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Nursing Care Plan: University of San Jose-Recoletos

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Ivan A. Elegino

The nursing care plan summarizes the care for a 24-year old married female patient admitted to the hospital with a diagnosis of superimposed severe preeclampsia. Upon admission, the patient's temperature, pulse, blood pressure, and respiratory rate were recorded. She reported a headache rating at 7/10 on the pain scale. The nursing diagnosis is acute pain related to the headache. The plan is to provide pain management, improve vital signs, and teach the patient relaxation techniques over 3 days of nursing intervention. The goals are for the patient to experience reduced pain and discomfort, stabilized vital signs, and ability to demonstrate relaxation strategies for pain management.

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Nursing Care Plan: University of San Jose-Recoletos

Uploaded by

Ivan A. Elegino
79 views2 pages
The nursing care plan summarizes the care for a 24-year old married female patient admitted to the hospital with a diagnosis of superimposed severe preeclampsia. Upon admission, the patient's temperature, pulse, blood pressure, and respiratory rate were recorded. She reported a headache rating at 7/10 on the pain scale. The nursing diagnosis is acute pain related to the headache. The plan is to provide pain management, improve vital signs, and teach the patient relaxation techniques over 3 days of nursing intervention. The goals are for the patient to experience reduced pain and discomfort, stabilized vital signs, and ability to demonstrate relaxation strategies for pain management.

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NCP

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The nursing care plan summarizes the care for a 24-year old married female patient admitted to the hospital with a diagnosis of superimposed severe preeclampsia. Upon admission, the patient's temperature, pulse, blood pressure, and respiratory rate were recorded. She reported a headache rating at 7/10 on the pain scale. The nursing diagnosis is acute pain related to the headache. The plan is to provide pain management, improve vital signs, and teach the patient relaxation techniques over 3 days of nursing intervention. The goals are for the patient to experience reduced pain and discomfort, stabilized vital signs, and ability to demonstrate relaxation strategies for pain management.

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© All Rights Reserved
Download as DOCX, PDF, TXT or read online from Scribd
Download as docx, pdf, or txt
79 views2 pages

Nursing Care Plan: University of San Jose-Recoletos

Uploaded by

Ivan A. Elegino
The nursing care plan summarizes the care for a 24-year old married female patient admitted to the hospital with a diagnosis of superimposed severe preeclampsia. Upon admission, the patient's temperature, pulse, blood pressure, and respiratory rate were recorded. She reported a headache rating at 7/10 on the pain scale. The nursing diagnosis is acute pain related to the headache. The plan is to provide pain management, improve vital signs, and teach the patient relaxation techniques over 3 days of nursing intervention. The goals are for the patient to experience reduced pain and discomfort, stabilized vital signs, and ability to demonstrate relaxation strategies for pain management.

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UNIVERSITY OF SAN JOSE-RECOLETOS

School of Allied Medical Sciences


Nursing Department

NURSING CARE PLAN


Patient’s Name:_______________L.L_________________ Age:___________24 __________ Gender:______Female________ Status:______Married _______
Medical Diagnosis:______________Super imposed severe Preeclampsia ( SISPE ) _______________ Physician:______DR.PEREZ_______
Date of Admission:____________________________________ Hospital:__________________________________________________
Subjective Cues Objective Cues Nursing Scientific Plan of Implementation Rationale Evaluation
Diagnosis References Care/Objectives
The patient Temp : 37.3 C Acute pain related to Acute pain is a complex Short term after 8 hours Independent  To assess etiology After 8 hours of nursing
Verabalizes headache as evidenced by process involving activation intervention the patient will  Take note of the or contributory intervention the patient will
Pulse : pain score of 7/10. of nociceptors chemical be able to client’s attitude factor be able to
“ labad akong ulo pero 73 beats/ min mediators and inflammation.  ease from pain / towards pain and  To provide  Ease from pain /
maagwanta ra sir “ Medications can be use d to discomfort his/her use of pain comfortable discomfort
target each of the key  improve BP within medication environment to  Improve BP within
BP: 130 /90 elements within the pain acceptable range.  Provide a calm and the client acceptable range
pathway and eliminate or  Lonmg term after quiet environment  Dizziness and Goal was met
RR: 23 cycles / min reduce the sensation of pain. 3 daus of nursing  Encourage patient blurred vision  After 3 days of
Pain management begins ,m  Intervention , the to maintain frequently are nursing
when possible , prior to the patient will be complete bed rest associated with intervention the
Pain scale : 7 / 10
tissue trauma continues able to :  Determine the vascular patient will be
throughout the perioperative  Demonstrate the pains location headaches able to :
eperiod when acute pain is use of relaxation characteristics  To facilitate  Demonstrate the
appropriately managed strategies and intensity (0-10 diagnosis of use of relaxation
patient clinical out comes and diversional scale ) problem and strategies and
satisfaction are improved activites as  , onset and initiation of diversional
appropriate for duration appropriate activities as
Reference : johnson , Q. , the situation goal therapy . appropriate for
Borshieski , R.R,& was meet . the situation .
Dependent : administer
Reevesvietes,J.L.(2013) medication as prescribed by
Painmanagementmini-series. the physician.
Part1 a review of
management of acute pain
Missouri medicine 110 (1)
,74-79

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