NURSING CARE PLAN

Name of Patient: ___________________________ Patient’s Health History: _______________________________

Age: _______ Sex: _________ _______________________________
Occupation: __________________________ _______________________________
Date of Admission: ____________________ _______________________________
Status: ____________ Religion: _____________ Initial Complaint: _______________________________
_______________________________
Diagnosis / Impression: _______________________________
_______________________________

Needs/Nsg Dx Cues Scientific Objectives Nursing Rationale Evaluation

Analysis Interventions

Inspired Physical A barrier to adequate SHORT TERM GOAL: a. Determine a. to identify

Mobility related to pain management has After 8 hours of nursing diagnosis that contributing
discomforts felt upon been the belief that pain, interventions the patient contributes to factors.
movement and feeling of while uncomfortable, has will be able to immobility.
nauseated when moving few physiologic effects. demonstrate behaviours
Unrelieved pain can that enable resumption b. Assess degree of b. To identify
SUBJECTIVE: affect the major organ of activities in pain listening to possible
“Dili man ko makalihok systems- pulmonary, accordance with client’s contributing
ug tarung kay sakit akong cardiovascular, physical limitations. description. factors.
tahi ug malipong ko.” As gastrointestinal,
verbalized by the patient. endocrine, and immune. LONG TERM GOAL: c. Observe c. To note any
Pain may also prevent After 2 days of nursing movement when congruencies with
OBJECTIVE: ambulation, contributing interventions the patient client is unaware report of abilities.
- Received patient to the development of will be able to increase of observation.
on bed, awake, deep vein thrombosis and strength and function d. To reduce fatigue.
conscious, potential life-threatening when performing ADLs d. Schedule
coherent pulmonary emboli. (activities of daily activities with
- With IVF no. 2, living) adequate rest
PNSS, infusing periods during the
 well at left arm, at day.
30 gtts/min with
remaining level of e. Encourage e. Enhances self
520 cc. participation on concept and sense
- With FBC self-care, of independence
attached to occupational/
urobag draining diversional/
freely with 50cc recreational
of dark yellow activities.
colored urine
- With surgical f. Identify energy f. .Limits fatigue.
dressing on the conserving
perineal area techniques for
- Limited range of ADLs.
motion noted
- Inability to stand g. Encourage g. Promotes well
and walk without adequate intake of being and
assistance fluids and maximizes energy
- Postured nutritious foods. production.
instability during
performance of h. Encourage client h. Enhances
routine ADLs or SO’s commitment to
(activities of daily involvement in plan, optimizing
living) decision making outcomes.
- Felt nauseated as much as
when trying to possible.
stand up.
i. Assist client in i. To promote
performing ADLs omptimal level of
function.
j. Administer j. To permit
medications prior maximal effort
to activity as involvement in
needed for pain activity.
relief.