NURSING CARE PLAN #1
ASSESSMENT DIAGNOSIS PLANNING INTERVENTIONS RATIONALE EVALUATION
SUBJECTIVE CUES: Acute pain related to SHORT TERM: INDEPENDENT: SHORT TERM:
"I feel like someone hit my disruption of skin, Within 2 hour of nursing 1. Assess patient’s pain intensity - To better comprehend certain After 2 hour of nursing
head with a crowbar... my tissue, and muscle interventions, the patient through the use of a pain scale. aspects of the patient’s pain and interventions, the patient
head hurts a lot," as stated integrity will be able to: have an objective data as a basis was able to:
by the patient. for the plan of care.
Demonstrate use of Demonstrate use of
OBJECTIVE CUES: relaxation skills and 2. Obtain the patient’s assessment of - To fully understand the patient’s relaxation skills and
Facial grimace diversional activities, pain including the location, pain symptoms. diversional activities,
Guarding behaviour as indicated, for characteristics, onset, duration, as indicated, for
Self-focused individual situation. frequency, quality, aggravating individual situation.
V/S are as follows: factors, and relieving factors.
Temp: 36.6 °C Verbalize Verbalize
PR: 60 bpm nonpharmacological 3. Monitor the skin color, - These are usually altered in acute nonpharmacological
RR: 16 cpm methods that provide temperature, and vital signs such pain. methods that provide
BP: 120/80 mmHg relief. as heart rate, blood pressure, relief.
respirations.
LONG TERM: LONG TERM:
Within 1 week of nursing 4. Evaluate pain regularly (every 2 - To provide information about After 1 week of nursing
interventions, the patient hrs noting characteristics, location, need for or effectiveness of interventions, the patient
will be able to: and intensity (0–10 scale). interventions. was able to:
Emphasize patient’s responsibility
Report pain is relieved for reporting pain/ relief of pain Report pain is relieved
or controlled. completely. or controlled as
evidenced by patient
Follow prescribed 5. Review intraoperative or recovery - Presence of narcotics and stating that, “I feel
pharmacological room record for type of anesthesia droperidol in system potentiates better now, the pain is
regimen. and medications previously narcotic analgesia, whereas gone.”
administered. patients anesthetized with
Fluothane and Ethrane have no Follow prescribed
residual analgesic effects. In pharmacological
addition, intraoperative local/ regimen.
regional blocks have varying
duration, e.g., 1–2 hr for regionals GOAL MET
or up to 2–6 hr for locals.
6. Encourage the use of relaxation - To relieve muscle and emotional
techniques such as deep-breathing tension, enhance sense of control,
exercises, guided imagery, and may improve coping abilities.
visualization, and music.
7. Provide additional comfort - To improve circulation, enhance
measures such as backrub and sense of well-being, and reduce
heat or cold applications. muscle tension and anxiety
associated with pain.
8. Reposition the patient as - To relieve pain and enhance
indicated. circulation.
DEPENDENT:
- To help alleviate pain through
pharmacological means if non-
9. Administer medication as
pharmacological measures are not
indicated.
effective.
- To assess the general condition of
COLLABORATIVE:
the patient through the aid of other
10. Collaborate in treatment of
members of the health care team
underlying condition or disease
and provide appropriate
processes causing pain and
interventions.
proactive management of pain
References:
Doenges, M. E., Moorhouse, M. F., & Murr, A. C. (2018). Nurse's pocket guide: Diagnoses, prioritized interventions, and rationales. FA Davis.
Vera, M. (2020, June 21). 13 Surgery (Perioperative Client) Nursing Care Plans. Nurseslabs. Retrieved from [Link]
NURSING CARE PLAN #2
ASSESSMENT DIAGNOSIS PLANNING INTERVENTIONS RATIONALE EVALUATION
SUBJECTIVE CUES: Impaired skin integrity SHORT TERM: INDEPENDENT: SHORT TERM:
“He has a pretty gnarly related to mechanical Within 1 hour of nursing 1. Assess the patient’s skin, noting - To provide comparative baseline After 1 hour of nursing
black eye,” as stated by the interruption of interventions, the patient type/s of disruption and general and opportunity for timely interventions, the patient
patient’s significant other skin/tissue will be able to health of skin. intervention when problems are was able to demonstrate
demonstrate behaviors or noted. behaviors or techniques to
OBJECTIVE CUES: techniques to promote promote healing and to
Intact suture on the left healing and to prevent 2. Assess the patient’s level of - To clarify intervention needs and prevent complications.
side of the head complications. discomfort. priorities.
Raccoon eyes LONG TERM:
Swelling of the eyelids LONG TERM: 3. Assess the wound regularly, noting - Early recognition of delayed After 1 week of nursing
V/S are as follows: Within 1 week of nursing characteristics and integrity. healing or developing interventions, the patient
Temp: 36.6 °C interventions, the patient complications may prevent a more was able to achieve timely
PR: 60 bpm will be able to achieve serious situation. wound healing.
RR: 16 cpm timely wound healing.
BP: 120/80 mmHg 4. Assess the amount and - Decreasing drainage suggests GOAL MET
characteristics of drainage. evolution of healing process, while
continued drainage or presence of
bloody or odoriferous exudate
suggests complications.
5. Monitor and maintain the - To avoid pressure on the wound
patient’s position and ensure that and to keep it from accidental
the suture is intact. reopening
6. Reinforce initial dressing and - To protect wound from
change as indicated while mechanical injury and
maintaining strict aseptic contamination and to prevent the
techniques. accumulation of fluids that may
cause excoriation.
7. Cleanse skin surface (if needed) - To reduce skin contaminants and
with diluted hydrogen peroxide aid in removal of drainage or
solution, or running water and exudate.
mild soap after incision is sealed.
8. Gently remove tape (in direction - To reduce the risk of skin trauma
of hair growth) and dressings and disruption of wound.
when changing.
DEPENDENT:
9. Review medication and therapy - To ensure that appropriate
regimen. interventions will be given in the
aid for timely wound healing.
COLLABORATIVE:
10. Consult with wound or stoma - To assist with developing plan of
specialist, as indicated. care for problematic or potentially
serious wounds.
References:
Doenges, M. E., Moorhouse, M. F., & Murr, A. C. (2018). Nurse's pocket guide: Diagnoses, prioritized interventions, and rationales. FA Davis.
Vera, M. (2020, June 21). 13 Surgery (Perioperative Client) Nursing Care Plans. Nurseslabs. Retrieved from [Link]
NURSING CARE PLAN #3
ASSESSMENT DIAGNOSIS PLANNING INTERVENTIONS RATIONALE EVALUATION
SUBJECTIVE CUES: Disturbed sleep SHORT TERM: INDEPENDENT: SHORT TERM:
“I couldn’t really pattern related to Within 1 hour of nursing 1. Ascertain the presence of factors - Sleep problems can stem from After 1 hour of nursing
sleep because I have tubes presence of tubes and interventions, the patient known to interfere with sleep. internal and external factors that interventions, the patient
hooked up to me drains will be able to identify may need assessment over time to was able to identify
everywhere,” as verbalized individually appropriate distinguish specific causes. individually appropriate
by the patient. interventions to promote interventions to promote
sleep. 2. Assess the patient’s usual sleep - To determine the intensity and sleep.
OBJECTIVE CUES: patterns and compare with duration of problems. Rely on the
Looks tired LONG TERM: current sleep disturbance. patient’s/significant other’s report LONG TERM:
Difficulty initiating sleep Within 3 days of nursing of problem. After 3 days of nursing
or maintaining sleep interventions, the patient interventions, the patient
state will be able to: 3. Note the patient’s report of sleep - To help clarify the patient’s was able to:
Unintentional quality and response from lack of perception of sleep quantity and
awakening Report improved good sleep. quality and response to inadequate Report improved sleep
Dissatisfaction with sleep. sleep. as evidence by patient
sleep stating that,
Feeling unrested Report increased 4. Perform monitoring and care - To allow for longer periods of “compared to the last
V/S are as follows: sense of well-being activities without waking the uninterrupted sleep, especially time, I have better
Temp: 36.6 °C and feeling rested. patient up whenever possible. during night. sleep now.”
PR: 60 bpm
RR: 16 cpm 5. Adjust ambient lighting. - To maintain daytime light and Report increased
BP: 120/80 mmHg nighttime dark. sense of well-being
and feeling rested as
6. Provide bedtime care such as - To promote physical comfort of evidenced by patient
straightening of bed sheets, patient. verbalizing that, “I feel
changing damp linens or gown, better and well-rested
and giving of back massage. compared to the past
few days after
7. Turn on soft music, calm TV surgery.”
program, or quiet environment, as
the patient prefers. - To enhance the patient’s GOAL MET
relaxation.
8. Minimize sleep-disrupting factors
such as shutting of room door,
inappropriate room temperature, - To promote readiness for sleep
talking, and other disturbing and improve sleep duration and
noises. quality.
DEPENDENT:
9. Discuss use and appropriateness
of over-the-counter sleep
medications or herbal - To provide assistance in falling
supplements. and staying asleep.
COLLABORATIVE:
10. Refer to physician or sleep
specialist as indicated.
- For specific interventions and
therapies, including medications
and biofeedback.
References:
Doenges, M. E., Moorhouse, M. F., & Murr, A. C. (2018). Nurse's pocket guide: Diagnoses, prioritized interventions, and rationales. FA Davis.
