MEDICAL COLLEGES OF NORTHERN PHILIPPINES
Alimannao Hills, Peñablanca Cagayan
College of Nursing
NURSING CARE PLAN
No. 1: ACUTE PAIN
ASSESSMENT
SUBJECTIVE:
"ang sakit ng tahi ko" as
verbalized by the patient.
OBJECTIVE:
*facial grimace
* restlessness
*weak in appearance
DIAGNOSIS
Acute pain related to
presence of surgical
incision as evidence
by expressive
behavior.
PLANNING
After 2 hours of
nursing intervention
the patient will be
able to decrease pain
from 9/10 to 4/10.
INTERVENTION
1. Keep at rest in semi fowler's
position.
RATIONALE
* to lessen the pain.
2. Encourage early ambulation
*promotes normalization of
organ function.
3. Provide diversional activities
* refocuses attention,
promotes relaxation and may
enhance coping abilities.
4. Place ice bag on abdomen
periodically during initial 24-48
hours as appropriate
* soothes and relieves pain
through desintization of
nerve ending.
EVALUATION
After 2 hours of nursing
intervention the client reported
that pain is controlled.
No. 2: DEFIC FLUID VOLUME
ASSESSMENT
DIAGNOSIS
SUBJECTIVE:
Risk for deficient
"grabe po ang pagka uhaw ko" fluid volume related
as verbalized by the patient
to postoperative
OBJECTIVE:
restrictions.
* decrease in urine output
PLANNING
after 4 hours of
nursing intervention
the patient will be
able to maintain
fluid volume at a
functional level.
INTERVENTION
1. Assess vital signs
2.monitor intake and output
RATIONALE
* variation helps identifying
fluctuating intravascular
volumes.
* decreasing output of
concentrated urine with
increasing specific gravity
suggests dehydration and
need for increased fluid.
3. Establish 24-48 hours fluid
replacement needs and routes to
be used.
* this prevent peak and
valleys in fluid level.
4. Provide clear liquids in small
amount when oral intake is
resumed, and progress diet as
tolerated
* reduces risk of gastric
irritation and vomitting to
minimize fluid loss.
5. Administer IV fluid and
electrolytes.
* the peritoneum reacts to
irritation and infection by
producing large amount of
intestinal fluid, possibly
reducing the circulating
blood volume, resulting in
dehydration and relative
electrolyte imbalance.
EVALUATION
After implementing nursing care,
the patient was able to maintain
fluid volume at a functional level.
No.3 KNOWLEDGE DEFICIT
ASSESSMENT
DIAGNOSIS
SUBJECTIVE:
Knowledge
deficient related to
information
OBJECTIVE:
misinterpretation as
Inaccurate follow-through of evidence by
instruction of performance
questions.
on a test procedure.
PLANNING
After 4 hours of
nursing intervention
the patient will
verbalize
understanding of
condition, disease
process, and
treatment.
INTERVENTION
1. Determine client's ability,
readiness, and barriers to
learning.
2. Identify symptoms requiring
medical evaluation
3. Encourage progressive
activities as tolerated with
periodic rest periods.
4. Discuss care of incision
including dressing changed,
bathing restrictions, and return
to physician for suture and
staple removal.
" discuss one topic at a time;
avoid giving too much
information in one session
RATIONALE
* this individual may not be
physically, emotionally, or
mentally capable at this time.
*prompt intervention reduces
risk of serious complication
* prevents fatigue, promotes
healing and feeling of wellbeing, and facilitates
resumption of normal
activity.
* understanding promotes
cooperation with therapeutic
regimen, enhancing healing
and recovery process.
* this allows the client to
proceed at his/her own pace.
EVALUATION
After 4 hours of nursing
intervention, the patient verbalize
understanding of the condition,
disease process and treatment
No 4: RISK FOR INFECTION
ASSESSMENT
DIAGNOSIS
SUBJECTIVE DATA:
Risk for infection
related to surgical
“Namamaga po yung parte
incision
kung saan ako inoperahan”
as verbalized by the patient
OBJECTIVE DATA:
Fever
Chills
Shortness of breath
Redness and swelling in
incision site
PLANNING
After 8 hours of
nursing intervention
the patient is less
risk for infection
INTERVENTION
1. Practice and instruct in good
handwashing and aseptic
wound care
* inspect incision and dressing.
RATIONALE
* reduce risk of spread of
bacteria.
2. Obtain drainage specimens if
indicated
* gram's stain, culture, and
sensitivity testing is useful in
identifying causative
organism and choice of
therapy.
*3. Watch closely for possible
surgical complications
* continuing pain and fever
may signal an abscess.
* provides for early detection
of developing infectious
process.
EVALUATION
After implementing nursing care,
the client is less at risk for
infection and more aware when it
comes to infection.
No 5: ANXIETY
Assessment
SUBJECTIVE DATA:
“Kinakabahan ako sa
operasyon ko” as verbalized
by the patient.
OBJECTIVE DATA:
Irritability noted
Anxious looking
Discomfort noted
Restlessness noted
Diagnosis
Anxiety related to
possible surgery
secondary to Acute
Appendicitis.
Planning
Interventions
In 8 hours of nursing
1. Establish rapport.
interventions, patient
will be able to
2. V/S taken and
understand
and
recorded.
demonstrate positive
coping mechanism
3. Assess awareness of
and
describe
a
patient about anxiety.
reduction in the level
of anxiety.
4. Provide accurate
information to the
client.
5. Provide comfort
measures.
6. Provide and maintain
quiet environment.
7. Encourage patient to
talk about anxious
feelings.
Rationale
 To gain trust and
cooperation.
 Serves as baseline
data.





Validate the feeling
and communicate
acceptance of the
feelings.
Helps the client to
identify what is
reality based.
To help the patient
relax.
Anxiety may
escalate with
excessive
conversation, noise
and equipment about
the patient.
Talking about
anxiety producing
situations and
anxious feelings can
help the person
perceive the situation
in less threatening
Evaluation
In 8 hours of nursing
interventions, patient was able to
understand and demonstrate
positive coping mechanism and
describe a reduction in the level of
anxiety.
-Goal met
manner.