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Nursing Care Plans

NCP 1: Pain, Chronic r/t disease process


Assessment

Diagnosis

Reports pain Pain Pain, Chronic r/t


scale 7/10
disease process
Facial grimacing
Restlessness
Changes in level
of consciousness
Guarding behavior

Goal of Care
Patient Will:

Intervention

1. Verbalization of 6/10
rate of pain to a score
of 4/10 and below.
2. Absence of facial
grimaces

3. Minimal guarding of the


affected area.
4. Expects exacerbations,
reports their quality &
intensity.
5. Demonstrate use of
relaxation skills and
diversionall activity as
indicated for individual
situation.
6. Follow prescibed
regimen.
7. Identifies strategies to
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Rationale

Evaluation

Pain is directly related to vital


Goal is met if
signs. Increased intensity of pain
patient:
can be seen in the form of
1. Verbalized relief
increased vital signs due to
of pain from
sympathetic stimulation.
6/10 rate of pain
Determining
nature
&
causes
of
to a score of
Evaluate nature of
pain & its intensity helps to
patients pain, its
4/10 and below.
location, intensity and select proper pain-relief
modality & provide baseline for
2. Exhibited
characteristics using
later
comparison
absence of facial
pain rating scale
grimaces
Monitor vital signs
and check before and
after drug
administration

Assess non-verbal
cues for pain

Although pain is a subjective


data, there are possibilities that
the significant of pain is denied
by the patient thereby altering
what he is saying. In conditions
where pain is likely to occur, we
must observe for this cue to
determine appropriate nursing
interventions for the patient.

3. With minimal
guarding of
the affected
area.
4. Expected
exacerbations,
reported their
quality &

avoid complication of
analgesic use (eg.
constipation).

Avoid activities that


aggrevate or worsen
pain
Because pain is
usually related to
bone metastasis
ensure that patients
bed has a board on a
firm mattress. Also
protect the patient
from falls/injuries
Provide support for
affected extremities

Provide
nonpharmacological
comfort measures
(repositioning)diversi
onal activities
(television) deep
breathing exercises

Bumping the bed is an example


of an action that can intensify
the patients pain.
This will provide added support
& is more comfortable.
Protecting the patient from
injury protects him from
additional pain

More support, coupled with


reduced movement of the part,
help in pain control
Promotes relaxation & help
refocus attention. Helpful in
decreasing the perception of
response to pain by stimulating
the descending control system,
resulting in fewer painful
stimuli being transmitted to the
brain.
This information help establish

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intensity.
5. Demonstrated
use of
relaxation
skills and
diversionall
activity as
indicated for
individual
situation.
8. Followed
prescibed
regimen.

Inform patient/So of
the expected
therapeutic effects
and discuss
management of side
effects.
Administer
medication as
indicated, Tramadol

realistic expectations,
confidence in own ability to
handle what happens.

A wide range of analgesics and


associated agents may be used
around the clock to manage
pain.

NCP 2: Nutrition: Imbalanced, Less than body requirements r/t decrease appetite secondary to disease process
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Assessment
Pale conjunctiva and
mucous membranes.
Dry, wrinkled, sagging
of the skin

Diagnosis
Nutrition:
Imbalanced, Less
than body
requirements r/t
decrease appetite
secondary to
disease process

Goal of Care

Patient Will:
1. Drink 6-8 glasses a
day.
2. Responds positively to
his favorite foods if
there
is
no
contraindication.
3. Reports increase
appetite.

Rationale

Assess the
amount of food eaten

This assessment will help


determine nutrient intake of
patient and in identifying specific
deficiencies.

Monitor I and O

Provides information about


overall fluid balance as well as
guidelines for fluid replacement.

in

4. Manifests absence of
signs of malnutrition.

Provide frequent
small meals & a
comfortable &
pleasant
environment.Offer
small frequent sips of
water

5. Participate in specific
interventions
to
stimulate appetite.

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Intervention

Provide oral
hygiene

Provide rest
periods after meals

Create pleasant
dining atmosphere;

Smaller portions of food are less


overwhelming to the patient and
enhances the patients drive to eat
food and also to avoid
dehydration.
A clean mouth can enhance the
taste of food
Stimulate appetite
Makes mealtimes more enjoyable,
which may enhance intake

Evaluation
Goal is met if patient:
1.
Drinks
6-8
glasses a day.
2.
Responds
positively
to
his
favorite foods if there
is no contraindication.
3.
Reports
increase in appetite.
4.
Manifests
absence of signs of
malnutrition.
5.
Participate in
specific interventions
to stimulate appetite.

encouraged patient to
eat with family
members/friends

Encouraged open
communication
regarding decrease
appetite or intake of
food

NCP 3 Risk for Infection r/t Immunosuppression secondary to disease process


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Often a source of emotional


distress especially for SO who
wants to feed patient frequently.
When patient refuses, SO may
feel rejected or frustrated.

Assessment
Patient has Prostate Ca,
Stage IV
-with foley catheter
-with IVF

Diagnosis
Risk for Infection r/t
Immunosuppression
secondary to disease
process

Goal of Care

Intervention

After 8 hours of nursing


Monitor v/s
and
medical especially temperature.
intervention:
1. Patient
will
maintain
vital
signs
within
normal limits.
2. Patient
and
significant

Assess all system


others
will
for signs and symptoms
identify
and
of infection on a
participate
in
continual basis.
interventions to
prevent/reduce

Monitor CBC with


risk
of differential WBC and
nosocomial
granulocyte count and
infection.
platelets as indicated

Promote good
hand washing procedures
by staff and visitors.

Emphasize
personal hygiene.

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Rationale
Vital signs are good indicators of
a possible infection. An
increased in vital signs indicates
bodys compensatory mechanism
against bacterial invasion. Early
indication of infectious process
enables appropriate therapy to be
started promptly
Early indication of infectious
process enables appropriate
therapy to be started promptly.
Early recognition and
intervention may prevent
progression to more serious
situation or sepsis.
Protects patient from sources of
infection.
Limit potential sources of
infection and secondary
overgrow.

Evaluation
Goal is met if :
1.
Patient
maintained vital
signs within normal
limits.
2.
Patient and
significant others
identified and
participated in
interventions to
prevent/reduce risk
of nosocomial
infection


Administer
antibiotic as indicated

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Maybe use to treat identified


infection or given
prophylactically in
immunocompromised patient.