NURSING CARE PLAN

ASSESSMENT NURSING PLANNING INTERVENTION RATIONALE EVALUATION

DIAGNOSIS

Subjective: Acute pain related to After 4 hours of 1. Perform pain 1. To rule out After 4 hours of
“sumasakit ang underlying illness as nursing intervention, assessment each time worsening of underlying nursing interventions,
aking tiyan” as manifested by facial patient’s pain will be pain occurs. condition/development patient’s pain was
verbalized by the grimace, restlessness, relief. of complications. relieved.
patient. reduced interaction 2. To help determine
with other people or 2. Assess for possibility of underlying
environment, and referred pain as condition or organ
Objective: pain scale of 5/10. appropriate. dysfunction requiring
Facial grimace treatment.
Restlessness 3. It usually altered in
Reduced acute pain.
interaction with 3. Monitor vital
other people or signs. 4. It helps in giving
environment the patient relaxation.
Pain scale of 4. Provide quiet
5/10 environment.
5. To provide non-
pharmacologic pain
5. Provide comfort management.
measures such as back
rub and changing of
position.
 6. To lessen the pain.
6. Encourage
diversional activities
such as watching TV
or listening to radio.
7. To prevent
7. Encourage fatigue.
adequate rest periods.

8. Administer 8. This will lessen the

analgesics as pain of the patient.
prescribed.

NURSING CARE PLAN

ASSESSMENT DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATION
Subjective: Altered Bowel After 2 hours of After 2 hours of
elimination nursing • Determine • Assist in nursing
“hindi ako masyado related to intervention, the stool color, identifying causative intervention, the pt
makadumi” as decreased dietary pt will establish consistency, and contributing was able to
verbalized by the pt intake as or return to frequency and factors and establish or return
manifested by normal patterns of amount. appropriate to normal patterns
Abdominal pain, bowel functioning intervention. of bowel
restlessness and functioning
Objective: discomfort. • Auscultate • Bowel sounds are
bowel sounds generally decreased
• Abdominal in constipation
pain
• Restlessness • Palpate • For presence of
• Discomfort abdomen distention, masses
• v/s taken as
follow:
• Encourages • To enhance easy
T= 38.2 fluid intake defecation
PR= 95
RR= 25 • Encourages a • To improve
Bp= 100/70 diet of balanced consistency of stool
fiber and bulk and facilitate through
colon.

SOUTHEAST ASIAN COLLEGE INC.

College of nursing
In partial Fulfillment for the Requirements in
Related Learning Experience NCM 205

Case study of

“Hepatobiliary Tuberculosis”

Submitted by:

Guillermo, Aaron S.
Iso, Maria Vida T.
Javar, Kathrina D.R.
Joven, Jean Irish J.
Lagaras, Rafunzel B.
Lopes, Sonia G.
Lucas, Anna Sherrie B.
Maderazo, Madeleen A.

Submitted to:

Mrs. De Leon