Saint Francis of Assisi College

COLLEGE OF NURSING
045 Admiral Village, Talon III, Las Pinas City

NURSING CARE PLAN

NAME OF PATIENT: _____________________ AGE: _____ SEX: ______ DIAGNOSIS: ______________________ROOM/BED NO. _______DATE: _______________

GOAL AND EXPECTED

ASSESSMENT NURSING DIAGNOSIS INTERVENTIONS EVALUATION
OUTCOME/S

Subjective cues:
“Nahihirapan akong
makagalaw dahil sa sakit ng
tahi ko.” as verbalized by the
patient.
Objective cues:
> Conscious and Cooperative
> (+) Facial Grimace
(+) Swelling around the
Incision Site.
VS
T-37
P-60 beats per minute
R-16 breaths per minute
BP- 110/60 mmHg
Pain r/t laceration of the
delicate tissues AMB facial
grimace.
Impaired skin/ tissue
integrity may be r/t
mechanical interruption of
skin/tissues, possibly
evidenced by disruption of
skin surface/ layers and
tissues.
Goal:
After 8 hr. shift patient will be
able to experience comfort.
Expected Outcome/s:
After 8 hr. shift pain will
be able to decrease, from the
level of 8 to 6 using pain scale of
1-10.
Independent > After 8 hr. shift the goal was attained,
 Positioned pt. comfortably. the patient was able to experience
comfort and the level of pain was
 Linens stretched for more comfort. reduced from level 8 down to 6.
 Keep pt’s back dry.
 Monitor Vital Signs.
Dependent:
Instruct the pt. to take the
medications prescribed by the
physician on time.
Collaborative:
> Examine patient to determine other
problems related to the incision
together with the physician in order
to avoid future complications.
NAME AND SIGNATURE OF STUDENT