‭MS-Clinical‬‭Form 016‬

‭Lyceum of the Philippines University‬

‭College of Nursing‬

‭NURSING CARE PLAN‬

‭ASSESSMENT‬ ‭DIAGNOSIS‬ ‭PLANNING‬ ‭INTERVENTION‬ ‭RATIONALE‬ ‭EVALUATION‬

‭Subjective:‬ ‭Somatic Symptom‬ ‭ hort-term Goal:‬

S I‭ndependent:‬ ‭Short-term Goal:‬
‭ isorder (SSD)‬
D ‭Within 3 days, the‬ ‭-Demonstrate empathy by‬ -‭ Validate the patient's‬
-‭ Patients report frequent and distressing physical‬ ‭characterized by‬ ‭patient will demonstrate‬ ‭acknowledging and‬ ‭experience by actively‬ -‭ Assess the patient's‬
‭symptoms, including pain, fatigue, or gastrointestinal‬ ‭persistent, distressing‬ ‭improved coping‬ ‭accepting the reality of the‬ ‭listening and expressing‬ ‭progress in coping with‬
‭discomfort.‬ ‭somatic symptoms‬ ‭mechanisms and‬ ‭patient's physical complaints‬ ‭understanding of their‬ ‭somatic symptoms and‬
‭leading to significant‬ ‭reduced distress‬ ‭without judgment.‬ ‭distressing symptoms.‬ ‭reducing distress‬
-‭ Expresses frustration or anxiety about the perceived‬ ‭impairment in daily‬ ‭related to somatic‬ ‭through therapeutic‬
‭severity or implications of symptoms.‬ ‭functioning.‬ ‭symptoms.‬ -‭ Engage in open and‬ ‭communication and‬
‭-Engage in open and‬ ‭non-judgmental dialogue‬ ‭education.‬
-‭ Describes difficulty in managing daily activities due‬ ‭ ong-term Goal:‬
L ‭non-judgmental dialogue‬ ‭with the patient to assess‬
‭to somatic complaints.‬ ‭By the end of 1 week,‬ ‭with the patient to assess for‬ ‭for any suicidal thoughts‬ -‭ Monitor the patient's‬
‭the patient will‬ ‭any suicidal thoughts or‬ ‭or substance abuse‬ ‭engagement in CBT‬
‭Objective:‬ ‭effectively manage‬ ‭substance abuse concerns.‬ ‭concerns‬ ‭techniques and‬
‭somatic symptoms and‬ ‭relaxation exercises,‬
-‭ Observable signs of distress such as restlessness or‬ ‭engage in activities of‬ -‭ Recognize and reinforce‬ ‭evaluating their‬
‭agitation.‬ ‭daily living without‬ -‭ Acknowledge and praise‬ ‭adaptive coping‬ ‭effectiveness in‬
‭significant impairment.‬ ‭the patient's efforts to cope‬ ‭behaviors and strategies‬ ‭symptom management.‬
-‭ Presence of somatic symptoms evident through‬ ‭positively with their current‬ ‭demonstrated by the‬
‭physical examination.‬ ‭condition.‬ ‭patient, promoting a‬ ‭Long-term Goal:‬
‭sense of self-efficacy and‬
-‭ No apparent organic cause identified through‬ ‭empowerment.‬ -‭ Evaluate the patient's‬
‭diagnostic tests.‬ ‭ability to effectively‬
-‭ Educate the patient about‬ -‭ Encourage regular‬ ‭manage somatic‬
-‭ Patient's medical history may reveal a pattern of‬ ‭the benefits of relaxation‬ ‭practice of relaxation‬ ‭symptoms and‬
‭seeking medical attention for various somatic‬ ‭techniques such as deep‬ ‭techniques as part of the‬ ‭participate in activities of‬
‭complaints.‬ ‭breathing exercises and‬ ‭patient's self-care routine,‬ ‭daily living without‬
‭guided imagery for‬ ‭emphasizing their role in‬ ‭significant impairment.‬
 ‭ anaging stress and‬
m ‭ romoting relaxation and‬
p -‭ Assess the need for‬
‭Vital signs:‬ ‭reducing physical‬ ‭well-being.‬ ‭ongoing support or‬
‭symptoms.‬ ‭adjustments to the‬
‭T: 36.9‬ ‭treatment plan based on‬
‭the patient's response to‬
‭PR: 74 bpm‬ -‭ Collaborate with the patient‬ -‭ Discuss potential coping‬ ‭interventions.‬
‭to explore alternative coping‬ ‭strategies such as‬
‭RR: 20bpm‬ ‭strategies beyond relaxation‬ ‭journaling, mindfulness‬
‭techniques that may be‬ ‭practices, or engaging in‬
‭BP: 110/80‬ ‭effective in response to‬ ‭enjoyable activities to‬
‭stress.‬ ‭promote emotional‬
‭O2: 95%‬ ‭well-being.‬

‭Dependent:‬

‭ dminister prescribed‬
A -‭ Follow medication‬
‭medications as directed by‬ ‭administration protocols‬
‭the healthcare provider to‬ ‭and guidelines to ensure‬
‭manage symptoms‬ ‭the safe and accurate‬
‭effectively and improve the‬ ‭delivery of medications.‬
‭patient's overall well-being.‬
-‭ Monitor the patient for‬
‭any adverse reactions or‬
‭side effects following‬
‭medication‬
‭administration, promptly‬
‭reporting any concerns to‬
‭the healthcare team.‬

-‭ Provide education to the‬

‭patient about the‬
‭purpose, dosage, and‬
‭potential side effects of‬
‭prescribed medications,‬
‭promoting adherence and‬
‭informed‬
‭decision-making.‬

‭MS-Clinical‬‭Form 016‬