cooperation intervention, the
obstruction as achieve normal patient participate
Objective Data: evidenced by elimination pattern Monitor vital signs To have a baseline in measures to
 Incontinence oliguria (retention) and participate in data compensate for
 Retention measures to defects
correct or Encourage fluid To help maintain
compensate for intake up to 3,000 renal function
defects mL/day

Discuss possible To avoid in

dietary restrictions worsening the
obstruction

Encourage client to Open expression

verbalize fears and allows client to deal
concerns with the feelings
and begin problem-
solving

Implement and To modify

monitor treatment, as
interventions for needed
specific elimination
problem

Administer
medication as
ordered
 ASSESSMENT DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATION
Subjective Data: Knowledge deficit After 30 minutes to Establish rapport To gain patient After 30 minutes of
“Hindi ko rin alam related to 1 hour of nursing trust and nursing intervention
bakit ako unfamiliarity with intervention the cooperation the patient
nagkaroon ng bato information patient will verbalized
sa kidney” resources as verbalize Active-listen Helps patient work understanding of
evidenced by understanding of concerns about through feelings the disease
Objective Data: questions; request disease process therapeutic and gain sense of
 Confusion for information and potential regimen and control over what is
complications lifestyle changes happening

Explain causes of For better

kidney stones and understanding
ways to prevent
recurrence

Emphasize Flushes renal

importance of system
increased fluid
intake

Discuss medication For better

regimen understanding