2.

Nursing Care Plan

PLANNING
NURSING
ASSESSMENT OBJECTIVE OF IMPLEMENTATION EVALUATION
DIAGNOSIS INTERVENTION RATIONALE
CARE
Subjective Cues: Acute Pain Related to Short Term Goal: INDEPENDENT:  Pain may be mild  The patient’s description The patient verbalizes
 Pain is extreme, Biological Injury After 2 hours, the patient  Assess intensity, to severe with of pain is extreme, decreased in pain and
Secondary to H. will report decreased in description, location, radiation to sharp, cramping, show normal face
remitting, sharp, Pylori Infection as paleness and exhaustion radiation of pain, and abdominal area, remitting in both inwards expression, verbalizes
Evidenced by Self- due to pain. changes in sensation. numbness or direction of the abdomen pain is relieved,
cramping, and
report of pain tingling controlled and able to
radiating intensity. Long Term Goals: discomfort may move laterally without
Patient will report pain is reflect return of pain.
laterally in both relieved or controlled, and sensation.
able to move laterally
inwards direction
without pain.  Instruct in regular use of  Standardized tool  The patient described
of the abdomen. a 0 to 10 (or similar) for rating pain the pain as extreme
pain- rating scale. helps in painful and scored it
Objective Cues: assessment and from 9-10.
 Pale & management of
pain.
exhausted
 Encourage client to  Positioning is  Encouraged the client to
assume position of dictated by assume position of
comfort, as indicated. physician comfort as desired.
preference and
type of
operation; for
example, head of
bed may be
slightly
elevated after
cervical
laminectomy.
COLLABORATIVE:

 Administer medication  To relieve the  Administered medication

as prescribed by the patient’s pain. as prescribed by the
physician. physician.

Reference/s:
Nurisng Diagnosis: In Herdman, T. H., In Kamitsuru, S., & North American Nursing Diagnosis Association,. (2018). NANDA International, Inc. nursing diagnoses: Definitions & classification 2018-2020.
Objective of Care:Doenges, M. E., Moorhouse, M. F., & Murr, A. C. (2008). Nursing diagnosis manual: Planning, individualizing, and documenting client care. Philadelphia, PA: F.A. Davis.
Nursing Intervention: Doenges, M. E., Moorhouse, M. F., & Murr, A. C. (2014). Nursing care plans: guidelines for individualizing client care across the life span. Edition 9. Philadelphia, PA: F.A. Davis Company.

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 PLANNING
NURSING
ASSESSMENT OBJECTIVE OF IMPLEMENTATION EVALUATION
DIAGNOSIS INTERVENTION RATIONALE
CARE
Risk for unstable Short Term Goal: INDEPENDENT: The patient’s blood
Subjective Cues blood pressure  Identify the  Some factors like  The patient has pressure dropped
 discomfort worsens related to After 2 hours the patient will presence of fluid imbalances, osteoarthritis. The significantly within
after taking NSAID inconsistency with maintain blood pressure associated endocrine patient is taking NSAIDS acceptable limits. The
for her knee pain medication regimen within acceptable limits. conditions disorders, when her knee is in pain. patient understands the
and drinking coffee as evidenced by the emotional stress condition, therapeutic
but relieved after adverse effects of Long Term Goals: may cause or regimen and preventive
taking antacids NSAID drugs Facilitate safe and effective exacerbate blood measures while using
 has Osteoarthritis, use of drugs by pressure drugs that affects her
diagnosed one year understanding the instability. blood pressure
ago, use of NSAID condition, therapeutic  Review current  Use of certain  The patient is taking
since diagnosis regimen, and preventive medication regimen medications such NSAIDS and antacids
measures. as vasodilators,
Objective cues antihypertensives,
 hypertensive and such can
have direct effect
Vital signs: on blood pressure
 BP 160/90 mmhg  Determine how  Blood pressure  As verbalized the patient
client takes fluctuations can is taking NSAID when
medication occur in clients her knee is in pain, and
who is taking takes antacids to relieve
unprescribed her stomach pain for
medications, such months.
use OTC meds.
 Measure blood  Incorrect readings  Measured. The client’s
pressure to may result to blood pressure is
determine the risk of inappropriate or 160/90mmhg. Currently
hypertension. lack of treatment hypotensive.
needed
 Note whether the  Reason may not  As listed, there are no
client has potential be pathological or other history of
cause for high blood may be due to hypertension and
pressure associated associated hypertension
conditions verbalized by the patient

 Address personal  Some personal  Factors that are noted

factors lifestyles need to such as coffee, and
require smoker may contribute
modification such to short term high blood
as in health care pressure to the patient.
management,
teaching, and
follow up.

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 COLLABORATIVE:

 Refer to nutritionist for  To fully modify the  Refered to nutritionist for

full nutritional evaluation client’s diet for full nutritional evaluation
of client’sneeds, aversion of high of client’sneeds,
especially noting dietary blood pressure. especially noting dietary
deficiencies deficiencies

Reference/s:
Nurisng Diagnosis:
In Herdman, T. H., In Kamitsuru, S., & North American Nursing Diagnosis Association,. (2018). NANDA International, Inc. nursing diagnoses: Definitions & classification 2018-2020.
Objective of Care:
Doenges, M. E., Moorhouse, M. F., & Murr, A. C. (2008). Nursing diagnosis manual: Planning, individualizing, and documenting client care. Philadelphia, PA: F.A. Davis.
Nursing Intervention: Doenges, M. E., Moorhouse, M. F., & Murr, A. C. (2014). Nursing care plans: guidelines for individualizing client care across the life span. Edition 9. Philadelphia, PA: F.A. Davis Company.

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