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    BSN 1 H Case Application Nursing Care Plan

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    Antonio Escoto
    The document describes two patient case applications for nursing care plans. 1. For Mr. Roman, who presents with abdominal pain and constipation, the goals are to relieve pain within 8 hours and reduce abdominal distension. Interventions include examination, medication administration, and bowel regulation. 2. For Mrs. Perez after a mastectomy, goals are for her to understand post-surgical care within 8 hours. Interventions include establishing rapport, avoiding movement, and teaching skin precautions to prevent infection.

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    © All Rights Reserved
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    BSN 1 H Case Application Nursing Care Plan

    Uploaded by

    Antonio Escoto
    57 views3 pages
    The document describes two patient case applications for nursing care plans. 1. For Mr. Roman, who presents with abdominal pain and constipation, the goals are to relieve pain within 8 hours and reduce abdominal distension. Interventions include examination, medication administration, and bowel regulation. 2. For Mrs. Perez after a mastectomy, goals are for her to understand post-surgical care within 8 hours. Interventions include establishing rapport, avoiding movement, and teaching skin precautions to prevent infection.

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    -BSN-1-H-Case-Application-Nursing-Care-Plan

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    The document describes two patient case applications for nursing care plans. 1. For Mr. Roman, who presents with abdominal pain and constipation, the goals are to relieve pain within 8 hours and reduce abdominal distension. Interventions include examination, medication administration, and bowel regulation. 2. For Mrs. Perez after a mastectomy, goals are for her to understand post-surgical care within 8 hours. Interventions include establishing rapport, avoiding movement, and teaching skin precautions to prevent infection.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    57 views3 pages

    BSN 1 H Case Application Nursing Care Plan

    Uploaded by

    Antonio Escoto
    The document describes two patient case applications for nursing care plans. 1. For Mr. Roman, who presents with abdominal pain and constipation, the goals are to relieve pain within 8 hours and reduce abdominal distension. Interventions include examination, medication administration, and bowel regulation. 2. For Mrs. Perez after a mastectomy, goals are for her to understand post-surgical care within 8 hours. Interventions include establishing rapport, avoiding movement, and teaching skin precautions to prevent infection.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    of 3

    University of San Agustin

    General Luna St., 5000 Iloilo City, Philippines


    www.usa.edu.ph

    COLLEGE OF HEALTH AND ALLIED MEDICAL PROFESSIONS - DEPARTMENT OF NURSING


    NAME: CARLOS MIGUEL S. DE LA GENTE YEAR/SECTION:BSN 1-H

    Case Application - Nursing Care Plan


    Construct a Nursing Care Plan for Mr. Roman & Ms. Perez:

    1. Mr. Roman, 25 years of age, presents to the triage nurse at the local emergency department,
    complaining of severe generalized abdominal pain. She describes it as sharp and
    intermittent. He states, “Over the last 4 days, I haven’t been able to have a bowel movement.”
    He states that he is able to drink liquids and urinating without difficulty. Bowel sounds are
    present in all 4 quadrants, however, they are hypoactive (decreased or quiet peristalsis).
    Abdomen is distended and firm to touch. He states, “Two weeks ago I feel that my back hurts.
    My doctor gave me a prescription of Tylenol #3 & I have been taking it every 6 hours for
    pain.” He denies pain at the present time. Abdominal x-ray reveals a large amount of stool in his
    lower colon. All other diagnostic tests are unremarkable. He was prescribed with Dulcolax 1
    tablet once a day.

    Diagnosis Goal Intervention Rationale Evaluation


    Acute Abdominal Within 8 Independent: Independent: Short term:
    Pain R/T pressure hours of  Examine  To The goal was
    from distended receiving the daily promote achieved. After 4
    abdomen as nursing care, routine of a patient hours of nursing
    evidenced by: the patient patient. cooperatio interventions, the
    will be able to n. patient reported
    Subjective: express relief  Obtain the  Helpful in that the pain was
     He states, from patient’s assessing relieved/controlle
    “Two gastrointestin vital signs. the need d, that he
    weeks al distress and for followed the
    ago I feel maintain a  Provide a interventio prescribed
    that my stable stool quiet n pharmaceutical
    back passage at environmen  To help regimen to relieve
    hurts. regular t and assess pain, that he
    intervals. reduce what could verbalized non-
     He also stimuli have been pharmacologic
    states, (e.g., noise, the factor ways that give
    "Over the lightning, affecting relief, and that he
    last 4 constant the patient was able to relax
    days, I interruption in his daily and sleep/rest
    haven’t s) routine. correctly.
    been able
    to have a  List all the Dependent:
    bowel patient’s
    movemen current  Used to
    t. prescription help
    s. relieve

    Email: cn@usa.edu.ph | Tel. No.: 0999-997-1485 | Fax No.: (033) 337-4403


    University of San Agustin
    General Luna St., 5000 Iloilo City, Philippines
    www.usa.edu.ph

    COLLEGE OF HEALTH AND ALLIED MEDICAL PROFESSIONS - DEPARTMENT OF NURSING


    mild to
    moderate
    Objective: Dependent: pain.
    Abdomen is 1. Dulcolax 1  It works
    distended and tab, once a directly on
    firm to touch. day the colon
    2. laxative to produce
    such as a bowel
    Dulcolax 1- movement
    tab qd .
    Interdependent:
     Suction to
    relieve
    buildup of
    gas and
    liquid
     Surgery

    2. Mrs. Perez, 48 years old, is admitted to the nursing unit 2 hours after undergoing a right
    surgical removal of her breast (mastectomy). The floor nurse receives a report from the
    post anesthesia care unit (PACU) nurse that includes the patient’s admitting diagnosis of
    breast cancer, latest vital signs, focused assessment, medication & intravenous (IV)
    orders, pain level & the time she was last medicated for pain & status of the surgical
    dressing. Initially, Mrs. Perez appears to be comfortable, dozing occasionally between
    short conversations with her husband, who is at her side. When she was fully awake 3
    hours after, she complains of sharp, constant pain on the right side of her chest. She
    rates her pain at 8 / 10 on the pain scale. She is grimacing and appears tense. The RN
    took her vital signs - T = 36.5 "C; BP = 130/100 mmHg; RR = 20 bpm; PR = 80
    beats/min. She inspected the surgical wound, at the right breast and reveals that the
    dressing is slightly soaked with blood and intact, no pus & slightly swelling noted.

    Diagnosis Goal Intervention Rationale Evaluation


    Mastectomy R/T After 1 Independent: Independent: Short Term:
    impaired skin hour of  Establish  This could Goal met. After
    integrity related nurse- Rapport serve as 1hour of nurse
    to surgery to patient baseline data patient
    breast removal interaction  Avoid sudden  Sudden interactionwithi
    as evidenced by: over an 8- movement movement n an 8 hour shift,
    hour shift, can cause the patient was
    Subjective: the patient  Access mode damage to able to verbalize
    She complains of will be able coping the healing and demonstrate
    sharp constant to know, abilities and tissues on the theright
    pain on the right pronounce, personality surgical measures
    side of her chest. and show styles wound intaking of her

    Email: cn@usa.edu.ph | Tel. No.: 0999-997-1485 | Fax No.: (033) 337-4403


    University of San Agustin
    General Luna St., 5000 Iloilo City, Philippines
    www.usa.edu.ph

    COLLEGE OF HEALTH AND ALLIED MEDICAL PROFESSIONS - DEPARTMENT OF NURSING


    the proper  To enhance post- surgical
    Objective: precaution  Consider the self- esteem skin.
     She rates s and post- importance of and sense of
    her pain surgical post-surgery self- worth.
    at 8 / 10 skin care to rehabilitation  The client
    on the prevent . stands to
    pain infection. accommodat
    scale e the change
    Dependent: in the center
     She is Tylenol 1 tab PRN of gravity by
    grimacin Advil 1 cap TID leaning to the
    g and side.
    appears
    tense.

    Email: cn@usa.edu.ph | Tel. No.: 0999-997-1485 | Fax No.: (033) 337-4403

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