Nursing Care Plan

ASSESSMENT DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATION

July 17, 2019
9:00 Am
S u b j e c t i v e Acute pain Within my 8 I N D E P E Goal met
“gasakit akong ulo sir ” related to hours span N D E N T : At the end of
as verbalized headache as of care the - Established - To gain trust and to my 8 hours
by the patient evidenced by patient will rapport h a v e b a s e l i n e d a t a span of care
: verbalized the patient
Objective cues: pain - Monitored - To determine if there is was verbalized
- Pain scale -Pain scale relieved. Vital Signs u n s u a l l i t i e s pain relieved.
- of 5 out of 10 of 5 out of 10 and recorded
- Facial grimaced - Facial
- noted grimaced
Restlessness noted - Assess time - To help determine possibility
to time condition that requiring
referred pain t r e a t m e n t

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-Evaluate pain - To identify worsening of
characteristics t h e c o n d i t i o n
and intensity

-Perform pain - To demonstrate

scale improvement status
assessment,
document, and
investigate
changes from
previous report
and evaluate
results of pain
interventions

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assessment diagnosis planning intervention rationale Evaluation
S u b j e c t i v e : Hyperthermia Within my 8 i n d e p e n Goal met
“”, as verbalized by related to skin hours span of d e n t At the end
the mother. warm to touch care the patient  Established to gain trust and to have of my 8
as evidenced will decrease rapport baseline data hours span
Objective cues: by: temperature of care the
 38. 6 degree -38. 6 degree within normal patient was
Celsius Celsius range  Monitored -Enhances heat loss by decrease
 Warm to touch -Dengue fever temperature evaporation and temperature
Flushed skin conduction within
normal
 Perform Tepid - To avoid dehydration range
sponge bath

- Reduces body heat

 Encouraged production
patient to
increase fluid
intake

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 Promote bed rest

 Provide cool
environment

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ASSESSMENT DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATIO
N
S u b j e c t i v e : Impaired Within my 8 I n d e p e n Goal met
“dili kayo kokalihok physical mobility hours span of d e n t : At the end of
ma’am related to body care pt. will be  Established - to gain trust my 8 hours
kaysakitakolawas” pain as able to have at rapport - to have baseline span of care
as patient evidenced by: least 10 steps data the patient
verbalized Difficult to as a sign of  VS checked and to determine if there is was
move side by recovery recorded. unusualities able to have
Objective cues: side  Assess degree of to determine if the pain at least 10
 Difficult to move Slowed pain and listen to management can steps as a
side by side movement clients description improve mobility sign of
 Slowed about which pain recovery
movement limit her mobility

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Assessment Diagnosis planning Intervention rationale evaluation

Objective: Risk for bleeding Within my 8 hours Established - to gain trust to After my 8 hours
Platelet count: related to span of care the rapport- have baseline span of care the
115 decreased platelet patient will receive data patient was able
as evidenced by health teachings Explain the to identify the risk
lab. Result. to avoid active different activities To avoid and engage in
bleeding. that can cause having a active appropriate
bleeding bleeding behavior change
to prevent the
Advise pt. To use bleeding.
a soft bristle Damaging the
toothbrush tissue inside of
the mouth that
can cause active
bleeding

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GENOGRAM

MATERNAL SIDE PATERNAL SIDE

GRANDMOTHER GRANDMOTHER
GRANDFATHER GRANDFATHER

Mother, 43 Father, 55

1ST Sibling, 23 2nd Sibling, 21 Patient L, 13

LEGENDS:

VII - Physical Assessment

Hypertensive Diabetes Tonsillitis
General Survey

Dengue Tuberculosis
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RHD
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