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J.

NURSING CARE PLANS


A D P I R E
Subjective Anxiety related to After 4 hours of Be available to the Establishes rapport, After 4 hours of
Natatakot akong cholecystectomy rendering proper patient. Maintain promotes expression rendering proper
maoperahan,” as nursing intervention, frequent contacts of feelings. nursing intervention,
verbalized by the the client will be able with the patient. Be Demonstrates the client is
patient. to verbalize available for listening concern and able to verbalize
awareness of and talking as willingness to help. awareness of feelings
Objective feelings of anxiety needed. of anxiety and health
 Weak in and health ways to ways to deal with
appearance deal with them and Identify patient’s Helps recognition of them and report
report anxiety is perception of the extent of anxiety and anxiety is reduced to
 Pale looking reduced to a threat represented by identification of a manageable level.
manageable level. the situation. measures that may
 Sleep be helpful for the
disturbance individual.

Encourage patient to Helps patient to


acknowledge reality accept what is
of stress without happening and
denial or reassurance reduce level of
that everything will be anxiety. False
alright. Provide reassurance is not
information about helpful, because
measures being neither nurse nor
taken to correct or patient knows the
alleviate condition. final outcome.
Subjective: Anxiety related to At the end of Assess patient’s level To establish baseline At the end of the 5 hr.
change in health 5Hrs. of nursing of anxiety. data intervention, client’s
“Nahihirapan ako status, as evidenced intervention patient anxiety is reduced.
ngayon sa sakit by fear of specified will be able to reduce Place patient in To help the
ko”. As verbalized by consequence. anxiety. comfortable position. patient have
the patient. adequate period of
rest and sleep.
Objective:
Provide To relax & provide
Vital signs taken nonpharmacological comfort to the patient
and recorded: Therapies such
BP: 120/80 as: watching T.V,
PR: 103 BPM listening to music,
RR: 36 CPM socializing with
Temp: 37.7°C others
Subjective Acute Pain related to After 8 hours of Observe and Assists in After 8 hours of
“Masakit ang tiyan inflammation and rendering proper document location, differentiating cause rendering proper
ko,” as verbalized by distortion of tissues nursing intervention, severity and of pain and provides nursing intervention,
the patient. client’s pain will be character of pain. information about client’s pain is
Pain scale rated as reduced to 2/10. disease progression/ reduced to 2/10.
5/10 resolution,
development of
Objective complications and
 Grimaced face effectiveness of
 With guarding interventions.
behavior
 Restlessness Take and record VS For baseline data
 Rigidity of the
abdomen
 Splinted Administer analgesic To relieve pain
respiration with as prescribed
short and
shallow
breathing Promote bedrest, Bedrest in Fowler’s
allowing patient to position reduces
assume position of intraabdominal
comfort. pressures; however,
patient will naturally
assume least painful
position.
Subjective Deficient knowledge After an hour of Provide explanations Information can After an hour of
“pwede bang related to condition, nurse-patient of/reasons for test decrease anxiety, nurse-patient
maulit ang sakit prognosis, treatment, interaction the patient procedures and thereby reducing interaction the patient
ko” as verbalized self-care, and will Verbalize preparation needed. sympathetic is able to verbalize
by the patient. discharge needs understanding of stimulation. understanding of
disease process, Review disease disease process,
prognosis, and process/prognosis. prognosis, and
Objective potential Discuss Provides knowledge potential
- Frequently complications hospitalization base from which complications.
asking question and prospective patient can make
about his treatment as informed choices.
condition, indicated. Encourage Effective
treatment and questions, communication and
diet expression of support at this time
- With worried concern. can diminish anxiety
gaze and promote healing.