NURSING CARE PLAN-Fall 2019

Student: Mohamed al kassem Date: 3/12/2019 Unit: MSU-5

(Total= 5 points)
Patient Initials E.D.D. Bed No. 502B
Medical history: asthma, dyslipidemia.
Case No. 190140950 Admission Date 1/12/2019
Nursing Diagnosis Scientific Rationale for Nursing Diagnosis Expected Outcome Nursing Intervention Scientific Rationale for Criteria for Evaluation of
(3pts) (10pts) (3pts) (13pts) Nursing Intervention (13pts) Expected outcome with
Diet: Regular diet(low fat) Surgical history: appendectomy justification (3pts)
Acute pain By the end of my shift, Assessment:
Activity: Ambulated
1. Patient with acute
related to my patient will: 1. Assess vital
Intravenous Therapy 1.5L NSS Q24 hrs. r= 62 ml/hr. Medications
pain an increase
inflammation
Allergies:NKFDA 1. Patient describes  signs40mg IV once daily 6am
Nexium
Treatments  Duphalac 30cc PO once daily 9 am
in BP, HR and
and smooth Vital signs satisfactory pain  (BP, RR,
Scoburen 20mgHR,
IV Q8hr TID 1am-9am-5pm
 pain assessment  Ceftriaxone 2000mg IV Q24hr 1 am
 PRN: temperature will
muscle spasm
 Physical assessment control at a level 
Sp02,
Ketesse 50mg IV Q12hr
 Lab tests  Perfalgan 1g IV Q6hr be present.
secondaryto ambulation less than 2 to 3  temperature)
Primperan 10mg IV Q8hr
 Medication administration
appendagitis,
 Teaching on rating scale of Q4hr.
 Fall precautions
2. Assessment of
evidence by the
Iv hydration 0 to 10. 2. Assess pain
 Monitoring complications
pain
patient report
 Check food trays , and type of diet 2. Patient will show characteristics:
experience is the
pain 6/10 score overall improved
 Quality (e.g.,
first step in
on pain scale mood, comfort
burning,
planning pain
with facial and coping.
sharp,
grimacing while 3. Have normal management
shooting)
palpate the left vital signs as an strategies. The
 Severity
lower quadrant indicative of less most reliable
(scale of 0 or
of his abdomen. severe pain (BP source of
no pain to 10
120/80 mmhg, information about
or most
HR from 60 to the pain is the
severe pain
100 beats per patient.
before and
minute and RR Descriptive scales
after giving
12-20 breath per such as a visual
the
minute). analogue can be
medication)
4. Patient uses utilized to
 Location
pharmacological distinguish the
(anatomical
and non- degree of pain
description)
pharmacological
 Onset
pain-relief
(gradual or
strategies.
sudden)

 Duration

(how long;
 intermittent

or

continuous)

 Precipitating

or relieving

factors

3. Assess for sign

and symptom
3. Some people
relating to pain
deny the

existence of pain.

Attention to

associated signs

may help the

nurse in

evaluating pain.

An increase in

BP, HR, and

temperature may
 be present in a

patient with acute

pain. The

patient’s skin

may be pale and

cool to touch.

Restlessness and

inability to

concentrate are

also some

manifestations.

To indicate if

patient is in pain

4. Some patients

4. Assess the may be satisfied

patient when pain is no

anticipation for longer massive;

pain relief. others will

demand complete
 elimination of

pain. This

influences the

perceptions of the

effectiveness of

the treatment of

the treatment

modality and

their eagerness to

engage in further

treatments.

5. To assess the

effectiveness of
5. Assess for facial
pain relievers.
grimacing and

guarding of
6. To indicate the
affected area.
level of pain the
6. Assess patient
patient is
response to pain
experiencing.
 relief Also, to adjust

medications. medication dose

(Perfalgan) as needed.

Intervention:

7. To reduce pain

and provide

Interventions: comfort.

7. Administer pain

medication when 8. The use of these

needed techniques

(Perfalgan) lessens the stress,

8. Use non- tension

pharmacological subsequently

techniques such decreasing the

as distraction by pain by gate

encouraging control therapy.

family visits,

watch TV and

relaxation
 exercise such as 9. One’s

listening to experiences of

music. pain may become

9. Provide rest exaggerated as a

periods to result of

promote relief, exhaustion. Pain

sleep and may result

relaxation in fatigue which

may result in

exaggerated pain.

A peaceful and

quiet environment

may facilitate rest

10. To reduce pain by

promoting

10. Provide patient comfort and

with adequate healing quiet

rest, comfortable environment.

environment. 11. Heat decreases

 pain through

11. Apply hot or improved blood

cold compress on blow to the area

the affected area and through

reduction of pain

reflexes. Cold

lessens pain,

inflammation,

and muscle

spasticity by

decreasing the

release of pain-

inducing

chemicals and

regulating the

conduction of

pain impulses.

Teaching:

12. Patient will know

Teaching: more about pain

12. Instruct patient management and

to ask for PRN the importance of

medication medications of

before pain gets pain

worse and management.

severe. 13. Side effects of

opioids can be

dangerous and

13. Teach patient the life threatening

important side 14. Patients may

effects of pain experience an

medication exaggeration in

14. Teach the patient pain or a

to Get rid of decreased ability

additional to tolerate painful

stressors or stimuli if

sources of environmental,

discomfort intrapersonal, or
 whenever intrapsychic

possible factors are further

stressing them.

15. The aid of an

imagined event or

a mental picture

15. Teach the patient involves use of

Cognitive- the five senses to

behavioral divert oneself

strategies as from painful

follows: stimuli.

Increasing one’s
 Imagery
concentration,
 Distraction
these techniques
techniques
help an individual
 Relaxation
decrease the pain
exercises,
experience.
biofeedback,
Breathing
breathing
modifications and
exercises, nerve

music therapy stimulations are

some of the

methods.The aim

of these

techniques is to

lessen the stress,

tension,

subsequently

decreasing the

pain.