NURSING CARE PLAN

Patient’s Name: ________________________________________________________ Age: __________________ Sex: _________________ Date: __________________

Diagnosis: ____________________________________________________________ Surgical Operation: ____________________________________________________

ASSESSMEN NURSING RATIONALE PLANNING INTERVENTION RATIONALE EVALUATION

T DIAGNOSIS
(CUES /
CLUES)
“Masakit po Acute Pain related  The patient will demonstrate Observe and document Assists in -After 2 hours of
ang balikat ko to inflammatory relief of pain as evidenced by location, severity (0-10 scale), differentiating nursing
at merong process as a decrease level of pain and character of pain. cause of pain, and interventions, the
presyon sa evidenced by provides patient’s pain
tyan ko” as reported pain of 8  a pain score of at least less information about level decreased
stated on a 10-point than 5 out of 10, disease from 8 to 7 on a
scale and demonstrates use of progression and pain scale of 0-10
-Reported that verbalization of relaxation skills resolution,
her pain is 8 pain in her
development of -Disease process,
on a 10-point shoulder and
 Provide information about complications, and prognosis, and
scale pressure in her
disease process, prognosis, effectiveness of therapeutic
abdomen.
and treatment needs. interventions. regimen
understood.
Promote bed rest, allowing the
patient to assume a position of
comfort.

Encourage use of relaxation

techniques, and provide
diversional activities.
 Dependent:
Administer 5 mg Morphine as Morphine is an
prescribed opioid medication used
treat moderate to
severe pain. It is used to
alleviate the symptoms of
acute pain.

Administer 4 mg IV as ordered

Promote adequate rest

Administer IV fluids, monitor intake and output
Prepared by: Submitted to:

_____________________________________ JOSEPHINE O. OCCIANO, PhD

Name and Section of Student Nurse
 Clinical Instructor
DRUG STUDY
Patient’s Name: ________________________________________________________ Age: __________________ Sex: _________________ Date: __________________
Diagnosis: ____________________________________________________________ Surgical Operation: ____________________________________________________

NAME OF THE DOSAGE, DRUG

DRUG FORM, ROUTEAND INICATIONS MECHANISISM OF CONTRAINDICATIONS SIDE EFFECTS/ NURSING
(BRAND NAME FREQUENCY OF ACTIONS ADVERSE EFFECTS RESPONSIBLITIES/
AND GENERIC ADMINISTRATION PATIENT EDUCATION
NAME)

Prepared by: Submitted to:

_____________________________________ JOSEPHINE O. OCCIANO, PhD
Name and Section of Student Nurse Clinical Instructor
 NURSING KARDEX

DATE MEDICATION REMARKS DATE DIET / TREATMENT TIME REMARKS

GENERAL LIQUID DIET

DATE DIAGNOSTIC TESTS REMARKS DATE PARENTERAL FLUIDS TIME REMARKS

INFUSED
CBC For repeat
FBS

DATE SINGLE / STAT TIME DATE PRN TIME REMARKS

ORDERS
SUCTION PATIENT

Patient’s Name: Belinda Armado Age/Sex: 49 years old/Female Date of Birth: February 20,
1972
Diagnosis: Cholecystitis, Cholelithiasis Surgical Operation: Cholecystectomy

Name of Student: ______________________________ Group No.: _____________________

Name of Clinical Instructor: ______________________________________________________