MA. THERESA DJ.
YUMANG
BSN 4
PATIENT NAME: Patient X
AGE: 65 Y/O
CASE NO.:
DIAGNOSIS: Sepsis sec.to Infection, Cellulitis (L) leg, HPN II, DM 2
ASSESSMENT
Subjective Data:
“Namamaga at masakit ang
kaliwang paa ko” as
verbalized.
Objective Data:
 Pain Scale of 8 out of 10
 Facial grimace
 Guarding behavior
 Slowed movement
 Swelling of the left leg
 Skin redness
 VS as follows:
PR = 130 bpm
BP = 150/80mmHg
February 5, 2020
MS. KATE GABRIDO
NURSING CARE PLAN
NURSING PLAN OF ACTION NURSING INTERVENTION RATIONALE EVALUATION
DIAGNOSIS
Acute pain related  After 8 hours of Independent  Client’s pain was
to bacterial nursing decreased to 5 out of
infection as intervention, the  Monitor vita signs q4  These are usually altered in 10
manifested by the client’s pain will be acute pain.
swelling on the left relieved as
leg. evidenced by pain  Demonstrate and encourage  Promote nonpharmacological
scale of 5 out of 10 deep breathing exercises. pain management.
 Encourage diversional activities  Distract attention and reduce
(TV, cp) tension.
 Provide comfort measure  Promote nonpharmacological
(touch) and quiet / calm pain management.
environment
 Distract attention and reduce
 Encourage use of relaxation tension.
techniques such as focused
breathing
 Prevent fatigue.
 Encourage adequate rest
periods.
Dependent
 Necessary for treatment of:
 Administer medications such
as: bacterial infections

prevent bacteria from growing

Clindamycin, on the skin
600 mg IV
Q8
Mupirucin
ointment, BID

 Deep breathing for relaxation

Collaborative
 Encourage and assist client to
do breathing exercises
 Encourage relatives to perform
touch therapy.
is easy to learn and
contributes to pain relief and
/or reduction by reducing
muscle tension and anxiety.
 The human body is believed to
have energy fields that
express aberrant patterns
when body systems are
insulted. Therapeutic touch is
thought to realign aberrant
fields.
 Meet pain control goal.
 Notify physician if regimen is
inadequate