Wesleyan University – Philippines

College of Nursing and Allied Medical Sciences

Tel No. (044) 463-2162; Fax No 463-0596 local 126

N u r s i n g C a r e P l a n

NAME: __________________________________________________________________ GROUP NO: ______________ BLOCK: ______________ DATE: _____

NAME OF PATIENT: ________________________________________________________
MEDICAl DIAGNOSIS:____________________________________________________________

ASSESSMENT NURSING DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATION

Subjective: Risk for infection Patient will free  Assess sign and  Fever may indicate Patient was free
from any signs symptoms of infection infection from any signs and
and symptoms of especially temperature symptoms of
Objective: infections as  Emphasize the  It serves as a first infections as
manifested by line of defense manifested by
importance of hand
absence of fever against infection absence of fever
washing technique.
 Keep area around  Wet area can be
wound clean and dry. lodge area of
bacteria

 Emphasized necessity of  Premature

taking antibiotics as discontinuation of
ordered. treatment when
client begins to feel
well may result in
return of infection.

NOTE: This NCP Form must be accomplished in handwriting.

Clinical Instructor: __________________________________________________ RLE Coordinator: ____________________________________________________

 Wesleyan University – Philippines
College of Nursing and Allied Medical Sciences
Tel No. (044) 463-2162; Fax No 463-0596 local 126

N u r s i n g C a r e P l a n
NAME: __________________________________________________________________ GROUP NO: ______________ BLOCK: ______________ DATE: ______________

NAME OF PATIENT: ________________________________________________________ MEDICAL DIAGNOSIS: ____________________________________________________________

ASSESSMENT NURSING DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATION

Independent Nursing Actions:

“Sobrang sakit po ng Acute pain related to After 4 hours of Asked the patient to rate pain on the Self report of a patient
binti ko” as verbalized by pathologic fracture nursing scale of 0 to 10 experiencing pain serves as
the patient distal third femur intervention pain the first choice to obtain
scale will lessen assessment information
Objective data
Facial grimace
Pain scale of 8/10 Asses and record vital signs
It serves as the baseline
Facial mask of pain
data
Reduce interaction
Provide a wrinkle free bed These following measures
aim to assist patient
Provide care that is unhurried and relaxation.
supportive

Involved patient in decions regarding

care activities

Keep patient well ventilated with fan

Advised patient to do diversional A pain management using

activities such as communicating with non pharmacologic
his relative, reading and watching. technique which desire to
help the patient focus to
activities rather than pain
 Administer pain medication as It reliefs pain
prescribed by the doctor

NOTE: This NCP Form must be accomplished in handwriting.

Clinical Instructor: __________________________________________________ RLE Coordinator: ____________________________________________________