CANONIZADO, RICA MAE

BSN-NBA2

NURSING CARE PLAN

ASSESSMENT DIAGNOSIS PLANNING IMPLEMENTATION RATIONALE EVALUATION

SUBJECTIVE: Acute Pain related to skin STO:  Consider reports of  The amount of STO:
-“sobrang sakit ng and tissue trauma Within 2-3 hours of nursing pain and stiffness, tissue, muscle, and After 2-3 hours of nursing
inoperahan sakin”, as secondary to post-operative intervention, the client will noting location, lymphatic system intervention, the client is
verbalized by the client. procedure, breast mass express a reduction in duration, and removed can affect now expressing reduction
excision pain/discomfort. intensity. Note the amount of pain of pain/discomfort.
OBJECTIVE: reports of numbness experienced.
-pain scale of 8 out of 10 LTO: and swelling. Be LTO:
-facial grimace is noted Within the shift of nursing aware of verbal and After the nursing
-guarding at the site of intervention, the client will non-verbal cues. intervention in the shift, the
operation is noted appear relaxed, able to client is now appeared to be
-vital signs taken as sleep/rest appropriately.  Facilitate patient to  Elevation of arm, relaxed and is able to
follows: find position of size of dressings, sleep/rest appropriately.
T- 37.6 C comfort. and presence of
RR- 15 cpm drains affect
HR-98 bpm patient’s ability to
SPO2- 95% relax ,rest and sleep
BP- 110/70 effectively.

 Provide basic  Promotes

comfort measures relaxation, helps
and diversional refocus attention
activities. and may enhance
 Encourage early coping abilities.
ambulation and use
of relaxation
techniques.

 Support chest  Facilitates

during coughing participation in
and deep-breathing activity without
exercises. undue discomfort.

 Administer  Provides relief of

narcotics or discomfort and pain
analgesics as and facilitates rest,
indicated. participation in
post-operative
therapy.

 Carry out  Maintains comfort

appropriate pain level and permits
medication on a patient to exercise
regular schedule arm and to ambulate
before pain is severe without pain
and before activities hindering efforts.
are scheduled.
CANONIZADO, RICA MAE
BSN-NBA2
ASSESSMENT
SUBJECTIVE:
-“nilalagnat naman ata
sya”, as verbalized by the
significant others.
OBJECTIVE:
-skin is warm to touch with
a temperature of 39.1 C
-RR: 28 cpm
-HR: 102 bpm
-weakness observed
-dry mucous membrane
-flushed skin
NURSING CARE PLAN
DIAGNOSIS PLANNING
Hyperthermia related to STO:
altered thermoregulation Within 2-3 hours of nursing
secondary to infectious intervention, the client’s
process. temperature will decrease
to normal levels: T- 36.5 C-
37.5 C.
LTO:
Within the shift of nursing
intervention, the client will
be free from complications
such us irreversible brain or
neurologic damage.
IMPLEMENTATION RATIONALE EVALUATION
 Assess and monitor  Temperature of 38.9 STO:
client’s temperature C- 41 C may After 2-3 hours of nursing
and note for suggest acute intervention, the client’s
presence of chills/ infectious disease temperature is decreased
profuse diaphoresis; process. from 39.1 C to 38 C.
also for degree
pattern and
reoccurrence. LTO:
After nursing interventions
 Adjust and monitor  Room temperature of the shift, the client is free
environmental may be accustomed from febrile convulsions.
factors like room to near normal body
temperature and bed temperature and
linens as indicated. blankets and linens
may be adjusted as
indicated to regulate
the temperature of
the client.
 Apply tepid sponge  It could help in
bath reducing
hyperthermia; avoid
 using alcohol and
iced water which
may even produce
chills and increase
client’s temperature.

 Encourage to  Water regulates

increase fluid body temperature.
intake.

 Educate client of  Providing health

signs and symptoms teachings to client
of hyperthermia and could help client
help him identify cope with disease
factors related to condition and could
occurrence of fever; help prevent further
discuss importance complications of
of increased fluid hyperthermia.
intake to avoid
dehydration.
CANONIZADO, RICA MAE
BSN-NBA2
NURSING CARE PLAN
ASSESSMENT DIAGNOSIS PLANNING
Risk for impaired skin STO:
integrity related to Within 3 hours of nursing
prolonged immobility intervention, the patient
will report any altered
sensation or pain at site of
tissue impairment.
LTO:
Within the shift of nursing
intervention, the client will
demonstrate understanding
of plan to heal tissue and
prevent injury including
wound care.
IMPLEMENTATION RATIONALE EVALUATION
 Monitor site of  Systematic STO:
impaired tissue inspection can After 3 hours of nursing
integrity at least identify impending intervention, the client
once daily for color problems early. reported altered sensation
changes, redness, or pain at the site of tissue
swelling, warmth, impairment.
pain or other signs
of infection. LTO:
After nursing intervention
 Monitor status of  Individualize plan is in the shift, the client
skin around wound necessary according demonstrated
and patient’s skin to patient’s skin understanding of plan to
care practices, condition, needs heal tissue and prevent
noting the type of and preferences. injury including wound
soap or other care.
cleansing agents
used, temperature of
water and frequency
of skin cleansing.
 Each type of wound
 Provide tissue care is best treated based
needed. on its etiology.
  This technique
 Keep a sterile reduces the risk of
dressing technique infection in the
during wound care. impaired tissue
integrity.

 Saturating dressings
 Wet thoroughly the will ease the
dressings with the removal by
sterile normal saline loosening adherents
solution before and decreasing pain,
removal. especially with
burns.

 Monitor patient’s  To prevent exposure

continence status to chemicals in
and minimize urine and stool that
exposure of skin can strip or erode
impairment site and the skin causing
other areas to further impaired
moisture from tissue integrity.
incontinence,
perspiration or
wound drainage.