Name: Ernesto M.

Canete III Patient’s data

Year & Section: BSN 3 – A Name: S, M. Room #: 410 E
Area of Exposure: CLMMRH – Surgical Ward Age: 48 yrs. old
Date of Exposure: March 18 – 20, 2019 Diagnosis: Ileocecal Mass
Clinical Instructor: Ms. Rosalinda Paderog RN., MAN Physician:

NURSING CARE PLAN

General Objectives: To promote good hygiene and physical comfort.

Assessment Nursing Rationale Specific Nursing Rationale Evaluation
Diagnosis Objectives Intervention
Subjective: Acute pain The ileocecal valve After 4 hours Independent: After 4 hours of
“Gasakit akon related to (ICV) is the of nursing nursing interventions
tiyan kada inflammation joining point interventions  Assess pain  We must have a the patient was able
mag giho ko – of the between the large the patient detailed baseline so to describe
pointing at ileocecal and small will be able we not only know how satisfactory pain
the RLQ area” valce intestines. The to describe to treat control. As evidence
As verbalized secondary to valve has two satisfactory appropriately, but by:
by the ileocecal mass primary functions. pain control. also to know if it *pain scale less than
patient The first is to As evidence has changed. (For 3 to 4 on a rating
control the flow by: example, a sudden scale of 0 to 10.
Objective: between these two *pain scale relief of pain in a *patient displays
*facial areas to serve as a less than 3 patient with improvement in mood
grimace barrier to prevent to 4 on a appendicitis and coping.
*guarding the bacteria rating scale indicates rupture *displays improved
behavior laden contents of of 0 to 10. and an emergency.) well-being such as
*weakness and the large bowel *patient  Control pain: baseline levels for
limited from contaminating displays repositioning pulse, BP,
movement the small improvement , heat/cold,  Patients who are in respirations, and
*protective intestine. in mood and medications pain have trouble relaxed muscle tone or
gestures coping. (muscle participating in body posture.
*pain scale relaxants, care, relaxing,
of 7 out of *displays analgesics), sleeping, and
10 improved and so forth healing. Do what is
*temperature: well-being (all as necessary to
36.9° such as clinically proactively treat
*pulse: 75bpm baseline appropriate) the patient’s pain,
*respiration: levels for and notify the MD as
30cpm pulse, BP, appropriate of
*blood respirations, changes or an
pressure: and inability to provide
100/60 mmHg relaxed muscl  Assess bowel adequate relief.
e tone or movements
body posture. (color,
consistency,
frequency,  This will aid the
amount) provider in making
clinical decisions
significantly. It is
essential to report
bowel movement
characteristics and
frequency accurately
to aid in this
important decision
making. This also
ensures accurate
 Assess bowel intake and output
sounds recording.

 Essential to know
their quality as a
baseline and to
routinely reassess
to detect changes.
If a patient had
bowel sounds, but
now does not, it is
essential to detect
 Assess that and notify the
abdominal provider, as the
distention, patient may not
report experience any
changes in symptoms.
size and
quality as
 appropriate

 Patients may be
experiencing
abdominal distention
Dependent: as part of the
*Collaborate with underlying disease
the other members process
of the health
team.

*Collaboration enhanced
communication and
interdisciplinary
teamwork