XI.

Nursing Care Plan

Patient name: OFN Age:43y/o Rm. # 405 Service: OB Ward

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 ASSESSMENT: NURSING SCIENTIFIC CLIENT OUTCOME NURSING
CUES AND DIAGNOSIS: RATIONALE Planning IMPLEMENTATIONS/ RATIONALE EVALUATION
CLUES (Problem+Etiolog INTERVENTIONS
Signs and y)
Symptoms

Subjective Cues: Acute pain RT Myometrial Short Term: Independent: After hours of nursing
“Sumasakit yung myometrial contractions interventions, the patient was
puson ko lalo na contractions AEB able to verbalize lesser pain
kapag nireregla reports of pain Following the 8-hour Establish nurse-patient To establish rapport scale of 3/10 from a 5/10
ako”, as verbalized during Increased nursing intervention,the relationship. pain scale.
by the patient. menstruation intracavitary patient will verbalize
pressure lesser pain scale below Monitor VS To monitor anyThe patient was able to show
Pain Rate of 5 in a 5 in a 1- 10 pain scale. alteration in the VS ofunderstanding on how to
pain scale of 1-10. the client manage pain.
Impingement of
Objective Cues: nerve and vessels Long Term: Assess patient’s level of To monitor any
- With Facial pain increase in patient’s
grimace During the client’s stay discomfort
when Feeling of bearing at the hospital the
moving. down patient will be able to Provide comfort measures Deep breathing
- With understand ways on such as deep breathing exercises
guarding how to manage pain. exercises. contribute to relief
behavior pain of pain
Irritable
- VS
T:36.5 Promote rest
BP:110/60
PR:71bpm Encourage patient to Promotes cooperation
RR:24cpm verbalize about pain from the patient

To divert attention
Encourage diversional from pain
activities

For the patient to

Promote health teaching on know about pain
pain management management

To decrease the pain

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Assist patient in their needs and discomfort of the
COLLEGE OF NURSING patient Page 70

Provide therapeutic touch To promote feeling of