DATE NURSING OBJECTIVE/ NURSING ORDERS NURSING

AND DIAGNOSIS OUTCOME INTERVENTION

TIME CRITERIA

Date Ineffective breathing Patient would maintain 1. Reassure patient and family 1. Patient and family were reassured that patient
at 5:45pm pattern (dyspnea) a normal breathing that breathing pattern will be will have adequate breathing pattern after
related to decreased pattern within 1 hour maintained with necessary necessary nursing care. This was done to relieve
lung expansion and as evidenced by: nursing care. them of anxiety.
bronchospasm
i. nurse observing 2. Loosen all tight clothing 2. Tight clothing were removed from patient’s
patient breathing from patient’s neck and chest chest and neck regions. This was carried out to
without difficulty. region. allow lung ventilation.

ii. Patient verbalizing 3. Prop up patient into 3. Patient was propped up in bed with three
an improved breathing fowler’s position and support pillows in an upright position. This was done to
pattern him with pillows at the back. facilitate breathing. He was also encouraged to
stay in a position that will enable him breath
4. Ensure adequate ventilation effectively.
in the ward. 4. Windows were opened to allow fresh and free
5. Monitor vital signs movement of air into the ward. This is to ensure
(respiratory rate every 30 adequate ventilation
minutes) and record. 5. Patient’s temperature, pulse, respiration and
6. Administer prescribed blood pressure were checked every 30 minutes and
medication recorded in the nurses’ notes. This was done to
serve as baseline measures for further nursing
care.
6. Oral Clopidogrel 75mg and oxygen was
administered. This is improve ventilation in the
lungs so as to improve breathing
DATE & NURSING OBJECTIVE/ NURSING ORDERS NURSING EVALUATION

TIME DIAGNOSIS OUTCOME INTERVENTION

CRITERIA

date Acute chest Patient would be 1. Reassure patient that 1. Patient was reassured that date
pain related to relieved of chest measures would be put in all measures would be put in at
at disease pain within 1 hour as place to alleviate chest place to alleviate chest pain. 7:30pm
process evidenced by pain. This is to relieve patient of
7.30pm 1. patient verbalizing 2. Assess patient’s level of anxiety.
the absence of pain. pain using the pain
2. Patient’s level of pain was
2. Nurse observing assessment scale. Goal fully met as
assessed (location, frequency
patient showing 3. Nurse patient in a patient verbalized
and intensity) using the pain
cheerful facial comfortable bed and reduction in intensity
assessment scale and had a
expression. ensure comfortable of pain and nurse
result of 8 indicating a severe
position as possible. observed patients
pain
4. Minimize noise on the showed a cheerful
3. Patient was nursed on a
ward. facial expression.
bed free of creases and
5. Engage patient in
crumps. This is to promote
diversional therapy.
patient’s comfort. Patient
6. Provide comfort
was also placed in a fowler’s
measures.
position to reduce pain.
7. Administer prescribed
4. The volume of TV and
analgesics radio sets were lowered and
visitors were restricted
during patient’s rest and
sleep periods. This were
done to reduce noise in the
ward and interference during
sleeping hours.
5. Patient was engaged in his
favorite radio program
(jokes) and television shows.
This is to divert his attention
from pain.
6. Patient was provided with
basic comfort measures such
as giving of therapeutic
touch and massaging the
chest region. This is to
ensure effective soothing and
comfort for the patient
7. Tab. Paracetamol 1g and
Cap. Tramadol 50mg were
administered. This was
administered to relieve pain.
DATE/ NURSING OBJECTIVE NURSING ORDERS NURSING EVALUATION
TIME DIAGNOSIS OUTCOME / INTERVENTION
CRITERIA
date Ineffective Patient’s body 1. Monitor and record 1. Vital signs were date at 10:30am
at thermoregulat temperature vital signs (temperature) monitored and recorded
ion ( 38.20C) would reduce to a before and after each before and after each Goal was fully
9:30am
related to normal range of tepid sponging. tepid sponging. This met as body
disease 36.5oC-37.20C served as baseline temperature was
condition within 1 hour of 2. Tepid sponge patient records for further reduced to
tepid sponging as and leave pieces of management. 37.7ºC after
evidenced by: flannels on patient’s body tepid sponging
2. Tepid sponging was and after
3. Reduce tight clothing done and pieces of
1. Nurse on patient. administration
observing a flannels were left on of antipyretic it
reduced 4. Open nearby windows patient’s forehead, two reduced to
temperature to ensure effective under each armpit, and 37.1ºC which
reading after circulation of fresh air two in-between each was within
3 series of into the room. groin. This is to ensure normal range.
tepid effective
5. Encourage liberal fluid thermoregulation
sponging.
intake
2. Patient’s skin 3. Tight clothing was
been 6. Encourage bed rest removed and patient was
moderately left in only loose bed
warm to 7. Administer prescribed
cloths. This is to ensure
touch antipyretic
adequate heat loss for
the patient.

4. Nearby windows in
patient’s room were
opened to ensure
effective ventilation.
This was done to replace
heat in the room by
replacing it with fresh
air.

5. Patient was served

with cold can malt. This
is to

6. Patient was
encouraged to stay in
bed.

7. Tab. Paracetamol 1g
was administered. This
would reduce high body
temperature
DATE NURSING OBJECTIVE/ NURSING ORDERS NURSING EVALUATION
& DIAGNOSIS OUTCOME INTERVENTIONS
TIME CRITERIA
date Self-care Patient would be able to 1. Assess patient’s level 1. Assessment was done to date
at deficit (bath) demonstrate increased and ability to perform find out patient’s level and at
10:10am related to tolerance for activity self-care activities. ability to perform self-care 10:10am
general body within 48 hours as 2. Engage patient in activities.
weakness evidenced by activities that patient 2. Patient was engaged in Goal fully met as
1. Nurse observing can tolerate. feeding, since she could eat nurse observed
patient performing self- 3. Assist patient in the without assistance. patient was able
care activities (bath) with performance of self- 3. Patient was assisted with to perform self-
little assistance. care activities. bathing activities. This is help care activities
2 Patient verbalizing 4. Encourage patient to patient reserve some amount of with little
increased energy levels use energy conservation energy. assistance and
for the performance of techniques during the 4. Patient was encouraged to patient
self-care activities. performance of self- sit on a stool during bathing verbalized
care activities. hours. This would prevent increased energy
5. Place patient’s items patient from falling in case he to perform most
within easy reach stands while bathing. self-care
6. Encourage patient to 5. Patient’s items were placed activities.
use assistive devices in side-bed locker. This is to
such as walking aid. ensure easy reach for the
patient.
6. Patient was encouraged to
use zimmer frame when
walking about. This would aid
patient in walking.
DATE NURSING OBJECTIVE/ NURSING ORDERS NURSING INTERVENTIONS EVALUATION
& DIAGNOSI OUTCOME
TIME S CRITERIA
date Sleep pattern Patient’s sleeping 1. Reassure patient that his 1. Patient was reassured that she date
at disturbance pattern would be sleep pattern would be would regain her sleeping pattern at
7:40am (insomnia) restored within 48 regained with necessary with the necessary nursing 7:30am
related to hours as evidenced nursing interventions. interventions. This is to relieve
change of by: 2. Orientate patient to the patient of any anxiety. Goal fully met as
environment 1. Patient ward and explain daily ward 2. Patient was oriented to the patient verbalized
secondary to verbalizing that he activities and all nursing ward and daily ward activities he slept well and
unknown was able to sleep procedures to him. were explained to him. Every nurse on night duty
outcome of uninterrupted for 3. Introduce ward staff and nursing procedure was also reported patient
disease more than 7 hours other ward mates to patient. explained to him. This is to slept
condition. throughout the night. 4. Explain to the patient that enable patient become conversant uninterruptedly
2. Nurses on night his stay in the ward is just with every aspect of the ward. throughout the
duty report for short period of time. 3. Ward staffs and in-mates were night
indicating patient 5. Provide comfortable bed introduced to the patient. This is
slept well. free of creases and crumps to enable patient easily call on
to induce rest and sleep. any of the nurses when the need
6. Ensure a quiet and well arises.
ventilated environment to 4. It was explained to the patient
induce sleep. that his stay in the ward is just for
7. Encourage patient to take a short period of time and would
warm bath before going to soon go home if he complies to
bed and serve warm drinks. the treatment regimen. This
8. Provide dim light in would relieve patient of any
patient’s room during night. anxiety.
5. Patient’s bed was dressed with
clean linen and made free of
creases and cramps. This would
provide comfort and aid
relaxation for the patient.
6. A quiet and well ventilated
environment was ensured by
reducing volumes of radio, TV set
as well restricting visitors during
rest periods. This is to prevent
any disturbances for the patient
during sleeping hours.
7. Patient was assisted to take a
warm bath each time she goes to
bed. Milo beverage was also
served. This would stimulate
sleep.
8. Bright lights were switched to
dim lights to induce sleep. This is
to stimulate sleep for the patient.
DATE NURSING OBJECTIVE/ NURSING ORDERS NURSING INTERVENTIONS EVALUATION
& DIAGNOSIS OUTCOME
TIME CRITERIA
date Risk for Patient’s 1. Plan diet with 1. Diet was planned with the patient date
at nutritional nutritional patient and the nurse in-charge. This is to at
8:00am imbalance balance would 2. Encourage patient ensure that patient gains knowledge on 8:00am
(less than be maintained to perform oral care his nutrition and know what to eat at a
body within 72 hours (mouth wash) before particular time.
requirements) as evidenced meals 2. Patient was encouraged to perform Goal fully met.
related to loss by: 3. Encourage patient mouthwash before meals. This is to Patient
of appetite 1. patient to drink warm water to prevent nausea verbalized the
verbalizing the stimulate peristalsis. 3. Patient was encouraged to drink return for
return of 4. Serve patient’s warm water in the early hours of the appetite and
appetite for preferred food day. This would stimulate peristalsis to nurse observed
food and 5. Encourage patient aid digestion. patient eating
2. nurse to eat food served in 4. Patient was served with tea with more than half of
observing bits and at frequent butter bread as breakfast, beans with food served for
patient eating intervals fried plantain and palm oil as lunch and lunch and
more than half 6. Serve patient’s two balls of akple and tilapia light soup supper.
of food served. preferred fruits as supper.
7. Remove unpleasant 5. Patient was encouraged to eat food
and nauseated items served in bits and at frequent intervals.
that are within This is to ensure that appetite returns.
patient’s reach. 6. Patient was served with two oranges
7. All unpleasant and nauseated items
such as vomitus ball, bed pan and
urinal were taken away from patient’s
vicinity. This would prevent nausea.
DATE/ NURSING OBJECTIVE NURSING NURSING INTERVENTION EVALUATION
TIME DIAGNOSIS OUTCOME / ORDERS
CRITERIA
date Deficient Patient and family 1. Establish an 1. An environment of mutual trust date
at knowledge would gain environment of and respect was created. This is to at
9:20am related to lack knowledge on the mutual trust and aid in the establishment of a cordial 10:05am
of education disease condition respect to facilitate relationship with the patient.
on the disease within 45 minutes learning. 2. Patient was asked what he knew
condition as evidenced by: 2. Assess patient’s about his disease condition. This Goal was fully
i. Patient giving at level of knowledge on was done to find out patient’s level met as;
least 80% feedback the disease condition of knowledge on the condition. Patient gave
on the education 3. Educate patient on 3. The definition, causes, clinical more than 80%
done on the disease the disease condition features, treatment and preventive feedback on the
condition using available visual measures on the condition was education done
ii. nurse observing aids. explained to the patient. on the causes,
patient asking 4. Ask for feedback 4. Patient was asked questions clinical features,
relevant questions. on the education about the education of which he treatment and
done. answered correctly. This was done prevention of the
5. Encourage patient to find out if patient had pay disease condition
to ask questions and attention and had learnt something and nurse
clear all doubts. during the discussion. observed patient
6. Reinforce on the 5. Patient was encouraged to ask ask relevant
relevance of adhering questions. This was to clear any questions
to treatment regimen doubts.
5. The relevance of adhering to
treatment regimen was reinforced.
This is to aid speedy recovery for
the patient to go home as early as
possible.
The health problems identified

1. Patient complained of headache

2. Patient was anxious about his condition

3. Patient was easily fatigued with little stress

4. Patient complained of difficulty in sleeping at night

5. Patient complained of loss of appetite

6. Patient had inadequate knowledge on condition, management and precautionary measures

Patient and Family Strengths

1. Patient was conscious and could answers all questions asked him.

2. Patient could speak clearly and coherently.

3. Patient could perform activities of daily living with assistance such as bathing and eating.

4. Patient could sleep only for 2 hours at night

5. Patient can tolerate liberal fluids

6. Patient and relatives were ready to comply with treatment regimen

Date Nursing Objective/Outcome Nursing Orders Nursing Interventions Evaluation
and Diagnosis Criteria
Time
date Impaired Patient will be 1. Assess Patient for 1. Patient was assessed for complaints date
at comfort comfortable with complaints of of palpitation at
3:00pm related to recovery from palpitation 3:00pm.
disease process
palpitation
within 24 hours as 2. Encourage Patient 2. Patient was encouraged to have rest
resulting evidenced by to have rest periods
from disease periods Goal fully met
process. 1. Nurses observing as evidenced
that Patient looks 3. Apply cold 3. Cold compress was applied to the nurses
relax in bed without compress to the forehead observed that
complaints of forehead Patient was
palpitation.
relaxed in bed
4. Monitor blood 4. Blood pressure was monitored and
pressure and recorded in the nurses’ notes. without
record in the complaints of
nurses’ notes palpitation.

5. Provide bed free of 5. Bed was made free of creases and

creases and crumps crumps
to enhance comfort

6. Advice Patient not 6. Patient was advised not lie down

to lie down immediately after meals
immediatly after
eating
7. Elevate head end 7. Head end of the bed was elevated
of the bed

8. Educate Patient on 8. Patient was educated on the causes

the causes of of palpitation and food that could
palpitation and the trigger it
need to avoid it

9. Serve prescribe 9. Prescribe medication (paracetamol)

analgesic to relieve was served
palpitation

10. Document all 10. All procedures were documented

nursing care
rendered
 Nursing Care Plan

Date / Nursing Objective/Outcome Nursing Orders Nursing Interventions Evaluation

Time Diagnosis Criteria

date Ineffective coping Patient would be 1. Give psychological 1. Continuous psychological care was
at (anxiety) related to relieved of anxiety care. given to Patient so as to allay his date at
5:00pm headaches due to within 4 hours as fears. 9:00pm
unknown outcome evidenced by;
2. Assess patient’s 2. Patient’s level of anxiety was
of the level of anxiety assessed
hypertension 1. Patient co- Goal fully met as
operating with the 3. Allow Patient 3. Patient was allowed to verbalize his evidenced by
health staff fully verbalise his concerns concerns and misconceptions about his Patient co-operated
during provision of and misconceptions condition. with health staff
care and other about his condition. fully during
activities provision of care
4. Orient Patient to the
ward and environment 4. Patient was oriented to the ward and and other activities.
its environment
5. Explain the nature
of his condition with
signs and symptoms 5. The nature of his condition with signs
and the need for co- and symptoms and the need for co-
operation with the operation with the health team were all
health team. explained to him.

6. Involve Patient and

family in the planning
of care and explain all 6. Patient and family were involved in
procedures carried out the planning of Patient’s care and
on client. procedures carried out were explained
thoroughly to client
7. Introduce clients
who have fully
recovered from
hypertension to the 7. Clients who have fully recovered
client. from hypertension were introduced to
him so that he can confide in them
8. Give Patient
diversional therapy
and maintain some
level of quiet on the 8. Patient was given diversional therapy
ward. by allowing Patient to watch television
with its volume down to reduce stress
and some level of quiet was maintained
9. Administer on the ward by restricting visitors
prescribed analgesic
and document
procedure in nurses’ 9. Prescribed analgesics such as Tablet
notes Paracetamol 1g and IM Tramadol
100mg stat. was administered and side
effects observed but none was seen with
client. Rather, desired effects of good
rest were achieved to reduce anxiety
and it helped to reduce the blood
10. Introduce patient to pressure, pulse and respiration to the
other patients who normal ranges on monitoring. Procedure
have successfully was documented in nurses’ notes.
recovered
10 Patient was introduced to other
patients who had successfully recovered
 Nursing Care Plan

Date Nursing Objective/ Nursing Orders Nursing Interventions Evaluation

and Diagnosis Outcome Criteria

Time

date Activity Patient will resume 1. Assess Patient’s 1. Patient’s level of weakness was date at 10:00am
at intolerance to normal activities level of weakness assessed
10:00am related to within 2 days
fatigue 2. Reassure patient that 2. The patient was reassured with
without assistance
the treatment will help words of encouragement Goal fully met as
as evidenced by; him to recover evidenced by nurse
observed that Patient
1. Nurse’s 3. Teach Patient not to 3. Patient was taught not to involve maintained personal
observing that involve himself in himself in strenuous activities hygiene unassisted
Patient maintained strenuous activities at the third day of
personal hygiene admission.
4. Assist Patient to do 4. Patient was assisted to do some
unassisted after the
some passive exercises passive exercises in bed by changing
second day. in bed positions to prevent bed sores.

5. Encourage early 5. Early ambulation was encouraged

ambulation with with little assistance on the second
assistance day and on the third Patient had
personal hygiene maintained with no
assistant.

6. Encourage rest 6. Patient was encouraged to have

periods rest and sleep periods at least 2 hours
 in the mornings and 6 hours at night
without interruptions.

7. Assist patient in the 1. Patient was assisted to perform

performance of activities of daily living
activities of daily living

8. Encourage patient to 2. Patient was encouraged to eat

take nutritious diet to nutritious diet to gain energy
gain energy/strength

9. Organize nursing 9.Nursing activites were organized so

activities to provide as not to interrupt patient’s sleep
interpretation of
patient’s sleep

10.Document all 10.All nursing activities carried out

nursing care rendered were duly documented
 Nursing Care Plan

Date Nursing Diagnosis Objective/Outcome Nursing Orders Nursing Interventions Evaluation

/Time Criteria

date Disturbed sleep Patient will resume to a 1. Reassure Patient 1. Patient was reassured that
at pattern related to normal sleeping patterns measures would be put in date
6:00pm restlessness resulting within 48 hours as place to enable his sleep at
from unknown evidenced by; 6:00pm
outcome of prognosis
1. Nurses’ observing 2. Clear Patient’s 2. Patient’s misconception
that Patient is able to misconception of of prognosis was cleared
sleep at least one (1) prognosis Goal patially met as
hour. evidenced by
nurses’ notes
2. Nurses’ observing 3. Assist Patient to 3. Patient was assisted to revealed that
and report reveal take his bath and help take a warm bathe and help
that Patient sleeps at in grooming. him in grooming 1. Patient sleeps at
least 6-8hours at least 2 hours a
night uninterrupted 4. Assist Patient to a day and 7 hours
well-prepared bed 4. Patient was assisted to a at night
3. Patient verbalizing free from creases well-prepared bed free from respectively
that he feels creases and crumps Uninterrupted
refreshed after each
sleep 5. Serve warm 2. Patient
beverages 5. Warm beverages were verbalizing that
given to Patient to facilitate he felt well and
Patient’s sleep refreshed after
each sleep.
6. Maintain activity 6. Activities on the ward
restrictions were restricted as well as
visitors and length of
 interaction with Patient was
reduced

7. Schedule treatment 7. Treatment for clients was

so as not to interrupt scheduled to allow for
with Patient’s sleep periods of uninterrupted
and serve prescribed sleep and prescribed
medications. medications were served.
Document procedure Procedure was documented
in the nurses’ notes in the nurses’ notes.

8. Provide queit and 8. Queit and calm

calm environment to environment was provided
facilitate patient’s to facilitate sleep
sleep

9. Restrict visitors to 9. Visitors were restricted

enhance enough bed
rest

10. Document all 10. All nursing activities

care rendered carried out were
documented
 Nursing Care Plan

Date Nursing Objective/outcome Nursing Orders Nursing Interventions Evaluation

and Diagnosis Criteria
Time
date Risk for Patient’s nutritional 1. Reassure Patient 1. Patient and family were reassured that
at imbalanced status would be restored and family Patient would be able to enjoy his meals 25/08/18
8:00pm nutrition (less within 2 days as as before and he should also take his mind at
than body evidenced by; off any misconception about the condition 8:00pm
requirement) because it can be resolved and will not
related to lack of 1. Patient verbalizing lead to death if he responds to treatment
appetite. that he enjoys his meals regimen
Goal fully met as
2. Nurses observing that
evidenced by Patient
Patient consumes all his 2. Remove all 2. All nauseating equipment such as verbalizing that
food served even with nauseating articles bedpan, urinals, wounds of other clients 1. He enjoys his
dietary restriction were taken away from Patient’s sight meals.
2.Nurses
observing that
3. Meals were planned with Patient and
3. Plan meals with family to note the likes and dislikes of Patient consumes
Patient taking into food and dietary restriction of low sodium all his food even
consideration his diet and sodium contained foods were with dietary
likes and dislikes stressed on to help reduce blood pressure restriction
to normal

4. Teach family 4. Family members were taught about all

members about kinds of dietary restriction
kinds of dietary
restriction

5. Serve kitchen 5. Food prepared from the kitchen hospital

food attractively (light soup without spices and salt was
added with rice for Patient in the and
interchange with substitute food)

6. Before Patient 6. Patient was encouraged to rinse his

eats, encourage mouth for some time before meals so as to
him to rinse his stimulate his appetite
mouth for some
time so as to
stimulate his
appetite

7. Encourage 7. Patient was encouraged to take in water

Patient to take at his request and document procedure in
water on request the nurses’ notes
and document
procedure in the
nurses’ notes

8. Measure Patient 8. Patient’s weight was measured on

weight on a daily daily basis and result documented
basis in the same
cloth, at the same
time and the
same scale

9. Administer 9. Prescribed intravenous fluids were

prescribed administered
intravenous fluids
10. Document all 10. All nursing activities carried out were
nursing care documented
rendered
 Nursing Care Plan

Date Nursing Diagnosis Objective/Outcome Criteria Nursing Orders Nursing Interventions EVALUATION
and
Time
date Knowledge deficit Patient will have adequate 1. Reassure Patient 1. Patient was reassured that date
at related to management knowledge on the disease and establish rapport his level of knowledge will at
8:00am of hypertension and condition by with him be upgraded 8:00am
precautionary
measures to note signs Patient verbalizing a basis of 2. Assess Patient’s 2. Patient’s knowledge on
and symptoms and understanding of hypertension knowledge on his his condition was assessed
complication of and its effects on the body. He condition Goal fully met as
hypertension will identify modifiable risk evidenced by
factors and ways to reduce them 3. Inform Patient 3. Patient was informed
from occurring and also about modifiable about modifiable factors that 1. Patient gave
understanding of medication factors which contribute to hypertension. feedback information on
therapy and schedule for taking contribute to They include; what has been taught
it within 2 days as evidenced vascular disease and Diet high in salt, saturated fat about the management
by; hypertension. They and cholesterol of hypertension
include; Obesity
Diet high in salt, Sedentary lifestyle
2. Patient giving feedback saturated fat and -Smoking
information on knowledge cholesterol -Heavy alcohol intake
acquired Obesity -Stressful lifestyle
Sedentary lifestyle
-Smoking
-Heavy alcohol
intake
-Stressful lifestyle
4. Each Patient on 4. Patient was taught on his
his condition and condition and available aid
utilize available aid. was also utilized

5. Provide
summarized handout 5. A summarized handout
for clients was provided

6. Allow Patient to
ask questions for 6. Patient was allowed to ask
clarification. questions for clarification

7. Answer Patient’s 7. Patient’s questions were

questions in simple answered in simple
understandable understandable language
language

8. Introduce other 8. Patient was introduced to

clients who have had other clients who have had
success with success with treatment
treatment because he because he had adhered to
adhered to treatment treatment regimen
regimen

9. Ask Patient to 9. Patient was asked to

summarize what he summarize what
heard and discuss the he had heard and discuss
purpose of the the purpose of the medication
medication before at the right schedule before
instructing him to he was instructed to take his
take his medication medication.
at the right schedule.

10. Thank Patient 10. Patient was thanked and

and document the procedure documented in
procedure in the the nurses’ notes
nurses’ notes
Patient’s Health Problems

1. Patient had lower abdominal pains.

2. Patient was anxious about the impending surgery and its outcome.

3. Patient had constipation.

4. Patient has surgical wound on the lower abdomen.

5. Patient had pain at the incisional site.

6. Patient could not perform activities of daily living without assistance.

7. Patient and relatives had inadequate knowledge about her disease condition (uterine fibroid).

Patient /Family Strengths

1. Patient could verbalize the intensity and the location of the pain.

2. Patient could co-operate well with medical staffs during treatment.

3. Patient could drink about two litres of water a day.

4. Patient could co-operate during wound dressing

5. Patient could change position in bed to assume a comfortable position

6. Patient could perform some activities of daily living with assistance.

7. Patient and relatives were ready to learn about the patient’s condition (uterine fibroid).
DATE NURSING OUTCOME NURSING ORDERS NURSING INTERVENTIONS EVALUATION
AND DIAGNOSES CRITERIA
TIME
Date Impaired body Patient will express 1 Assess Patient level of pain, 1. Patient level of pain was assessed through date
@ comfort (lower noting location and intensity of facial expressions (grimace) and verbal @ 9:10am
normal body comfort
9:10am pain on the pain numeric scale of communication to be moderate and was Goal fully met as:
abdominal pain) within 24 hours as
1-10. recorded as 5 using the pain numeric scale of a) patient
related to benign evidence by; 2. Monitor vital signs and record 1-10 verbalized

tumor arising four hourly. 2. Patient’s vital signs were checked every 4 reduction in pain
a. Nurse observing that
3. Assist her to assume a position hours. Recordings were done in the b) Patient had
from the smooth Patient has a cheerful
that relieves pain. temperature chart. relaxed facial
muscle of uterus. and relax facial 4. Encourage patient to have bed 3. She was put in lateral position to reduce expression.
rest. muscle tension and to promote relaxation.
expression.
5. Administer prescribed 4. Patient was encouraged to have enough
b. Patient verbalizing
analgesics and monitor for bed rest and therapeutic environment was
absence of abdominal desired and adverse effects of provided.
drugs. 5. Prescribed analgesic, intramuscular
pain.
Pethidine 100mg 6 hourly for 24 hours
suppository Diclofenac 100mg daily for 10
days.
Nursing Care Plan
 Nursing Care Plan

DATE NURSING OUTCOME NURSING ORDERS NURSING INTERVENTIONS EVALUATION

AND DIAGNOSES CRITERIA
TIME
Date Anxiety related Patient will express 1. Reassure Patient and family of 1. Patient and family were reassured of Date
@ relieve of anxiety competent nursing care. competent nursing care and medical @ 12:00pm
to impending
12:00pm within 24 hours as management. Goal fully met as:
surgery and
evidenced by: 2. Assess her psychological and 2. Patient level of psychological and Patient
unknown a. Patient verbalizing physiological comfort. physiological was assessed and reassured of demonstrating
positively about competent nursing care. understanding of
outcome of the
outcome of surgery. 3. Introduce to Patient to other 3. She was introduced to other patients with surgical
surgery.
b. Patient patients with the same condition the same condition but are doing well. procedures and
demonstrating but are doing well. 4. Privacy was provided, rapport established post-operative
understanding of 4. Provide privacy, establish and the need for surgery explained. care by splinting
surgical procedures and rapport and explain the need for 5. Patient and family verbalized their the abdomen and
post-operative care by surgery as well as the concerns and fears which were all cleared by doing deep
splinting the abdomen advantages. answering them. breathing exercise
and doing deep 5. Encourage patient and family 6. Patient was introduced to other patients and out.
breathing exercise out. to verbalize their concerns and who had same operation done and were
fears about surgery.
 6. Introduce patient to other recovering well.
patients who had same operation
done and are recovering well.
DATE NURSING OUTCOME NURSING ORDERS NURSING INTERVENTIONS EVALUATION
AND DIAGNOSES CRITERIA
TIME
Date Constipation Patient will express 1. Reassure the Patient 1. Patient was reassured that everything Date
@12:30p related to reduced @ 12:30pm
relieve of constipation 2. Encourage Patient to take in possible will be done to help him empty his
m Goal fully met as
intake of within 24 hours as adequate fluids. bowel
evidenced by;
roughages and evidenced by; 3. Educate and serve the patient 2. Patient was encouraged to take in about 2-
a. Patient
oral fluids. a. Patient verbalizing with high roughages. 3 liters of fluid per day.
verbalizing that he
that he has been able to 4. Assist her to do passive 3. Patient was served with yam and
has been able to
pass stool. exercises. kontomire stew to add bulk to the stool to
pass stool.
b. Nurse observed that 5. Encourage Patient to eat more facilitate bowel elimination.
b. Nurse observed
the patient had passed liquid foods such as porridge. 4. Patient was assisted to flex and extend the
that the patient
semi-solid formed 6. Document all procedures. arms and legs.
had passed semi-
stool. 5. Patient was served with porridge in the
solid formed
morning.
stool.
 6. All procedures documented.

DATE NURSING OUTCOME NURSING ORDERS NURSING INTERVENTIONS EVALUATION

AND DIAGNOSES CRITERIA
TIME

Date Impaired skin Patient ’s skin integrity 1. Assess the wound for skin 1. Wound was assessed daily for skin intact Date @
@ 8:00am
@ intact and signs of wound and signs of wound infection (bleeding,
integrity related will improve within
8:00am infection (bleeding, odour, odour, discharges). Goal fully met
to surgical 7days as evidenced by: as:
discharges) 2. Wound was dressed aseptically with sterile
a) Patient ’s
wound. a. Patient’s wound 2. Dress wound aseptically as gauze, methylated spirit, and povidine.
wound healed by
ordered. 3. Patient was educated to keep incisional site
healing by first first intention
3. Educate patient to keep dry always and also refrain from touching the
intention.
incisional site dry always and also site.
b. Patient developing refrain from touching the site. 4. Patient was served with nutritious diet and
4. Serve patient with nutritious fruits (oranges and pineapple) when bowel
minimal scar.
diet and fruits when bowel sound sound returned.
returns to promote healing. 6. Patient was reminded to splint incision site
6. Remind patient to splint when coughing.
incisional site when
coughing/sneezing. 8. Intravenous Cefuroxime 750 milligrams 8
8. Administer prescribed hourly for 24 hours was administered.
 antibiotics.

Nursing Care Plan

DATE NURSING OUTCOME NURSING ORDERS NURSING INTERVENTIONS EVALUATION

AND DIAGNOSES CRITERIA
TIME
Date Acute pain Patient will express 1 Assess Patient level of pain, 1. Patient ’s level of pain was assessed date @ 4:00pm
@ (abdomen) noting location and intensity of through facial expressions (grimace) and Goal partially met
relieve of incisional
3:00pm pain on the pain numeric scale of verbal communication to be moderate and was as:
related to pain within 1 hour as
1-10. recorded as 5 using the pain numeric scale of a) Patient
incisional wound evidenced by; 1-10 complained of

secondary to 2. Monitor vital signs and record 2. Patient’s vital signs were checked every 4 pain.
a. Nurse observing that
four hourly. hours. Recordings were done in the
total abdominal patient has a relaxed
temperature chart.
hysterectomy. facial expression. 3. Assist her to assume a position 3. She was put in lateral position to reduce
that relieves pain. muscle tension and to promote relaxation.
b. Patient verbalizing
4. Encourage Patient to have bed 4. Patient was encouraged to have enough
absence of pain.
rest. bed rest and therapeutic environment was
5. Engage Patient in diversional provided.
therapy. 5. Patient read a book as a way of relieving
6. Administer prescribed pain.
 analgesics and monitor for 6. Prescribed analgesic, intramuscular
desired and adverse effects of Pethidine 100mg 6 hourly for 24 hours
drugs. suppository.
DATE NURSING OUTCOME NURSING ORDERS NURSING INTERVENTIONS EVALUATION
AND DIAGNOSES CRITERIA
TIME
Date Self-care deficit Patient will regain self- 1. Assess the level of patient 1. Patient’s level of activity tolerance was date @
@ care within 24 hours activity tolerance. assessed. 7:00am
(bathing and
7:00am post operation as 2. Encourage rest. 2. All forms of disturbances such as noise and Goal fully met as
grooming)
evidenced by patient: 3. Plan activities for periods when visitors were restricted to promote rest.
Patient:
related to general a. Being able to meet patient has the most strength. 3. Most of Patient’s activities were planned
a) was able to
5. Encourage passive exercise. early morning.
body weakness. all self-care needs with
6. Encourage bulk nursing. 5. Passive exercise was encouraged. meet her self-care
or without assistance.
7. Assist Patient in bed bath and 6. Bulk nursing was encouraged.
needs without
b. Looking groomed. change soiled sanitary pad to 7. Patient was assisted in bed bathing and
assistance.
promote comfort after perineal changing soiled sanitary pad was to promote
care. comfort after perineal care was done. b) looked
8. Encourage her to perform 8. She was encouraged to perform minor self-
groomed
minor self-care activities such as care activities such as sitting up to brush her
sitting up to brush her teeth and teeth.
gradually progress.
 Nursing Care Plan

DATE / NURSING OUTCOME NURSING ORDERS NURSING INTERVENTIONS EVALUATION

TIME DIAGNOSES CRITERIA

Date at Deficient Patient/relatives will 1. Reassure Patient that with 1. Patient was reassured that with date
2:30pm knowledge related education, her level of education, her knowledge will increase. @ 6:30pm
acquire adequate
lack of knowledge will increase. 2. An environment of mutual trust and Goal fully met as
knowledge regarding
information about 2. Establish environment of respect was established to enhance Patient;
the disease uterine fibroid within mutual trust and respect to learning. Answering at
process, methods enhance learning. 3. Clear and simple terms were used in
48 hours as evidenced least 70% of
of prevention, and 3. Build on what patient knows Ewe where needed to build on existing
by patient and relatives: questions asked
care instructions at using clear and simple terms knowledge to enhance patient and
home. a. Answering at least and ensure her understanding. family’s understanding. on uterine fibroid.
4. Patient was taught skills such as hand
70% of questions asked b. Verbalizing
4. Teach skills that patient washing; perineal care and the type of
on uterine fibroid. understanding of
must incorporate into daily under wears to use that must be
b. Verbalizing lifestyle and have patient incorporated into daily lifestyle and was the need and
demonstrate in return each new allowed to demonstrate the new skills
understanding of the importance of
skill. learnt.
need and importance of undergoing the
5. Emphasis the need to 5. The need to complete course of
undergoing the surgery. complete course of treatment treatment and honor follow up visits surgery.
and honor follow up visits. were emphasized.
Health Problems

1. Patient had difficulty in breathing on observation.

2. Patient had a high body temperature (38.7ºC).

3. Patient had general bodily weakness.

4. Patient had severe lower abdominal pain.

5. Patient had loss of appetite.

6. Patient had difficulty in sleeping resulting from excessive coughing.

7. Patient had little knowledge on disease condition.

Patients / Family Strength

1. Patient could assume a comfortable position (semi-fowlers) in bed.

2. Patient could tolerate tepid sponging.

3. Patient was able to perform activities of daily living (bathing/grooming) with little assistance.

4. Patient was able to locate site of pain and tolerated diversional therapy (watching television).

5. Patient was able to eat more than half of food (rich in iron and vitamins) and fruits served.

6. Patient was able to sleep about 2 hours during the day and 6 hours at night.

7. Patient was willing to be educated more on disease condition.

 NURSING CARE PLAN

DATE/ NURSING OBJECTIVE NURSING ORDERS NURSING EVALUATION

TIME DIAGNOSIS OUTCOME/ INTERVENTION
CRITERIA
date Ineffective Patient’s 1. Reassure patient of 1. Patient was reassured that date
@ breathing breathing pattern competent nursing care to her breathing problem is due 6:00pm
pattern will be restored to allay anxiety. to the disease condition and
5:00pm (dyspnoea) normal within that all necessary measures
related to 1hour as 2. Prop up patient in a are going to be kept in place Goal fully met
congestion in evidenced by; sitting up position in bed to to restore her normal Patient had a normal respiratory
the lungs facilitate breathing. breathing pattern. rate of 19 beats per minute and
a) Patient having This was done to relieve looked relaxed and comfortable
a normal 3. Monitor vital signs patient off anxiety. in bed.
respiratory rate every1 hour and respiration
(16-20cpm). every 15 minutes, 2. Patient was propped up in
proceeding to Semi-fowlers position in bed
b) Nurse 30minutes,1hour,2hours, to facilitate breathing
observing that 4hours as condition
patient looks becomes stable and record 3.Patient’s temperature,
relaxed and to detect progression or pulse and blood pressure
comfortable in deterioration of condition. were checked and recorded
bed. every hour and respiration
4. Monitor oxygen every 15 minutes, proceeding
saturation and administer to 30minutes,1hour,2hours
oxygen if it’s below 95%. and then 4hours to detect
progression or deterioration
5. Maintain a clear airway of patient’s condition.
by encouraging patient to 4. Oxygen saturation was
clear secretions with monitored to be within the
effective coughing or range of 95%-99% on air.
suctioning to prevent
congestion. 5. A patent airway was
achieved as patient coughed
6. Teach patient appropriate out secretions to prevent
breathing and coughing congestion.
techniques to facilitate
adequate clearance of 6. Patient was taught
secretions. appropriate breathing and
coughing technique like
7. Document all procedures taking a deep breath and
to communicate with coughing deeply to facilitate
healthcare team. adequate clearance of
secretions.

7. All procedures were

documented to communicate
with healthcare team.
 NURSING CARE PLAN

DATE/ NURSING OBJECTIVE NURSING ORDERS NURSING INTERVENTION EVALUATION

TIME DIAGNOSIS OUTCOME/
CRITERIA
Date @ Hyperthermia Patient’s body 1. Reassure patient 1. Patient was reassured with date
5:00pm (38.70C) temperature will be with words of words of encouragement to allay 6:00pm
related to restored to normal within encouragement to allay fears. Goal fully met
infection 24hours as evidenced by: fears. Patient’s body
process 2. Patient was tepid sponged temperature was reduced
a) Nurse observing that 2. Tepid sponge patient with Luke warm water to reduce to 37.7ºC on tepid
patient’s body to reduce body temperature. sponging but after
temperature is falling temperature. administration of
within the normal range 3. Bed linen and any other antipyretic it reduced to
(36.2ºC -37.2ºC). 3. Remove extra clothing used to cover patient 36.5ºC which was within
clothing to improve air was removed to improve air normal range and was
b) Patient’s body been circulation circulation. cold to touch.
cold to touch and
calm in bed. 4. All windows were opened to
4. Ensure adequate ensure adequate ventilation to
ventilation to improve temperature.
improve
temperature.

5. Patient’s body temperature

 was checked every 15minutes
5. Monitor patient’s proceeding to 30minutes, 1hour,
vital signs especially 2hours; 4hours as condition
temperature and record becomes stable. Recordings were
to detect any done in the temperature chart
abnormalities and nurses notes respectively.

6. Cold drink (Don Simon) was

served in bits to client according
to her preference to help reduce
6. Serve cold oral fluids temperature.
in bits according to the
patient preference to 7. Tablet Paracetamol of 1g was
help reduce administered orally to patient as
temperature. prescribed. No side effects were
observed but the desired effect
7. Administer of a relieve of pyrexia was seen
prescribed antipyretics as temperature read (37.70C then
to reduce temperature. 36.50C)

8. All procedures were

documented for continuity of
care.

8. Document all
procedures for
continuity of care.
NURSING CARE PLAN
DATE/ NURSING OBJECTIVE NURSING ORDERS NURSING INTERVENTION EVALUATION
TIME DIAGNOSIS OUTCOME/
CRITERIA
date Self- care Patient will 1. Reassure, encourage 1. Patient was reassured, date
6:30pm deficit maintain and explain all nursing encouraged and all nursing
(bathing, optimum self- procedures to patient to procedures explained to her to 8:00pm
grooming) care (bathing, enhance cooperation. enhance cooperation.
related to grooming) Goals fully met
general body within 72 hours 2. Monitor and record 2. Vital signs were monitored Patient verbalized
weakness. as evidenced by: vital signs to detect any and recorded on the vital signs the absence of
a) Patient abnormalities. chart. weakness and was
verbalizing the able to effectively
absence of 3. Encourage client to 3. Patient was encouraged to do perform self-care
weakness. partake in active active exercises and some range activities (bathing,
exercises and some of motion exercises to maintain grooming) without
b) Nurse range of motion muscle strength and joint assistance.
observing that exercises to maintain flexibility.
patient performs muscle strength.
safely self-care
activities 4. Assist patient in 4. Patient was assisted in
(bathing, performing self-care performing self-care activities
grooming) with activities (bathing, (bathing, grooming) till she
no assistance. grooming) until full became fully active to conserve
mass is regained. energy and perform it without
assistance.

5. Encourage patient to 5. Patient was encouraged to

 perform self-care perform self-care activities
activities (bathing, (bathing, grooming) without
grooming) without assistance.
assistance.

6.Involve patient in 6. Patient’s consent was sought

planning and decision in making relevant decisions to
making to enhance her enhance her cooperation.
cooperation

7. Teach patient energy 7. Patient was taught energy

conservation techniques conservation techniques like
to reduce oxygen sitting to do tasks, changing
consumption. positions to reduce oxygen
consumption.
8. Document all
procedures carried out 8. All nursing procedures
on client. carried out were documented.

NURSING CARE PLAN

DATE/ NURSING OBJECTIVE NURSING ORDERS NURSING EVALUATION
TIME DIAGNOSIS OUTCOME / INTERVENTION
CRITERIA
date Impaired body Patient’s body 1. Reassure and 1. Patient was reassured and date
6:00pm comfort related to comfort will be encourage client that pain encouraged to relax and that
lower abdominal restored to will reduce in no time. the pain will reduce in no 7:30pm
pain. normal within 90 time.
minutes as
evidenced by: 2. Assess for quality of 2. Quality of pain was
a) Patient pain (e.g. sharp, burning, assessed to be sharp. Goals fully met
verbalizing shooting) using the patient verbalized
absence of pain PQRST pain assessment the absence of pain
tool and looked calm
b) Patient and cheerful in
looking calm and 3. Assess and rate 3. Patient’s pain level was bed.
cheerful in bed. client’s pain level using assessed to be at a level of 6
the numerical rating pain
scale of 0-10.

4. Check and record 4. Patients vital signs were

patient’s vital signs to checked and recorded.
detect abnormalities.

5. Teach client a 5. Patient was provided with

diversional therapy. a television to watch to help
take her attention off the
pain.
6. Administer prescribed 6. Prescribed tablet
analgesic. paracetamol 1g was
 administered.

7. Document all 7. All nursing procedures

procedures carried out on carried out on patient were
patient. documented
 NURSING CARE PLAN
DATE/ NURSING OBJECTIVE NURSING ORDERS NURSING INTERVENTION EVALUATION
TIME DIAGNOSIS OUTCOME /
CRITERIA
date Imbalanced Patient’s 1. Reassure and encourage 1. Patient was reassured and date
nutrition (less nutrition pattern patient to eat to improve encouraged to eat to boost her
10:00am than body will improve her health. energy and improve her health. 12:00pm
requirement) within 72 hours
related to loss as evidenced by: 2. Assess patient’s 2. Patients nutritional status was Goals fully met patient was
of appetite a) Patient being nutritional status with the assessed with the Anthropometric able to eat more than half of
able to eat more Anthropometric Measurement Tool to be moderate. the meal served.
than half of Measurement Tool to And a body weight reading
meals served. develop a specific nutrition of 58kg.
care plan.
b) Nurse 3. Patient’s oral hygiene was
observing a 3. Maintain oral care to maintained to stimulate her
significant stimulate patient’s appetite. appetite.
increase in
patient’s body 4. Patient was involved in planning
weight. 4. Plan diet with patient her diet, so that her likes and
and dietician to consider dislikes would be catered for.
patient’s choice of meals.
5. Patient was encouraged to take
more fluids such as water and fruit
5. Encourage patient to juice to help in hydration
take more fluids to help in 6. Meals were served attractively
hydration. and also under hygienic condition.

6. Serve food attractively 7. Food was served in smaller

to stimulate appetite. quantities and at regular intervals.

8. Patient’s weight was monitored

7. Serve food in bits and at to notice any decrease in weight.
regular intervals to enhance
nutrition. 9. All procedures were
documented.
8. Monitor patient’s weight
to notice any decrease in
weight.

9.Document all procedures.

NURSING CARE PLAN FOR MRS. A. R.

DATE/ NURSING OBJECTIVE NURSING ORDERS NURSING EVALUATION

TIME DIAGNOSIS OUTCOME / INTERVENTION
CRITERIA
date Sleep pattern Patient will have a 1. Reassure patient that 1. Patient was reassured that date
disturbance normal sleeping measures will be put in all necessary measures will be
6:00am related to pattern within 72 place to restore her sleep put in place so that she can 10:00am
persistent hours as evidenced pattern. have enough sleep.
coughing by; Goal fully met patient verbalized
2. Monitor vital signs to 2. Patient’s vital signs were the absence of cough and was able
a) Patient detect any abnormalities. monitored and documented. to sleep for about 2hours during
verbalizing the the day and about 7hours during
absence of 3. Make patient 3. Patient was made the night
cough. Comfortable in bed to comfortable in bed by making
ensure adequate rest and bed free from creases. Pillows
b) Patient sleep. were arranged nicely and
verbalizing patient’s head was put on it to
having enough raise the upper part of the body
rest and to enhance easy breathing.
improved sleep
pattern. 4.Instruct patient to avoid 4.Patient was instructed to
heavy meals and large avoid heavy meals and large
fluid intake close to fluid intake close to sleeping
sleeping time. time to avoid insomnia.

5.Encourage patient to 5. Patient had a warm bed bath

have a warm bath before before bed time to help dilate
bed time to help dilate peripheral blood vessel to
peripheral blood vessel to induce sleep.
induce sleep.

6. Reduce noise on the 6.Noise on the ward was

ward to enhance sleep reduced by lowering the
volume of the radio and
television set to enhance sleep.

7. Perform all nursing 7. All nursing procedures were

procedures in bulk to performed in bulk in other not
prevent interruption of to disrupt or wake patient up
patient’s sleep. while sleeping.

8. Administer prescribed 8. Prescribed syrup simple

demulcents to treat linctus 5mls was administered
cough. to treat the cough.

9. Document all 9.All procedures were

procedures. documented.
NURSING CARE PLAN
DATE/ NURSING OBJECTIVE NURSING ORDERS NURSING INTERVENTION EVALUATION
TIME DIAGNOSIS OUTCOME /
CRITERIA
date Knowledge Patient/family will 1. Assess the 1. Patient/family level of date
deficit (causes, gain adequate patient/family knowledge knowledge was assessed by
10:00am treatment and knowledge on level on the treatment, using questions and determined 12:00pm
prevention) disease condition prevention and cause of and revealed she had little
related to lack within 2hours as pneumonia using knowledge about pneumonia and Goals fully met Patient
of information evidenced by; questions to provide misconceptions about was able to answer 80%
on pneumonia. a) Patient/family baseline information for pneumonia was clarified in of questions correctly
verbalizing that they further education and simple terms. and verbalized they have
have enough clear misconceptions enough understanding
understanding about about pneumonia. into the condition
causes, treatments 2. Education was built upon (pneumonia).
and prevention of 2. Educate patient and what they knew which gave
pneumonia. family based on their them insight on the condition
b) Nurse observing previous knowledge to and cleared any misconception.
that patient/family give them insight on the
demonstrates a condition and clear any
significant level of misconception. 3. Patient/ Family asked
knowledge about the questions to enhance their
condition 3. Allow patient and understanding.
(pneumonia) by family to ask questions to
answering 4 out of 5 enhance their
questions correctly understanding. 4. Questions asked by patient
on the condition . and family were answered
when asked. 4. Respond to questions correctly.
appropriately to provide
correct information to the
patient. 5. Patient and Family’s
knowledge were assessed by
5. Assess patient and asking 5 questions which they
family’s knowledge by got 4 correct.
asking questions about
the education given to
know if indeed they
understood what they
were taught. 6. Patient/family were
congratulated to acknowledge
6. Congratulate their effort.
patient/family for their
cooperation to
acknowledge their effort. 6. All nursing procedures were
documented
6. Document all
procedures.
Patient’s Health Problems

1. Patient had lower abdominal pain.

2. Patient had pain at the incisional site.

3. Patient was anxious about the impending surgery and its outcome.

4. Patient has surgical wound on the lower abdomen.

5. Patient could not perform activities of daily living without assistance.

6. Patient was prone to infection due to indwelling urinary catheter in- situ.

7. Patient was feeling dizzy.

8. Patient and relatives had inadequate knowledge about her disease condition (uterine fibroid).

Patient and Family Strengths

1. Patient was able to state the onset and nature of the pain.

2. Patient was able to rate the level of the pain on a scale of 1-10.

3. Patient was calm and cooperative with nursing interventions.

4. Patient can cope with the pain associated with the wound dressing.

5. Patient had items such as bathing soap and sponge, tooth brush needed to perform activities of daily living.

6. Patient was able to keep cannulated site dry

7. Patient was able to stay calm in bed.

8. Patient and family were able to ask questions about the disease condition (uterine fibroid).
 Nursing Care Plan

DATE NURSING OBJECTIVES/ NURSING ORDERS NURSING INTERVENTION EVALUATION

AND DIAGNOSIS OUTCOME
TIME CRITERIA

date at Acute Patient will express 1. Reassure patient that with 1. Patient was reassured that with Date and time
pain(abdomen relief of abdominal competent nursing competent nursing management
2:40 pm
) related to pain within 2 hours management her pain will the pain will reduce to allay
disease as evidenced by: reduce. anxiety. Goal fully met on

condition(uter 2. Assess the patient’s level of 2. Patient’s level of pain was as:
a) Patient
ine fibroid) pain using pain assessment assessed and documented as 7
verbalizing a a) Patient verbalized
scale of 1-1 out of 10.
significant relief from pain
3. Assist patient to assume a 3. Patient was assisted to assume a
reduction in
position that helps alleviate supine position with hips and b) Nurse observed
pain
her pain. knees flexed to reduce tension in patient having a
b) Nurse observing
4. Perform nursing activities the abdomen. relaxed and cheerful
patient having a
together in bulk to prevent 4. Nursing activities were grouped facial expression
relaxed facial
unnecessary disturbance to and patient had adequate rest.
expression
patient. 5. Prescribed analgesics
5. Administer prescribed (diclofenac, pethidine) were
analgesics and monitor for prescribed to reduce pain with
desired and adverse effects
 of drugs. no adverse effects.
6. Document all procedures. 6. All procedures were documented
in the nurse’s note.

Nursing Care Plan continued

 DATE NURSING OBJECTIVES / NURSING ORDERS NURSING EVALUATION
AND DIAGNOSIS OUTCOME INTERVENTION
CRITERIA
TIME

1st October, Anxiety related Patient will express 1. Reassure patient and 1. Patient and family were Goal fully met on 1st October,
2020 to unknown relief of anxiety family of competent reassured of competent 2020 at 9:00am.
outcome of within 2 hours as health care. health care to allay anxiety.
at as:
surgical evidenced by: 2. Assess patient and 2. Patient and family anxiety
7:00 pm procedure family anxiety level level was observed. a) Patient verbalized
a) Patient
(myomectomy) by observing their 3. Privacy was provided, positively about outcome
verbalizing
demeanor whiles rapport established and the of surgery.
positively about
engaging them in need for surgery explained b) Nurse observed patient
outcome of
discussions about to patient and relatives to demonstrating
surgery.
the surgery enhance cooperation. understanding of surgical
b) Nurse observing
3. Provide privacy, 4. Patient and family procedures and post-
patient
establish rapport verbalized their concerns operative care by
demonstrating
and explain the need and fears which were all splinting the abdomen
understanding of
for surgery as well cleared by answering them and doing deep breathing
surgical
as the advantages. in simple language. exercise.
procedures and
4. Encourage patient 5. Patient was introduce to
post-operative
and family to other patients and who had
care by splinting
verbalize their same operation done and
the abdomen and
concerns and fears
doing deep
 breathing about surgery. were recovering well.
exercise. 5. Introduce patient to 6. Patient’s vital signs were
other patients who closely monitored; blood
had same operation pressure was within the
done and are normal range.
recovering well. 7. Patient’s anxiety level was
6. Check patient’s vital assessed for improvement
signs especially to determine the
blood pressure 4 effectiveness of nursing
hourly to serve as a interventions.
baseline. 8. Patient and family were
7. Reassess patient’s thanked for their co-
anxiety level. operation.
8. Thank patient and
family for their
cooperation.

Nursing Care Plan continued

DATE NURSING OBJECTIVES / NURSING ORDERS NURSING EVALUATION

 AND DIAGNOSI OUTCOME INTERVENTION
TIME S CRITERIA

date at Impaired Patient’s skin 1. Reassure patient of 1. Patient was reassured of Date and time
skin integrity integrity will be competent nursing competent nursing care to
1:00 pm
related to restored to normal care. allay anxiety.
surgical within 4 days as 2. Educate patient to 2. Patient was educated to Goal fully met

wound on the evidenced by: keep incisional site keep incisional site dry as :
lower dry always and also always and also refrain
a) Patient’s wound a) Patient’s wound healed
abdomen. refrain from touching from touching the site to
healing by first by first intention
the site. prevent prolong healing.
intention.
3. Dress wound 3. Wound was dressed
b) Nurse observing b) Nurse observed absence
aseptically as ordered. aseptically; stitches were
absence of of complications of
4. Serve patient with removed on 08/10/2020 as
complications wound such as Discharge
light diet and progress ordered.
of wound such of pus.
to nutritious diet and 4. Patient was served with
as pus
fruits when bowel nutritious diet and fruits
discharge.
sound returns to when bowel sound
promote healing. returned to maintain
nutritional balance.
5. Patient was encouraged to
5. Encourage and ensure
take high intake of fluid to
patient drinks at least
help prevent constipation.
 1.5 liters of fluid daily. 6. Patient was reminded to
6. Remind patient to splint incision site when
splint incisional site coughing to prevent the
when wound from gaping.
coughing/sneezing. 7. Tablet Amoksilav 625
7. Administer prescribed
milligrams twice daily
antibiotics.
were administered as

prescribed.

Nursing Care Plan continued

 DATE NURSING OBJECTIVES /
AND DIAGNOSIS OUTCOME
NURSING ORDERS NURSING EVALUATION
CRITERIA
TIME INTERVENTION

Date Acute pain Patient will express 1. Reassure patient that 1. Patient was reassured Date and time
related to relief of pain within nurses will do that with nurses will in
1:00 pm
inflammatory 2 hours as evidenced everything within their their capacity help her
process. by: capacity to relieve her of have relief from the pain. Goal fully met on

pain. 2. The nature, location and as:

a) Patient
2. Assess the nature, intensity of pain were
verbalizing she a) Patient verbalized
location and intensity of assessed through
is comfortable absence of pain.
pain whether moderate interview and
and pain has b) Nurse observed patient
or severe. observation; there was
subsided. staying cheerful in
3. Maintain a quiet moderate pain at the
b) Nurse observing bed.
environment. incisional site.
patient staying
4. Engage patient in 3. A quiet environment was
cheerful in bed
diversional therapy. ensured by reducing
5. Administer prescribed noise in the ward.
analgesics and observe 4. Patient was engaged in
for the desired and general conversations as
adverse effects. a way to divert her mind
from the pain.
6. Reassess patient’s level 5. Prescribed analgesics
 of pain. were administered and
7. 10. Document all patient observed for
procedures. desired and adverse
effects.
6. Patient’s level of pain
was assessed.
7. All procedures were
documented in the
nurse’s note.

Nursing Care Plan continued

DATE NURSING OBJECTIVES /

AND DIAGNOSIS OUTCOME
 TIME CRITERIA NURSING ORDERS NURSING INTERVENTION EVALUATION

Date at Self-care Patient will regain 1. Reassure patient of 1. Patient was reassured of Date and time
5:00 am deficit self-care within 48 competent nursing competent nursing care to
(bathing) hours post care. allay anxiety.
related to operation as 2. Assist patient in bed 2. Patient was assisted to bath
incisional pain evidenced by bath and change in bed. Soiled bed linen was Goal fully met at as:
patient: soiled bed linen. changed and replaced with
a) Patient was able to
3. Assess patient ability new one.
a) Patient able to perform all self-care needs
to perform self-care 3. Patient was able to dry
perform self- with or without assistance.
(bathing). herself with towel upon
care needs
4. Encourage patient to assessment. b) Nurse observed patient
(bathing)
perform minor self- 4. Patient was encouraged to grooming herself.
without
care activities such brush her teeth by herself.
assistance.
brushing her teeth.
b) Nurse observing
patient
grooming
herself
 Nursing Care Plan continued

DATE NURSING OBJECTIVES /

AND DIAGNOSIS OUTCOME CRITERIA
NURSING ORDERS NURSING INTERVENTION EVALUATION
TIME

Date at Risk for Patient will be free from 1. Reassure patient of 1. Patient was reassured of Date and time
6:00 am infection infection throughout the competent nursing care. competent nursing care to
related to period of indwelling 2. Perform catheter allay anxiety.
prolonged catheter is in situ as hygiene daily 2. Catheter hygiene was
indwelling evidenced by patient: aseptically. performed aseptically. Goal fully met on as:
catheter in 3. Empty urine bag when 3. Urine bag was emptied at
a) Nurse observing a) Nurse observed
situ ¾ full to prevent back least 6 times in a day to
patient having no patient having no
flow and subsequent prevent back flow of urine.
signs and signs and symptoms
infection. 4. Urethral catheter was patent
symptoms of of infection (such as
4. Maintain patency of the by applying adhesive tape to
infection (such as fever and chills,
urethral catheter by keep it in place.
fever and chills, cloudy urine,
preventing kinking of 5. Urine bag was hanged below
cloudy urine, redness and pus
the catheter. the bed which ensured free
redness and pus around the urethra)
5. Hang urine bag below flow of urine out of the
around the b) Patient had normal
the bed to ensure free bladder.
urethra) body temperature
flow of urine out of the
b) Patient having
bladder.
normal body
temperature 6. Vulva was observed daily
with no obvious discharges
6. Observe the vulva daily and swellings.
for any discharges and 7. Patient’s urine was observed
swellings. for colour, odour,
7. Observe the patient’s constituent, and has no
urine for colour, odour anomaly.
and constituent.
 Nursing Care Plan continued

DATE NURSING OBJECTIVES /

AND DIAGNOSIS OUTCOME
NURSING ORDERS NURSING EVALUATION
CRITERIA
TIME INTERVENTION

date at Risk for fall Patient will the relief of 1. Reassure patient of 1. Patient was reassured that Date and time
related to dizziness throughout the safety. measures will be put in
6:00 pm Goal fully met as :
dizziness period of hospitalization 2. Assess the level of place to ensure her safety.
as evidenced by: dizziness. 2. Patient’s level of dizziness a) Patient performed

3. Teach patient to turn was assessed by interview activities such as

a) Patient perform
sideways, sit on the and observation to be bathing and toileting
activities of daily
bed for a while and mild. without assistance
living without
get up slowly. 3. Patient was taught to turn b) Nurse observed patient
assistance.
4. Place patient’s items sideways, sit on the bed stay calm in bed
b) Nurse observing
near her for easy for a while and get up
patient staying calm
access. slowly to prevent
in bed
5. Floor should be lightheadedness.
mopped dry to 4. Patient’s items were
prevent falling. arranged in order and near
6. Document all her for easy access.
procedures.
5. Floor was mopped dry to
prevent falling causing
physical trauma
(abrasions).
6. All procedures were
documented in the nurse’s
note.
 Nursing Care Plan continued

DATE NURSING OBJECTIVES /

AND DIAGNOSIS OUTCOME
NURSING ORDERS NURSING INTERVENTION EVALUATION
CRITERIA
TIME

date at Deficient Patient and relatives 1. Assess patient/relatives 1. Patient/relatives asked Date and time
knowledge(ca will acquire adequate readiness to learn about the questions about patient’s
6:00 pm Goal fully met
uses, signs knowledge regarding condition condition as a sign of
and uterine fibroid within 2. Provide privacy and assess readiness to know more about as :

symptoms, 24hour as evidenced patient/relatives current level the patient condition. a) Patient and family
management, by patient and of knowledge on uterine 2. Privacy was provided and answered simple
and relatives: fibroid. patient/relatives current questions asked on
complication 3. Reassure patient and relatives knowledge on uterine fibroid uterine fibroid
a) Answering simple
of uterine that teaching and learning was fair. correctly
questions asked
fibroid) will be done at their own pace 3. Patient/relatives were b) Nurse observed
on uterine fibroid
related to and time. reassured that teaching and patient and relative
correctly
patient level learning will be done at their answering
b) Nurse observing
of education own pace and time. questions on the
patient and 4. Gather appropriate teaching
on health 4. Appropriate teaching and surgery(myomecto
relative and learning aids such as
learning aids (flyers and my) correctly
answering flyers and diagrams.
diagrams of the uterus) were
questions on the 5. Explain the nature of uterine
surgery(myomect fibroid to the patient and gathered to aid in
omy) correctly relatives using the available understanding.
teaching aids such as 5. The nature of uterine fibroid
diagrams to facilitate was explained to the patient
learning. and relatives in the simplest
6. Allow time for patient and term using the available
relatives to ask questions and teaching aids such as
answer all questions diagrams to facilitate learning.
appropriately in very simple 6. Patients and relatives asked
language and avoiding questions on cause, signs and
medical jargons as much as symptoms, prevention and
possible. answers were provided to
7. Congratulate patient/relatives improve knowledge I simple
for correct answers to terms.
questions asked. 7. Patient and relatives were
8. Thank patient/relatives for congratulated for correct
their maximum co-operation. answers to questions asked.
8. Patient and relatives were
thanked for their maximum
co-operation.