Nurse Care Plan

Name of MCN Patient: Patient Cub Student Name:

Patient Diagnosis: PCAP-C Date of Submission:
Complaint: Fever Clinical Instructor:
Ward/Dept: FAMED
Problem List Assessment/ Nursing Plan/Objectives Nursing Intervention Rationale Evaluation
According to Cues Diagnosis
Priority
Objective: Acute Pain Short term:  Encourage the  Patient Goal met.
Physiologic  Loud related to After 1 hour of use of involvement
factor coughing persistent nursing relaxation in pain After 1 hour of
 Chest pain coughing/ intervention, and/or control nursing
and croup patient will be breathing measures intervention the
Headache able to : exercises. promotes patient was able
as independenc to;
evidenced a) Rate pain e and
by facial scale less enhances the a) Rate pain
grimace than 3-4. sense of scale at 2
 Discomfort b) will be in well-being. b) Noted
a more  Instruct asleep and
relaxed frequent oral  Mouth is at rest
manner as hygiene breathing and c) Able to
evidenced oxygen minimize
by therapy can coughing
resting/ irritate and and has
sleeping. dry out verbalize
c) Minimize mucous preventive
coughing membranes, measures.
and will potentiating
verbalize general
preventive  Instruct and discomfort.
measures assist the
for pain. patient in chest  Aids in
splinting control of
techniques chest
during discomfort
coughing while
episodes enhancing
the
effectiveness
of cough
 Administer effort.
analgesics as
prescribed.  Medications
Encourage the allow for
patient to take pain relief
analgesics and the
before ability to
discomfort deep breathe
becomes and cough.
severe. Analgesics
help prevent
 Provide peak periods
comfort of pain.
measures; back
rubs and bed  Lessens pain
positioning. and promote
comfort and
relaxation.