POLYTECHNIC COLLEGE OF DAVAO DEL SUR, INC.

MacArthur Highway, Brgy. Kiagot, Digos City, Davao del Sur, Philippines 8002

NURSING CARE PLAN

Name of Patient:         MR C                                                         Attending Physician:          Dr Panuda                                    
Age:    23          Sex:     M        Civil Status:          Single                       Diagnosis:                                                                
Occupation:                           Religion:         Roman Catholic                          
Address:                                                                        Chief Complaint:            Abdominal pain                                       
Ward:        Internal medicine              Room No:     106         Bed No:                  Date of Admission:                                                       

Date/ Cues Needs Nursing Scientific  Basis Goals/Objectives Nursing Rationale Evaluation
Time Diagnosis /Criteria Interventions
1/31/2 “nag sakit P Acute pain as >when such >At the end of >Monitor VS >to provide At the end
3 akong tiyan H evidence by stimuli triggers in my 8 hour shift of and record baseline data of my 8
sir murag the abdominal nursing >conduct a hours
gina kumot”
Y reports of pain intervention the comprehensive > identifying the span of
part of the body
as S pain is the patient will report pain location, nursing
verbalized I normal response abdominal pain assessment intensity, and interventio
by the O that indicates of 2 out of 10 or >Assess dietary frequency n goals
patient L that there is less by discharge habits determines the met
>asses bowel underlying
>good skin
O something
habits abdominal pain
G wrong.
turgor >>Review and the
I history and effectiveness of
>skin is C diagnostic the treatment
warm to studies
touch >Provide >To provide
medication as nutritional
doctors order advises
>Assist the
 >pain scale patient to a >to assess
of 6 out of comfortable bowel
10 position movement
patterns

>to help relieve

pain

>abdominal pain
may be relieved
with a specific
position that
promotes
comfort

Student Name:          Clark Anthony S. Savage                                     Year & Sec.:        4A            Group No.:        4b          Rating:                  
Reference:                                                                                                                                                        
Criteria:  Promptness (5%)        Assessment (15%)       Objectives of care (10%)  Evaluation (10%)
         Format/Neatness (15%)  Nursing Diagnosis (15%)  Nursing Action (30%)  
Clinical Instructor: