Nursing Care Plan

 

NURSING CARE PLAN ASSESSMENT

O> Received on semi-fowler’s 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

INTERVENTION

SHORT TERM:

INDEPENDENT

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

 

RATIONALE

EVALUATION SHORT TERM:

Assessed general condition; monitored V/S   Provided safety by raising the side rails and placing pillows under bony prominences

 

To obtain baseline data

 

Prevent client from any injuries and pressure sores

 

Used pain rating scale; observed nonverbal cues and pain behaviours

 

Indicator present when client is unable to verbalize

 

Provided comfort

 

To relieved pain

measures  

Provided perineal care and diaper changing

 

To promote comfort and prevent further infection

 

Provided comfort

 

To promote nonpharmacolo

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

 

measures and calm activities

gical pain management

 

Instructed in and encouraged use of relaxation techniques

 

To distract attention and reduce tension

 

Encouraged adequate rest periods

 

To prevent fatigue

 

To maintain acceptable level of pain

 

To check for any imbalances

DEPENDENT

 

Administer analgesics, as indicated and notify the physician if regimen is inadequate

COLLABORATIVE

 

Evaluated laboratory results

 

NURSING CARE PLAN ASSESSMENT

Received on

O> semi-fowler’s 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

PLANNI NG

INTERVENTION

SHORT TERM:

INDEPENDENT

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

RATIONALE

Assessed general condition; monitored V/S   Provided safety by raising the side rails and placing pillows under bony prominences

 

To obtain baseline data

 

Prevent client from any injuries and pressure sores

 

Auscultated abdomen

 

For presence, location and characteristics of bowel sounds

 

Provided comfort measures

 

To relieved pain

 

Provided perineal care and diaper changing

 

To promote comfort and prevent further infection

 

To promote nonpharmacolo gical pain

 

 

Provided comfort

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

 

measures and calm activities

management

 

Instructed in and encouraged use of relaxation techniques

 

To distract attention and reduce tension

 

Encouraged adequate rest periods

 

To prevent fatigue

 

To check for any imbalances

COLLABORATIVE

 

Evaluated laboratory results

NURSING CARE PLAN ASSESSMENT

O> Received on semi-fowler’s 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

PLANNI NG

INTERVENTION

SHORT TERM:

INDEPENDENT

RATIONALE

After 8 hours of nursing intervention, the client will remain free from injury

 

Assessed general condition; monitored V/S

 

To obtain baseline data

LONG TERM:

 

Assessed muscle strength

 

To identify risk for falls

Provided safety by raising the

 

After 3 days of nursing intervention, the client will be able to modify environment as

 

EVALUATION SHORT TERM:

Prevent client from any

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

 

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

injuries and pressure sores

 

Provided comfort measures

 

To relieved pain

 

Provided perineal care and diaper changing

 

To promote comfort and prevent further infection

 

Provided comfort measures and calm activities

 

To promote nonpharmacolo gical pain management

 

Encouraged adequate rest periods

 

To prevent fatigue

 

To check for any imbalances

COLLABORATIVE

 

Evaluated laboratory results

indicated to enhance safety