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St. Michael's College: Nursing Care Plan Form

- Poor appetite, swelling of right maxillary of face, right eye swelling noted. - Observed guarding behavior, protective gesture, thick yellow and greenish discharges from nose. - Tenderness and swelling around eyes, cheeks, and nose noted. Sore throat also noted.

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355 views

St. Michael's College: Nursing Care Plan Form

- Poor appetite, swelling of right maxillary of face, right eye swelling noted. - Observed guarding behavior, protective gesture, thick yellow and greenish discharges from nose. - Tenderness and swelling around eyes, cheeks, and nose noted. Sore throat also noted.

Uploaded by

academic purposes
Copyright
© © All Rights Reserved
Available Formats
Download as DOCX, PDF, TXT or read online on Scribd
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St.

Michael’s College
College of Nursing
Iligan City

NURSING CARE PLAN FORM

Group: A Date/Shift: FEB 3, 2021 / 7:00- 3:00PM


Area: STATION I

Pt Initials: Age: Sex: Civil Status: Ward: Room/Bed No


G.L.L 50YRS OLD FEMALE MARRIED FEMALE WARD- RM # 23

Date Admitted: JANUARY 27, 2021 Chief Complaint: SWELLING RIGHT MAXILLARY
Attending Physician: DR. MARK YU Admitting Diagnosis/Impression: MAXILLARY INFECTION

Significant Medical and Nursing History:

POOR APPETITE, SWELLING OF RIGHT MAXILLARY OF FACE, RIGHT EYE SWELLING

Prepared by: GERLYN L. GINGOYON Supervised by: _MAE F. CABIGON


Student Nurse Clinical Instructor

Trace/write the pathophysiology or psychosocial explanation/consequences of the nursing diagnosis at the back of this form.
1
ASSESSMENT NURSING DIAGNOSIS PLANNING/ Goals: IMPLEMENTATION RATIONALE EVALUATION:
(Indicate the time the
outcome was met.)

Subjective: Short-term: Independent:


Acute Pain Related to At the end of 8 hours of -interact client to report - To Verbalized pain After 8 hrs of my care
“ aki tang akong toong Maxillary Infection duty patient will: any improvement that can create other patient will be able to ;
aping” as verbalized by - Report pain is /exacerbation to pain problems such as
patient relieved and experience. anger, anxiety, Report pain is relived
controlled immobility, respiratory and controlled
- Lessen bad problems and delay in
gesture and healing Follow prescribed
guarding behavior pharmacological
Objective: - Follow prescribed -encourage verbalization of - Only the client can regimen.
- Observed pharmacological feelings about the pain . judge the level of
evidence of pain at regimen distress of pain; pain
the right side of pt. management should
face. be a term approach
- Guarding behavior Long-term: that includes the client
- Protective gesture During my 4 days of duty vary few people lie
- Thick, yellow and the patient will: about pain.
greenish - Verbalize Dependent/Collaborative:
discharges from nonpharmacologic - Administer medication - Necessary for
the nose-noted al methods that particularly analgesic as treatment of the
- With nasal provide relief. prescribed by the underlying cause
congestion - Demonstrate use physician
- With tenderness, of relaxation skills - Assist with laboratory/ - To determine changes
and swelling and diversional diagnostic studies as indicative of healing/
around the eyes, activities, as indicated infection/ complication
cheeks, and nose . indicated for and to identify
- Sore throat noted individual situation causative and
precipitating factors

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