NURSING CARE PLAN

DATA NSG DIAGNOSES GOALS & NSG RATIONALE EVALUATION

OUTCOMES INTERVENTIONS
S: Acute pain related After 4 hours of 1. Frequently 1. Changes in Goal met
-“Ang sakit talaga ng to inflammation of nursing assessed the these VS After 4 hours of
tiyan ko, nahihirapan the small intestine. interventions, the VS. often nursing
ako makagalaw patient will be able 2. Encouraged indicate interventions, the
galaw.” As verbalized to demonstrate verbalization acute pain patient was able to
by the patient. ways to alleviate of feelings and demonstrate ways
pain. about pain. discomfort. to alleviate pain
O: 3. Provided 2. Enhances like DBE and
-pain scale of 8/10 After 2 days of additional sense of well- change of position.
-facial grimace nursing comfort being.
-BP: 150/90 interventions, the measures like 3. Improves Goal met
patient will be ab back rub. circulation, After 2 days of
le to have reduced 4. Encouraged reduces nursing
pain in the pain the use of muscle interventions, the
scale. relaxation tension and patient was able to
techniques anxiety have a reduced
like DBE. associated pain in the pain
5. Encouraged with pain. scale (4/10).
adequate 4. Relieves
rest periods. muscle and
6. Administered emotional
analgesics as tension,
administered. enhances
sense of
control and
may improve
coping
abilities.
 5. To prevent
fatigue.
6. To maintain
acceptable
level of pain.
S: Hyperthermia After 2 hours of 1. Monitored 1. Fever pattern Goal met
-“Sobrang init ng related to nursing patient’s may aid in After 2 hours of
pakiramdam ko.” As increased interventions, the temperature diagnosing nursing
verbalized by the metabolic rate patient will and patterns. underlying interventions, the
patient. caused by the demonstrate ways 2. Observed for disease. patient
illness. to reduce chills and 2. Chills often demonstrated
O: hyperthermia. profuse precede ways to reduce
-warm to touch diaphoresis. during high hyperthermia like
-night sweats After 3 days of temperature performing tepid
-chills nursing and in sponge bath.
-T: 38 C interventions, the presence of
patient will be able generalized Goal met
to maintain core 3. Provided infection. After 3 days of
temperature tepid sponge 3. May help nursing
within normal bath. reduce fever. interventions, the
range. 4. Monitored patient was able to
for sign of 4. May reflect maintain core
deterioration inappropriat temperature of 37
of condition e antibiotic C.
or failure to therapy.
improve with
therapy.
S: Imbalanced After 4 hours of 1. Assessed 1. To know the Goal met
-“Graben a ang Nutrition: Less nursing patient’s eating After 4 hours of
ipinayat ko halos 4 than body interventions, the nutritional patterns, nursing
kg.” as verbalized by requirements patient will patterns. eating habits, interventions, the
the patient. related to increase. and how patient’s appetite
inadequate intake. regular meals increased as
O: After 3 days of are. evidence of regular
-no appetite nursing 2. Assessed the 2. To improve meals and more
-appears weak to interventions, the likes and the status of intake.
even walk out of bed patient will be able dislikes when preferred
to present weight it comes to food and Goal met
gain. food. avoid feeding After 3 days of
that is not nursing
preferred. interventions, the
3. Encouraged 3. To save patient was able to
bed rest. energy which present weight
then reduces gain of 1 kg.
body of
work.
4. Measured 4. Helps to
weight know
everyday. whether
there is a
decrease or
increase in
weight.
5. Monitored 5. Knowing the
the amount cause of the
of nutrients less intake so
and calories. as to
determine
appropriate
and effective
intervention.