NURSING CARE PLAN

Name: Santos, Rodrigo Date Admitted:

Age: 45 yrs. old Chief Complaints: Persistent Diarrhea and Abdominal Pain
Sex: Male Diagnosis:
Civil Status: Married Attending Physician:
Address: Ward/Area: OPD

ASSESSMENT NURSING PLANNING IMPLEMENTATION RATIONALE

DIAGNOSIS

Subjective Cues:
● “patient stated Acute pain related After 8 hours of nursing ● Monitor vital signs ● Alterations from normal
that he to prolonged interventions, the patient will maybe signs of infection
experienced diarrhea and be able to alleviate and Perform an assessment of
crampy skin/tissue manage the abdominal pain pain to include location,
abdominal pain, irritation as and discomfort. duration frequency,
especially in the evidenced by quality, severity, grimacing
lower left abdominal pain (0 to 10 scale)
quadrant”
● Non-Pharmacologic: ● Reduces abdominal
Encourage the patient to tension and promotes a
assume position of comfort sense of control.
Objective Cues: (knees flexed)
● There is
tenderness in the ● Provide comfort measures ● Promotes relaxation,
lower left (back rub, repositioning, and refocuses attention, and
quadrant of his diversional activities. may enhance coping
abdomen abilities.
● skin appears pale
● mucous ● Monitor pain and manage ● To manage mild-to-
membranes are with scheduled IV infusion of moderate pain or
dry acetaminophen (Ofirmev) moderate-to-severe pain
1000 mg every 6 hours and 1 with an adjunctive opioid.
vital signs mg morphine sulfate IV push It can also be used to
for breakthrough of pain reduce fever.
 NURSING CARE PLAN
● T: 37.7 ● Administer analgesics, as ● To maintain an acceptable
indicated, to maximum level of pain
dosage, as needed