Camille O.

Arive

NURSING CARE PLAN

ASSESSMENT
Objective dry lips pale conjunction had several episode of vomiting lack of fluids

PLANNING
short term goal partially compensatory at the end of the nursing

INTERVENTION
encourage to give ice chips encourage to increased fluids intake inhabit foods that might cause or exacerbate abdominal cramping the caffeinated beverages, chocolate citric juices encourage to eat nutritious

RATIONALE

EVALUATION

Subjective -Nagsusuka ako As verbalized by the patient

to reduce gastric stimulation and remitting response prevent severe dehydration. might increase abdominal champing to prevent for possible complication like anemia

patient condition improved.

invention (4hrs) will be able to restore the body fluids and episode of vomiting will be subside

food with high in folic acid like green leafy vegetables

Nursing diagnosis fluid volume deficit related to dehydration -nutrition imbalanced related to less than body requirements

Ella Mae F. Septimo

NURSING CARE PLAN

ASSESSMENT
SUBJECTIVE:

PLANNING
Partially Compensatory Short-term Goal After 1 hour of nursing intervention the patient will report alleviation of pain from pain scale of 7/10 to 5/10

INTERVENTION
Promote position of comfort (e.g. knees flexed) Provide comfort measures (e.g reposition)

RATIONALE
Some measure of comfort and pain relief Promotes relaxation, refocuses attention, and may enhance coping abilities

EVALUATION
Patient condition improved as evidence by alleviation of pain from 7/10 to 5/10

Sumasakit ang tiyan ko as patient verbalized

Facial grimace of pain Abdominal guarding Irritability Has left over foods Pain scale of 7/10

Provide a calm, restful environment

Removing patient from outside stressors promotes relaxation, may enhance coping skills

Provide small, frequent meals as indicated for individual patient Frequent eating keep HCl neutralized, dilutes stomach contents to minimize action of acid on gastric mucosa. Small frequent meals prevent gastric over distention.

NURSING DIAGNOSIS
Acute pain related to illness

Administer medication as indicated (e.g. ranitidine) To reduce hydrochloric acid production, increase gastric pH, and aid in healing

Anna Veronica C. Peralta ASSESSMENT

NURSING CARE PLAN PLANNING INTERVENTION

RATIONALE
Minimize stimulation/ promotes relaxation

EVALUATION
Patient condition

Sumasakit ang ulo ko as

Supportive

patient verbalized
OBJECTIVE:

Educative Short-term Goal After 1 hour of nursing intervention the patient will report decrease in pain from 7/10 to 4/10

phase

improved as

Provide/ recommend nonpharmacological measures for relief of headache (e.g. cool cloth to forehead), and diversional activities

Measures that reduce cerebral vascular pressure and that slow/ block sympathetic response are effective in relieving headache and associated complications

evidence by decrease in pain from 7/10 to 4/10

Facial grimace when in pain Weak in appearance Irritable

Elevated BP:
150/100 mmHg Pain scale of 7/10

Minimize vasoconstricting activities that may aggravate headache

Activities that increase vasoconstriction accentuate the headache in the presence of increased cerebral vascular pressure

NURSING DIAGNOSIS
Acute pain related to increased cerebral vascular pressure

Assist patient with ambulation as needed

To prevent any kind of accidents because dizziness and blurred vision frequently are associated with vascular headache.

Administer medication (Pritor) as needed

To decrease elevated blood pressure

Rachel Ann M. Carmesis

NURSING CARE PLAN

ASSESSMENT
SUBJECTIVE:

PLANNING Partially

INTERVENTION Encourage/ maintain bed

RATIONALE Minimize stimulation/

EVALUATION
Patient condition

Tumataas ang presyon

ko as patient verbalized
OBJECTIVE:

Compensatory At the end of 1 hour of nursing intervention patient will established decreased in blood pressure from 150/100 to 120/80

rest during acute phase Eliminate/ minimize

promotes relaxation Activities that increased vasoconstriction increased cerebral vascular pressure Promote relaxation To prevent increased in blood pressure To check if blood pressure is improving

improved

Elevated blood pressure 150/100 mmHg Weak in appearance Irritable

vasoconstricting activities that may increase blood pressure Provide quiet environment Advise patient to avoid

NURSING DIAGNOSIS Elevated blood pressure related to underlying illness

fatty and salty foods Monitoring blood pressure

Give antihypertensive

To decreased elevated blood pressure

drugs (captopril) as prescribed by the physician

ASSESSMENT
SUBJECTIVE: Nahihirapan akong huminga as patient verbalized

PLANNING
Supportive Educative Short term goal

INTERVENTION
Put the patient in highfowlers position Encourage with abdominal or pursed-lip breathing

RATIONALE
Allows maximum chest expansion for ventilation Provides patient with some means to cope with/

EVALUATION
Patient condition improved

OBJECTIVE:

abnormal breath sound (wheezes) Statement of difficulty of breathing Cough (persistent), with sputum production RR: 32 cpm Weak on appearance

After 30 minute of nursing intervention patient will demonstrate behaviors to improve airway clearance

exercises

control difficulty of breathing and reduce airtrapping

Increased fluid intake to 2500 ml/day within cardiac tolerance. Provide warm tepid liquids

Hydration helps decrease the viscosity of secretions, facilitating expectoration. Using warm liquids may decrease bronchospasm

Keep environmental pollution to a minimum e.g. dust, smoke, and feather pillows, according to individual situation Give medication as prescribed by the physician (e.g epinephrine)

Precipitators of allergic type of respiratory reactions that can trigger/ exacerbate onset of acute episode This medication relax smooth muscles and reduce local congestion, reducing airway spasm, wheezing and mucus production

NURSING DIAGNOSIS: Airway clearance ineffective related to increased production of secretion: thick viscous secretions