Nursing Care Plan

Subjective Objective Nursing Diagnosis Planning Interventions Rationale Evaluation

“Masakit at kumikirot ang -pallor - After 8 hours of Independent: After 8 hours of nursing
ang tahi ko”, as -slowed movement Risk for infection related nursing 1.Note risk factors for To help the patient intervention, the patient
verbalized by the patient -body maliase to post operative incision intervention, the occurrence of infection in identify the present risk was able to meet the
patient will: the incision factors that may add up goals with an evidence of
to the infection the absence of the signs
Short term: and symptoms related to
 Identify the risk 2. observed for localized infection.
factors that are sign of infection at To evaluate if the
present insertion sites of invasive character, presence and
 Have partial lines, surgical incisions condition of the present
understanding or wounds. infection
about infection
control 3. Make health teachings
especially in
Long term: identification of To help the client
 Client’s full environmental risk modify/change/avoid
knowledge in factors that could add up some of the
identifying the on infection. environmental factors
risk factors of the present which could
infection Dependent: reduce the incidence of
 Be free from any 1. Administer infection.
signs and antibiotics as
symptoms of ordered by the
related to physician Antibiotics will help kill
infection and stop the proliferation
and growth of the
bacteria which could
cause infection.
 Subjective Objective Diagnosis Planning Intervention Rationale Evaluation

“Sumasakit ang puson - with pain scale of 8 out Acute pain related to After 8 hours of nursing Used pain rating scale To assess the rate of the Goal met.
ko” as verbalized by the of 10 distention of the fallopian intervention, the patient appropriate for age/ intensity, quality and After 8 hours of nursing
patient. -with facial grimace tube as evidenced by will verbalize and show condition . frequency of pain. interventions, the patient
-irritable verbal reports of relief of pain lessened able to verbalized and
-with weak and pale discomfort and pain from 8/ 10 to 6/ 10 in Obtained client’s To rule out worsening of showed relief of
looking pain scale assessment of pain to underlying discomfort, pain
- with guarding behavior include location, condition/development of lessened from 8/10 to
- with limited movement characteristics, complications. 6/10 in pain scale
onset/duration,
frequency, quality,
intensity, and
precipitating factors.
Reassessed each time
pain occurs/is reported.

Provided comfort
measures such as To promote
touch, repositioning, use nonpharmacological pain
of cold packs, nurse’s management.
presence and quiet
environment and calm
activities.

Instructed and
encouraged use of To distract attention and
relaxation techniques reduce tension.
such as focused
breathing, imaging.

Administered
analgesics, as ordered. To decrease pain at
tolerable level. Notify
physician if regimen is
inadequate to meet pain
control goal.