Nursing Care Plan
ASSESSMENT           Nursing         Background      Long Term         Short Term           Plan of         Rationale        Evaluation
                     Diagnosis        Knowledge                                           Interventions
Subjective         Impaired          The client is   After 3 days,     In 4 hours, the    Monitor VS  To look for           Reassessmen
                   Comfort r/t       diagnosed to    the client will   client will be                     significant         t of client’s
 “masakit sa      Abdominal         have            feel no pain      able to                            changes in          pain felt
  may tiyan”                                                                                              vital signs
                   Cramps            appendicitis    at all.           tolerate felt
                                                                                                         To alleviate
                   Secondary         wherein one                       pain as            Administer
                                                                                                          pain felt
Objective          to active fluid   of the                            manifested by      pain
                   loss              symptoms is                       (-)facial          medications
 4/10 pain felt                     abdominal                         grimace. The       as per
 (+)facial                          pain                              client will also   Doctor’s
  grimace
                                                                       verbalize a        order
                                                                       decrease in
                                                                                                         Client’s
                                                                       rated felt pain    Promote
                                                                                                          position may
                                                                       from 4 to 1 or     comfort by      aggravate pain
                                                                       0 in the 0-10      making sure     felt.
                                                                       numerical pain     patient is      Positioning
                                                                       distress scale     positioned      properly may
                                                                       using the pain     properly.       promote
                                                                       scale:                             comfort and
                                                                                                          also ensure
                                                                           0- No pain
                                                                                                          good
                                                                               felt                       circulation.
                                                                           1- 3 mild
                                                                               pain                        To facilitate
                                                                                          Encourage         expansion of
                                                                                          deep              abdomen and
                                                                                                            to decrease
                                                                                                            pain
4-7        breathing
moderate   exercises
pain
8-10       Give health
severe     teachings       Deep
pain       on:               breathing
             Deep           exercises can
               breathing     help lessen
               exercises     the pain.
                           Diversional
                             activities will
             Diversion      help the client
               al            focus on other
               activites     things rather
               such as       than the pain
               reading a     felt.
               book,
               watching
               TV or
               playing
                          -To make the
               board
                          client feel
               games
                          rested.
             Energy
               conserva
               tion
               techniqu
               es such
               as
               resting
               wheneve
               r possible