care plan
LOS ANGELES HARBOR COLLEGE Associate Degree Nursing Program
STUDENT NAME: America Escobedo
Client Initials:
NURSING COURSE: 323
Client’s Secondary Roles: : Husband, father
Primary Role: DDP
NURSING PROCESS
Nursing Care Plan
Maturation Stage: The Generative Adult
Tertiary Roles: reading, watching T.V
Developmental Tasks: 1. Maintaining established economic standard and quality of living.
2. Likes to read for leisure time activities
3. Likes to assist children with growth and development
Stage of Illness: Acceptance
Assessment
First Level
Behaviors
Assessment
Second Level
Stimuli
Nursing
Diagnosis
GOALS/Expected
Outcomes
THERAPEUTIC NURSING INTERVENTIONS
(Nursing activities to achieve outcomes and Rationales for interventions)
Evaluation
Check Outcomes:
Yes? No?
Subjective Data:
1. States sharp pain (7/10) in abdomen
2. “my stomach feels bloated and hurts”
3. “my stomach has never been this big”
Increased amount of gas in intestines
abnormal level of bacteria in intestines
Increased perception and sensitivity to what is happening in digestive tract
Acute Pain R/T abdominal distention
As manifested by:
1. States sharp pain (7/10) in abdomen
2. “my stomach feels bloated and hurts”
3. kept demanding pain medicine
Goal(s):
The patient will have satisfactory pain relief
1. Assess pt. for pain presence routinely at frequent intervals , often at the same time as vital signs are taken, and during activity and rest. Also assess for pain with interventions or procedures likely to cause pain. R: Assessing pain while taking vital signs or in routine intervals will help ensure prompt interventions for pain.
2. Administer opioids orally or intravenously as ordered and in a timely manner. R: Will help decrease pain and provide comfort.
3. In addition to administering analgesics, support the patients use of nonpharmacological methods to help control pain, such
STUDENT NAME: America Escobedo
Client Initials:
NURSING COURSE: 323
Client’s Secondary Roles: : Husband, father
Primary Role: DDP
NURSING PROCESS
Nursing Care Plan
Maturation Stage: The Generative Adult
Tertiary Roles: reading, watching T.V
Developmental Tasks: 1. Maintaining established economic standard and quality of living.
2. Likes to read for leisure time activities
3. Likes to assist children with growth and development
Stage of Illness: Acceptance
Assessment
First Level
Behaviors
Assessment
Second Level
Stimuli
Nursing
Diagnosis
GOALS/Expected
Outcomes
THERAPEUTIC NURSING INTERVENTIONS
(Nursing activities to achieve outcomes and Rationales for interventions)
Evaluation
Check Outcomes:
Yes? No?
Subjective Data:
1. States sharp pain (7/10) in abdomen
2. “my stomach feels bloated and hurts”
3. “my stomach has never been this big”
Increased amount of gas in intestines
abnormal level of bacteria in intestines
Increased perception and sensitivity to what is happening in digestive tract
Acute Pain R/T abdominal distention
As manifested by:
1. States sharp pain (7/10) in abdomen
2. “my stomach feels bloated and hurts”
3. kept demanding pain medicine
Goal(s):
The patient will have satisfactory pain relief
1. Assess pt. for pain presence routinely at frequent intervals , often at the same time as vital signs are taken, and during activity and rest. Also assess for pain with interventions or procedures likely to cause pain. R: Assessing pain while taking vital signs or in routine intervals will help ensure prompt interventions for pain.
2. Administer opioids orally or intravenously as ordered and in a timely manner. R: Will help decrease pain and provide comfort.
3. In addition to administering analgesics, support the patients use of nonpharmacological methods to help control pain, such