Nursing Care Plan

NURSING CARE PLAN
ASSESSMENT
O> Received on
semi-fowlers position, conscious, coherent, afebrile, oriented; conversant; obeys command; with GCS score of 15/15; 2mm size of pupils; PERRLA; able to follow six cardinal gazes; intact hearing and gag reflex; muscle strength of 5/5 in BUE; 1/5 on BLE; can turn sideways with assistance; with IVF # 6 infusing well @ right hand; with Foley catheter intact and patent
DIAGNOSIS Acute pain r/t perianal irritation with pain scale of 7/10 as manifested by crying and moaning
PLANNING SHORT TERM: After 8 hours of nursing intervention, the client will be able to report pain is relieved LONG TERM: After 3 days of nursing intervention, the client will be able to demonstrate use of relaxation skills and diversional activities, as indicated, for individual situation
INTERVENTION INDEPENDENT Assessed general condition; monitored V/S Provided safety by raising the side rails and placing pillows under bony prominences Used pain rating scale; observed nonverbal cues and pain behaviours Provided comfort measures Provided perineal care and diaper changing
RATIONALE To obtain baseline data Prevent client from any injuries and pressure sores
EVALUATION SHORT TERM: After 8 hours of nursing intervention, the client was able to report pain is relieved at pain scale of 3/10 LONG TERM: After 3 days of nursing intervention, the client was able to demonstrated use of relaxation skills and diversional activities, as indicated, for individual situation
Indicator present when client is unable to verbalize
To relieved pain
To promote comfort and prevent further infection
Provided comfort
To promote nonpharmacolo
measures and calm activities
gical pain management
Instructed in and encouraged use of relaxation techniques Encouraged adequate rest periods DEPENDENT Administer analgesics, as indicated and notify the physician if regimen is inadequate COLLABORATIVE Evaluated laboratory results
To distract attention and reduce tension
To prevent fatigue
To maintain acceptable level of pain
To check for any imbalances
NURSING CARE PLAN

ASSESSMENT
O> Received on
semi-fowlers position, conscious, coherent, afebrile, oriented; conversant; obeys command; with GCS score of 15/15; 2mm size of pupils; PERRLA; able to follow six cardinal gazes; intact hearing and gag reflex; with hyperactive bowel sounds heard upon auscultation 5 sec/min; muscle strength of 5/5 in BUE; 1/5 on BLE; can turn sideways with assistance; with IVF # 6 infusing well @ right hand; with Foley catheter intact and patent
DIAGNOSIS Bowel incontinence r/t loss of rectal sphincter control
PLANNING SHORT TERM: After 8 hours of nursing intervention, the client will be able to feel comfortable and clean LONG TERM: After 3 days of nursing intervention, the client will be able to identify individually appropriate interventions
INTERVENTION INDEPENDENT Assessed general condition; monitored V/S Provided safety by raising the side rails and placing pillows under bony prominences Auscultated abdomen
RATIONALE To obtain baseline data Prevent client from any injuries and pressure sores
EVALUATION SHORT TERM: After 8 hours of nursing intervention, the client was able to felt comfortable and cleaned LONG TERM: After 3 days of nursing intervention, the client was able to identify individually appropriate interventions
For presence, location and characteristics of bowel sounds
Provided comfort measures Provided perineal care and diaper changing
To relieved pain
To promote comfort and prevent further infection To promote nonpharmacolo gical pain
Provided comfort
measures and calm activities
management
Instructed in and encouraged use of relaxation techniques Encouraged adequate rest periods COLLABORATIVE Evaluated laboratory results
To distract attention and reduce tension
To prevent fatigue
NURSING CARE PLAN

ASSESSMENT
O> Received on
semi-fowlers position, conscious, coherent, afebrile, oriented; conversant; obeys command; with GCS score of 15/15; 2mm size of pupils; PERRLA;
DIAGNOSIS Risk for injury r/t decreased muscle strength in lower extremities
PLANNING SHORT TERM: After 8 hours of nursing intervention, the client will remain free from injury LONG TERM: After 3 days of nursing intervention, the client will be able to modify environment as
INTERVENTION INDEPENDENT Assessed general condition; monitored V/S Assessed muscle strength Provided safety by raising the
RATIONALE To obtain baseline data
EVALUATION SHORT TERM: After 8 hours of nursing intervention, the client remained free from injury LONG TERM: After 3 days of nursing intervention, the client was able to modify environment as
To identify risk for falls
Prevent client from any
able to follow six cardinal gazes; intact hearing and gag reflex; muscle strength of 5/5 in BUE; 1/5 on BLE; can turn sideways with assistance; with IVF # 6 infusing well @ right hand; with Foley catheter intact and patent
indicated to enhance safety
side rails and placing pillows under bony prominences Provided comfort measures Provided perineal care and diaper changing
injuries and pressure sores
indicated to enhance safety
To relieved pain
To promote comfort and prevent further infection To promote nonpharmacolo gical pain management
Provided comfort measures and calm activities Encouraged adequate rest periods COLLABORATIVE Evaluated laboratory results
To prevent fatigue

Nursing Care Plan

Uploaded by

Copyright:

Available Formats

Nursing Care Plan

Uploaded by

Document Information

Original Description:

Copyright

Available Formats

Share this document

Share or Embed Document

Sharing Options

Did you find this document useful?

Is this content inappropriate?

Copyright:

Available Formats

Nursing Care Plan

Uploaded by

Copyright:

Available Formats

NURSING CARE PLAN

Indicator present when client is unable to verbalize

To promote comfort and prevent further infection

measures and calm activities

gical pain management

To distract attention and reduce tension

To maintain acceptable level of pain

To check for any imbalances