XVII.

Nursing Care Plan

Assessment Inference Nursing Planning Intervention Rationale Evaluation

Diagnosis

S: “Masakit yung paa Wound pain Acute pain Within 8 hours 1. Perform pain assessment - to rule out Goal was met.
ko, kumikirot”, as can be caused r/t of holistic each time pain occurs. worsening of Patient was able
by skin surgical site nursing care, underlying to alleviate pain
verbalized by the
damage, nerve infection the client condition or as manifested
patient. damage, blood will be able development of by verbalization
vessel injury, to: complications. of pain felt as
O: pain scale of 6/10 infection or 3/10 on the pain
-facial grimace and ischemia. Pain Verbalize that 2. Encourage pt. to verbalize - this could alleviate scale and no
restlessness noted can also cause pain has feelings about pain. the pain facial grimace
-pt. is massaging significant decreased to a psychologically and
region above surgical problems for rate of equal or restlessness
site on left foot to the person lesser than 3/10 3. Assist pt. to a comfortable - to provide comfort observed within
lessen pain experiencing it on the pain position. 8 hours of
-displays a guarded and delay scale and show effective nursing
behaviour when postoperative no signs of 4. Educate pt. on the use of - to provide interventions.
being approached. recovery. discomfort. relaxation techniques such as relaxation
-BP: 140/80 deep breathing exercises or
cutaneous stimulation.

5. Encourage adequate rest -to prevent fatigue

periods

6. Maintain a clean, safe, and - to relieve mind of

quiet environment. discomfort

7. Provide diversional activities -to reduce concern

such as socialization with of the unknown and
others. stress

8. Administer analgesics as - to medicate

ordered prophylactically as
appropriate
Assessment Inference Nursing Planning Intervention Rationale Evaluation
Diagnosis

Subjective: Sleep is required Disturbed Within 8 hours of 1. Assess sleep pattern -to obtain baseline The goal was met;
“Dalawang to provide energy sleep nursing disturbances that are associated data and plan patient was able to
beses ako for physical and pattern intervention, the with specific underlying illness. interventions that are verbalize that he felt
nagising mental activities. r/t patient will: significant to the rested within 8 hours of
kanina Such disruption acute pain underlying cause. effective nursing
madaling araw may result in both interventions.
dahil sa sakit” subjective 2. Arrange care to provide for -this allows less
Be able to
as verbalized distress and uninterrupted periods for rest, disruptions in sleep
verbalize that
by the patient apparent especially allowing for longer resulting in longer rest
he is feeling
impairment in periods of sleep at night when periods for the pt.
rested.
Objective: function abilities. possible. Do as much care as
- Irritability of Stimuli such as possible without waking up pt.
the patient discomfort, injury,
noted. and 3. Provide quiet environment -to promote an
- Lethargic environmental and comfort measures in environment
and inattentive factors has preparation for sleep. conducive for rest
sometimes to potential to
questions disrupt sleep thus 4. Discuss/implement effective -to enhance client’s
- frequent interfere with age-appropriate bedtime rituals ability to fall asleep.
yawning patient’s sleep-
observed. awake pattern. 5. Administer analgesics (if -to relieve discomfort
required) 1 hour before sleep and take maximum
advantage of sedative
effect.
Assessment Inference Nursing Planning Intervention Rationale Evaluation
Diagnosis

S: “Hindi ako Immobility of Activity Within 8 hours of Render nursing measures Appropriate measures Goal was met.
makalakad left foot due to Intolerance nursing helpful in increasing energy level will be implemented to Patient was
infection of r/t interventions, the of the patient to tolerate increase energy level. able to tolerate
dahil sa sugat
surgical site Immobility patient will be activities within level of own activities to the
ko”, as has made it of left foot able to tolerate ability. maximum use
verbalized by hard for the activities within of his
the patient. patient to walk level of own 1. Assess current limitations or -aids in defining what capabilities.
thus gives him ability. degree of deficit in light of usual the patient is capable
O: - sleepy limitations to status. of which is necessary
-looks tired some The patient will be before settling realistic
-generalized activities. able to: goal.
Resulting in a
weakness
insufficient a. Adapt lifestyle 2. Assess emotional or -stress or depression
noted-with the physiological to increase psychological factors affecting may be increasing the
following vital or energy level. the current situation. effects of an illness
signs: psychological 3. Perform active or passive -prevent contractures
T – 38.7C energy to ROM exercises to all extremities and promote muscle
PR - 77bpm endure b. Develop an every 2-3 hours strength and tone,
R - 23cpm complete activity and rest maintain joint mobility
required or pattern that
BP -
desired daily promotes optimal 4. Encourage proper nutritional -necessary to meet
130/80mmHg activities. independence intake. energy needs for
and minimizes activity.
fatigue.
5. Plan care with rest periods - to reduce fatigue
between activities.

6. Promote comfort measures -to enhance ability to

and provide for relief of pain participate in activities.

7. Assist client to learn to learn -to prevent injuries.

and demonstrate appropriate
safety measures.