Nusing Careplan

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NUSING CAREPLAN

Cues/Evidence Nursing diagnosis scientific Goals/Outcome Nursing Actions Rationale of Evaluation


basic Criteria Nursing Action
S= “mag lisud jud Sleep pattern disturbance After 1 hour of *identify presence *to give After 1 hour of
kog tulog igka related to physical discomfort nursing of related factors appropriate nursing
gabie kay mag as evidence of abdominal pain intervention, tge that can contribute intervention interventions the
ngul-ngul akong during night. patient will be to sleep pattern patient promote
tyan” as able to promote disturbance and control pain
verbalized by the Scientific Basis: pain with and control the *observe/obtain *to determine during sleeping
patient liver, may also alter the pain during feedback from the sleep pattern and hours
patient’s sleeping pattern sleeping hours client regarding provide *verbalixed the
O= especially when patient is specially he will: client’s usual comparative understanding of
*receive patient aware of his/her condition. bedtime, time of baseline sleep impairment.
on bed, conscious Pain is caused by stretching of *verbalize the rising *reported
* with ongoing the liver capsule. understanding of increased sense of
PNSS at the right sleep impairment. *obtain feedback *to determine well-being and
arm at 20 gtts/min http://www.about from client usual pattern and feeling rested
livertumors.com/Theliver.aspx *report increased regarding sleep provide *appreciated the
*fatigue noted sense of well- problems comparative nursing
*lack of energy being and feeling baseline intervention given
during day rested *provided comfort *provide a non >patient reported
*dry skin noted measures like pharmacologic that “makatulog
*appreciated the changing of pain management na jud kog tarong
Checked the nursing position during kay ako gi sunod
following V/S: intervention given sleep imo gi ingon”

T= 36.7 *assure client that *worrying about


PR= 84 bpm occasional not sleeping can
RR= 23 cpm sleeplessness perpetuate the
BP= 110/70 should not problem
mmHg threatened

*recommend *napping in
midmorning nap if afternoon can
one is required distrupt normal
sleep pattern
*obtain feedback *to determine
from client usual pattern and
regarding sleep provide
problems comparative
baseline
* limiting intake *to prevent of
of chocolate or staying awake
caffeine. especially at
bedtime

(Nurse Pocket
guide 11th edition
page 424-426)

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