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Nursing Care Plan: Assessment Nursing Analysis Planning Interventions Rationale Evaluation

The patient is a 32-year-old female admitted with complaints of leg cramps and dizziness. She has been diagnosed with chronic pain due to antiphospholipid syndrome, a disease where the immune system produces antibodies against normal blood proteins, which can lead to blood clots. After 8 hours of nursing intervention, the goal is for the patient to report pain management at a level less than 3-4 on a scale of 0-10 through establishing rapport, assessing her description of pain and response to medication.

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Jelaveil De Vera
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77 views1 page

Nursing Care Plan: Assessment Nursing Analysis Planning Interventions Rationale Evaluation

The patient is a 32-year-old female admitted with complaints of leg cramps and dizziness. She has been diagnosed with chronic pain due to antiphospholipid syndrome, a disease where the immune system produces antibodies against normal blood proteins, which can lead to blood clots. After 8 hours of nursing intervention, the goal is for the patient to report pain management at a level less than 3-4 on a scale of 0-10 through establishing rapport, assessing her description of pain and response to medication.

Uploaded by

Jelaveil De Vera
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PPTX, PDF, TXT or read online on Scribd
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NURSING CARE PLAN

Patient’s Initials: Ms. C____________ Age & Gender: 32 yrs old/ F____ Chief Complaint: Leg cramps and Dizziness
Name of Student Nurse: _Jelaveil De Vera________________________ Birthdate: _April 5, 2001_____________
Admitting Diagnosis:__Chronic pain________ _______ Level/Block/Group: __2BSN01_______________
Address: _195 Malabago, Mangaldan, Pangasinan____________________ _________________________
Hospital/Area: _PHINMA Hospital_____________________ _________________________________
Date of Confinement: __12/28/2021________ Clinical Instructor: _Prof. Amelita D. Dumaguin

ASSESSMENT NURSING PLANNING INTERVENTIONS RATIONALE EVALUATION


ANALYSIS
SUBJECTIVE Antiphospholipid After 8 hours of  Establish rapport  Rapport help gain After 8 hours of
DATA: syndrome is a nursing patient’s nursing
“Nurse sobrang disease wherein intervention, cooperation and intervention, the
sakit po ng the immune the client will active client was able to
binti ko tas system report pain participation in manage pain at a
nahihilo po incorrectly management at therapeutic level less than 3
ako” as produces a level less than communication. to 4 on a scale of
verbalized by antibodies 3 to 4 on a scale 0 to 10.
the patient. against certain of 0 to 10.  Assess the  Assessment ,
normal proteins client’s documenting pain
OBJECTIVE present in the description of and response to
DATA: blood. It can lead pain and medication is
• Facial to formation of response to needed in order
grimace blood clots along medication. to improve
• Leg the arteries or   management of
Swelling veins and can   pain.

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