POLYTECHNIC COLLEGE OF DAVAO DEL SUR, INC.

MacArthur Highway, Digos City

NURSING CARE PLAN

Name of Patient: Leonsio Galamgam
Age: 54 Sex: Male Civil Status: Married
Diagnosis: Stab wound
Occupation: Carpenter Religion: Roman Catholic
complaint: Mauling
Address: Brgy. Sinawilan, Hagonoy
admitted: August 20, 2016
Ward: MSW Room No. _______ Bed No. ______

DATE/TI
ME

8/25/16
10:30
am

CUES

Attending Physician: Dr. Clapano

Chief
Date

NEE
DS

NURSING
DIAGNO
SIS

SCIENTIFIC
BASIS

GOALS
OBJECTIVES
CRITERIA

NURSING
INTERVENTIONS

RATIONALE

EVALUATION

Subjective:
Sakit ang
akong mga
samad ug
bunog as
verbalized
by the
patient

C
O
G
N
I
T
I
V
E

Acute
pain
related
to tissue
trauma
secondar
y to
mauling

After 8 hours
of nursing
interventions,
patient will be
able to
decrease pain
as evidenced
by:

1. Establish
rapport with
the patient.
2. Monitor vital
signs
3. Maintain bed
rest

Objective:
Grimace
Decrease
d
appetite
Disturbe
d
sleeping
pattern
Exertiona
l
discomfo

P
E
R
C
E
P
T
U
A
L

Inflammati
on triggers
the
vascular
system to
release
prostagland
ins which
are
neurotransmitters of
pain

GOAL MET
After 8 hours
of nursing
interventions,
patient was
able to
decrease pain
as evidenced
by:

a. Absence of
grimace
b. Increased
ROM
c. Able to do
ADL
independe
ntly
d. Decreased
pain to 2
out of 10
e. Provide

4. Limit activity
levels

1. To gain
cooperation.
2. Serves as
baseline data
3. Reduces
stress and
decreases
muscle
spasm
4. Gradual
progression
of activities
decreases
forces of
gravity and
motion.
5. Relieves pain

Source:
NANDA

5. Administer
pain
medications
as ordered
6. Apply cold
compress to
inflamed
areas

6. Decreases
inflammation

a. Absent
grimace
b. Increased
ROM
c. Able to do
ADL
independe
ntly
d. Pain scale
of 2 out of
10

rt
Pain
scale of 5
out of 10
Decrease
d ROM
Unable to
do ADL

verbal
feedback
of pain
relief

7. Provide a
safe and
calm
environment
8. Encourage to
verbalize
feelings of
pain
9. Encourage
diversional
activities
10.Observe
nonverbal
cues

7. This
promotes
healing
8. This allows
the nurse to
assess the
level of pain
9. Distracts the
patient from
feeling the
pain
10.Nonverbal
cues may not
be congruent
with verbal
cues

e. Absence of
fatigue
f. Decreased
swelling on
injured
areas
g. Verbal
feedback of
Sakit na
lang gamay
akong
kalawasan

Name: Pryll John O. Colita Section & Year: BSN-III Group No.: _______________ Rating: _______________
Reference: Nurses Pocket Guide Diagnoses, Interventions and Rationales 9 th Edition, Marilyn E. Doenges, et.al.
Criteria:
Promptness (5%) _______
Objective of Care (10%) _______
Format/Neatness (5%)
_______
Nursing Actions (40%)
_______
Assessment (15%) _______
Evaluation (10%) _______
Clinical Instructor: Julia Mayor, RN
Nursing Diagnosis (15%) _______