NURSING CARE PLAN

Problem: Abdominal Pain secondary to Caesarian Section

Nursing Diagnosis: Altered comfort-acute pain related to surgical incisions.
Taxonomy: COGNITIVE-PERCEPTUAL PATTERN
Cause Analysis:

CUES OBJECTIVES NURSING INTERVENTION RATIONALE

Subjective: STO: Independent:

“Gasakit pa jud kayo akong tiyan After 2-4 hours of giving nursing
kay bag-o lang ko nanganak…” interventions, the patient’s pain
decreases on a pain scale of 1-10
with pain less than 2, as evidence of
the absence of facial grimace and
feeling of relaxation.
Objective:
>Facial grimace LTO:
>General Weakness
>Restlessness After 8 hours of giving effective
nursing intervention, the patient’s
level of pain is 0 and is able to sleep
or rest appropriately.
Dependent:
 Reassure patient that you
know pain is real and will
assist her in dealing with it.
 Assess and record pain and its
characteristics, location,
quality, frequency and
duration.
 Encourage relaxation exercise
such as deep breathing
exercise when pain occurs.
 Review factors that aggravate
or alleviate pain.
 Provide comfort measures and
diversional activities and
promote bed rest, allowing
the patient to assume of
comfort.
 Fear that pain will not be
accepted as real increases
tensions, anxiety and
decreases pain tolerance.
 Data assist in evaluating pain
and pain relief and identifying
multiple sources and types of
pain.
 Promotes relaxation,
refocuses attention, and may
enhance coping abilities.
 Helpful in establishing
diagnosis and treatment
needs.
 This contributes pain, relief
muscle tension and anxiety
whenever patient naturally
assume least painful position.

 Prove and implement

prescribe dietary medications.
 Administer medications if
indicated. e.g., Analgesics
 Patient may receive nothing
by mouth (NPO) initially.
When oral intake is allowed,
food choices depend of the
diagnosis.
 Analgesics are more effective
 if administered early in pain
cycle.

NURSING CARE PLAN

Problem Identified: bilateral flank pain

Nursing Diagnosis: Acute Pain r/t biological injuring agent: inflammatory process secondary to Urinary Tract Infection
Taxonomy: Cognitive-Perceptual Pattern
Cause Analysis: Fluid shifts from the intravascular to the interstitial spaces as a result of the release of vasoactive amines by inflammatory process. It causes the nerve endings to be
compress hence resulting in excruciating pain. Reference: Medical Surgical Nursing 10th Edition Volume 2 by Smeltzer and Bare
CUES OBJECTIVES NURSING INTERVENTION RATIONALE
Subjective: Short term objectives: Independent Independent
“Sakit gyud akoang mga kiliran diri sa Within 8 hours of interventions, the pt. Observe and document location, severity Assists in differentiating cause of pain, and
luyo” as verbalized by Pt will be able to verbalize a relief or control (0–10 scale), and character of pain (e.g., provides information about disease
steady, intermittent, colicky). progression/resolution, development of
from pain. complications, and effectiveness of
P – pain upon movement interventions.
Q – sharp sensation
R – bilateral flank Long term objectives: Note response to medication, and report to Severe pain not relieved by routine
S – 3/10-4/10 Within 3 days of giving effective nursing physician if pain is not being relieved. measures may indicate developing
T – pain lasts for a maximum of 20-40 interventions, the patient will be able to complications/need for further
seconds verbalize relief of pain and to demonstrate intervention.
Promote bedrest especially in low-fowler’s
use of relaxation skills and diversional position Bedrest in low-Fowler’s position reduces
activities as indicated for individual intra-abdominal pressure;
situation.
Objective: Allow patient to assume position of
• facial grimace comfort. Patient will naturally assume least painful
position.
• Weakness
Control environmental temperature.
Cool surroundings aid in minimizing
dermal discomfort.
Encourage use of relaxation techniques,
e.g., guided imagery, visualization, deep- Promotes rest, redirects attention, may
breathing exercises. Provide diversional enhance coping.
activities.

Make time to listen to and maintain

frequent contact with patient. Helpful in alleviating anxiety and
refocusing attention, which can relieve
 pain.
Collaborative
Administer Mefenamic Acid 250 mg po Collaborative
q8h, prn for pain Management of mild to moderate pain
Reference: Nursing Care Plans 6th Ed. by Doenges
NURSING CARE PLAN
PROBLEM: Anxiety
NURSING DIAGNOSIS: Anxiety related to illness secondary to hypertension
TAXONOMY: Self Perception Concept Pattern
CAUSE ANALYSIS: Anxiety is common reaction to stress, a state of mental uneasiness, apprehension, or feeling of helplessness related to impending or
unidentified threat to self or significant relationship.

CUES OBJECTIVES NURSING INTERVENTION RATIONALE EXPECTED OUTCOME

INDEPENDENT:

SUBJECTIVE: STO: >Assure patient of >provides reassurance and After 8 hours of giving nursing
“Sige ko ug hunahuna sa After 8 hours of giving confidentiality within limits of opportunity for patient to interventions the patient was
akong kahimtang karon” nursing interventions the situation. problem solve solutions to able to lessen or decrease as
verbalized by the patient. patient will be able to lessen or anticipated situations. evidenced by expressing
decrease as evidenced by >Maintain frequent contact with >Provide assurance that feelings regarding the situation.
expressing feelings regarding patient, talk with and touch patient is not alone or
the situation. patient. rejected: conveys respect
for and acceptance of the
person, fostering trust.
>Provide reliable and consistent >Allow for better
information and support for S.O. interpersonal interaction and
reduction of anxiety and
>Encourage in guided imagery/ fear.
relaxation techniques such as >Moderate anxiety After 3 days of giving nursing
OBJECTIVE: LTO: deep breathing and socializing heightens awareness and intervention the patient was
After 3 days of giving nursing with S.O. can help motivate patient to able to verbalized awareness of
>Fear of unspecific intervention the patient will be focus on dealing with feeling and healthy ways to
consequences. able to verbalized awareness of DEPENDENT: problems. deal with them and demonstrate
>restless feeling and healthy ways to decreasing level of anxiety.
>the patient appear tensed deal with them and demonstrate >Administer antianxiety
& anxious decreasing level of anxiety. medication as needed. >May be useful for brief
 >BP – 160/120.
Mindanao Sanitarium and Hospital College
Name:_____________________ Age:_____ Gender:_______
Chief Complaints: ____________ Room No.:______________
Problem Identified: Grieving
Nursing Diagnosis: Grieving related to loss of child
Cause Analysis: Grief is emotional response of losing someone, feeling of helplessness related to impending significant relationship.
CUES OBJECTIVES
Objective cues: STO:
After 2 hrs of providing open
Crying environment in w/c patient feels
Anger free to realistically discuss feelings
Guilt and concerns, the patient will be
Feelings of sorrow able to be freely discussed her
Denial of loss feelings and concerns.
LTO:
After 2 weeks of discussing
healthy ways of dealing w/ difficult
situations, the patient will be able
to slowly cope-up w/ grieving.
Department of Nursing
NURSING CARE PLAN
NURSING INTERVENTION
Independent
1.provide open environment in w/c
patient feels free to realistically
discuss feelings and concerns
2. Identify stage of grieving and
effects on functioning: denial,
anger, bargaining, depression, and
acceptance.
3. Active-listen to patient’s
concerns and be available for help
as necessary.
4. Assess needs of SO and assist
periods of time to help
patient handle feelings of
anxiety related to diagnoses
and personal situation.
RATIONALE Evaluation
1. Therapeutic communication
skills such as active-listening
silence, being available, in
acceptance provide
opportunity and encourage
patient to talk freely and deal
w/ the perceived/ actual loss.
2. Awareness allows for
appropriate choice of
interventions because
individuals handle grief in
many different ways.
3. The process of grieving
does not proceed in an orderly
fashion, but fluctuates w/
various aspects of all stages
present at onetime or another.
If process is dysfunctional or
prolonged, more aggressive
interventions may be required
to facilitate the process.
4. Identification of problems
 as indicated.
5. Discuss healthy ways of dealing
w/ difficult situation.
Collaborative:
1. Refer to other resources, e.g.
support groups, counseling,
spiritual/pastoral care,
psychotherapy as indicated.
Reference: Nusing Care Plans 6th ed. By Doenges
indicating dysfunctional
grieving allows for individual
interventions
5. Provides opportunity to look
toward the future and plan
family’s/ SO’s needs.
1. May need additional help to
resolve grief, make plans and
look toward the future.
 Mindanao Sanitarium and Hospital College
Department of Nursing

NURSING CARE PLAN

Name:_____________________ Age:_____ Gender:_______

Chief Complaints: ____________ Room No.:______________
Problem Identified: Anxiety
Nursing Diagnosis: Anxiety related to fear of possible loss of child
Cause Analysis: Anxiety is an emotional reaction to the perception of reality that is experience physiologically, psychologically and behaviorally. (Psychiatric
Nursing p.318)

CUES OBJECTIVES NURSING INTERVENTION RATIONALE Evaluation

Subjective Cues: STO: Independent:

“Abi naku mamatay to siya, After 2 hrs of providing open
abi jud naku dili masalo”, as environment in which patient feels
verbalized by the client. safe to discuss feelings, the
patient will be able to openly
Objective Cues: discuss her concerns.
23 cpm LTO:
100/70 mmhg After 2-3 days of identifying and
Uneasiness encouraging patient interaction
Apprehension with support systems, the patient
Feeling of helplessness will be able to slowly cope-up with
her anxiety.
1. Assure patient of confidentiality
within limits of situation.
2. Provide open environment in
which patient feels safe to discuss
feelings or to refrain from talking.
3. Identify and encourage patient
interaction with support systems.
Encourage verbalization/interaction
with family/SO.
4. Provide reliable and consistent
information and support for SO.
5. Include SO as indicated when
major decisions are to be made.
1. Provides reassurance and
opportunity for patient to
problem-solve solutions to
anticipated situations.
2. Helps patient feel accepted
in present condition without
feeling judged, and promotes
sense of dignity and control.
3. Reduces feelings of
isolation.
4. Allows for better
interpersonal interaction and
reduction of anxiety and fear.
5. Ensures a support system
for patient, and allows SO the
chance to participate in
patient’s life.

1. May require further

Collaborative: assistance in dealing with
 1. Refer to psychiatric counseling. diagnosis/prognosis,
especially when suicidal
thoughts are present.
Reference: Nusing Care Plans 6th ed. By Doenges