NURSING CARE PLAN

Name: Mr. R.M.

Age: 55yrs old
Diagnosis: Distal Esophageal Mass s/p Biopsy (Lymphoma)
ASSESSMENT NURSING PLANNING NURSING INTERVENTIONS RATIONALE EVALUATION
DIAGNOSIS

SUBJECTIVE: Acute pain After 4 hours of Independent: After 3 hours of

“Tulong aldaw na related to nursing intervention  Perform a comprehensive  Pain is a subjective nursing
akong dae disease process the client will assessment of pain to experience and must be intervention, the
nakakabawas saka as evidenced by verbalize pain relief include location, described by the client in client verbalized
makulog pag increased and comfort. characteristics, onset, order to plan effective pain relief and
tigakaputan digdi sa systolic duration, frequency, treatment. comfort.
may parteng tulak pressure, quality, intensity or
ko.” as verbalized by abdominal severity, and precipitating
patient. guarding and factors of pain.
report of 5/10  Reduce or eliminate  Personal factors can
OBJECTIVE: abdominal pain. factors that precipitate or influence pain and pain
-BP= 140/80mmHg increase patient’s pain tolerance. Factors that may
-needs assistance experience. be precipitating or
upon getting up on augmenting pain should be
bed reduced or eliminated to
-refused to ambulate enhance the overall pain
or to do ROM management program.
exercises  Teach the use of non-  The use of noninvasive pain
- slowed movement pharmacologic techniques relief measures can increase
-unable to pass stool before, after, and if the release the release of
-distended abdomen possible during painful endorphins and enhance the
-abdominal activities; before pain therapeutic effects of pain
tenderness noted occurs or increases; and medications.
-conscious and along with other pain
coversant relief measures.
 Dependent
 Provide client optimal
pain relief with prescribed
analgesics.
 Instruct patient to request  Severe pain is more difficult
prn pain medication
before the pain is severe.
Constipation After 2 days of nursing Independent
related to intervention, the  Auscultate abdomen for
insufficient patient will be able to presence, location, and
physical activity establish/regain characteristics of bowel
normal pattern of sounds.
bowel movement,  Ascertain client’s belief
demonstrate and practices about bowel
behaviors or lifestyle elimination.
changes to prevent  Ascertain client’s usual
recurrence of elimination pattern.
problem, and  Encourage intake of
participate in bowel balanced fiber and bulk in
program as indicated. diet.
 Promote increased fluid
intake unless
contraindicated.
 Encourage participation in
activity/exercise within
limits of own ability.
 Instruct patient to
respond to urge to
 Each client has a right to
expect maximum pain relief.
to control and increases the
client’s anxiety and fatigue.
The preventive approach to
pain management can
reduce the total 24-hour
analgesic dose.
 Reflects bowel activity After 2 days of
nursing
intervention, the
patient was able to
 To identify individual risk establish/regain
factors/needs. normal pattern of
bowel movement,
 To assess individual risk demonstrate
factors/needs. behaviors or
 To improve consistency of lifestyle changes to
stool and facilitates passage prevent recurrence
through colon. of problem, and
 To promote moist/soft stool. participate in
bowel program as
indicated.
 To stimulate contractions of
intestines.
 To promote comfort and
prevent complications.
 defecate.
 Instruct client and  To help monitor bowel
watcher to ascertain pattern.
frequency, color,
consistency of stool once
defecated.

Collaborative:
 Notify physician for  For prompt management.
unusalities.

Dianne Kaye M. Sarmiento

BUCN BSN III-C
Group 12