NURSING CARE PLAN

DATE &

INITIALS	NURSING DIAGNOSIS	PATIENT OUTCOMES	RELATED INTERVENTIONS	EVALUATION
5.16.12 SP	Acute Pain R/T tissue trauma of lower abdomen AEB:	Patient will display improved level of pain BY discharge AEB:	1. Assess vital signs Q 4 hours (0700, 1100, 1500..etc)

Rationale: monitor patient stability and health status, especially respiratory rate and pulse oximetry, pulse	5.16.12 Goal Partially Met AEB:
Pain 8/10 on verbal scale	Pain less than 3/10 on verbal scale	2. Assess pain Q 2 hours (0700, 0900, 1100..etc)

Rationale: monitor worsening or improvement in patient pain	Pain 4/10 on verbal scale after administration of Morphine
Facial grimacing and moaning with position change	No visible facial grimacing or moaning with position change	3. Assess abdominal wound site bilaterally Q 4 hours (0700, 1100, 1500..etc)

Rationale: assess to make sure wound site is intact, as well as J Vac system to be sure it is not causing pain, and working correctly	No visible facial grimacing or moaning during position change
SOB with exertion	Denies SOB with exertion	4. Administrate Pain medications (morphine and Tylenol) Q 4 hours, PRN as ordered by physician

Rationale: improve and control client pain, and reduce anxiety	SOB with exertion
Abdominal guarding over lower abdomen	No visible abdominal guarding over lower abdomen	5. Apply O2 Q AAT (0100-2400)

Rationale: help with SOB, ensure client has adequate oxygenation	No abdominal guarding
BMI 39.7	Verbalizes understanding of need to increase activity and modify diet	6. Administrate anti-anxiety medications (Celexa, Zyprexa, Desyrel) Q as ordered by physician

Rationale: helps reduce anxiety and calms patient	BMI 39.7, does not verbalize understanding of need for lifestyle change
Anxiety	Denies anxiety	7. Assist client to change positions Q 2 hours (0700, 0900, 1100..etc)

Rationale: helps client to change positions to ensure comfort and prevent skin breakdown	Denies anxiety
Pulse 122 BPM	Pulse WNL 60-100 BPM	8. Assist client to ambulate at least 50 feet (if tolerated) Q 4 hours while awake (0700, 1100..etc)

Rationale: improve patient mobility and help with position change, and increases activity	Pulse 68 BPM
Decreased ability to perform ADL’s	Improved participation with ADL performance	9. Assist patient with ADLS Q AM, HS (0900, 2100)

Rationale: Assists client with ADLS and reduces pain r/t activity, and encourages participation in ADLS	Decreased ability to perform ADL’s
Poor appetite due to pain	Improved appetite	10. Assist/ encourage client to perform Cough and Deep breathe and IS Q 1 hours while awake (0700, 0800…etc)

Rationale: helps prevent respiratory complications from surgery, and helps the client to relax	Patient ate 50% late breakfast
11. Assist/ Encourage to find alternate relaxation techniques (i.e reduce excess stimuli) Q 2 hours while awake or upon patient request

Rationale: helps provide alternate techniques to reduce pain, and reduce anxiety	Continue P.O.C

Samantha Paris

SNFRMC
12. Provide small nutritious meals 6 times per day Q AAT (Daily), or per patient request

Rationale: helps provide client to have several times a day to have intake and improves nutritional status
13. Assist/ educate client in choosing diet high in protein, increase activity Q 6 times a day at meals, or until client demonstrates ability to make acceptable food choices, and increase activity

Rationale: : Helps teach client to make better diet choices to improve health and reduce BMI

NURSING CARE PLAN

Bussard, Michelle - Faculty

2012-05-18

michael dover

Firelands Regional Medical Center