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NURSING CARE PLAN

Patient Name: Ms. Meredith Grey


Age: 24
Physician: Dr. Derek Shepherd

ASSESSMENT DIAGNOSIS PLANNING IMPLEMENTATION RATIONALE EVALUATION

SUBJECTIVE: Acute abdominal  Assess the - Assess pain - These data can After 2hrs of
- Ms. Grey pain related to condition of characteristics. be used to nursing
complain that she hyper acidity as the patient determine the intervention, the
has abdominal evidenced by  Plan to provide - observe or severity of pain as pain is lessened,
pain chest pain, medication monitor signs and well as to establish the patient
vomiting, nausea,  Advice the symptoms of a baseline. verbalized relief
“nahihirapan po heart burn,and patient to discomfort, such from pain and
akong huminga at tiredness. avoid smoking as blood pressure, When pain is rated as 2/10 from
nasusuka po” -as  Advice the heart rate, present, some 7/10.
verbalized by patient to temperature, skin people refuse to
patient regularize meal color and acknowledge it.
patterns and moisture. Paying attention
OBJECTIVE: to the associated
timings
- Restless -Examine the signs can aid the
 The patient
- Rigid abdomen patient’s Nurse in deter
will verbalize
- Wrinkled nose willingness and mining the
relief from
- Pacing ability to try a severity of pain.
pain after 2hrs
- Rapid Breathing variety of pain-
of nursing
-Rated pain as relieving - Some patients
interventions
7/10 in a pain techniques may be unaware
and score it as
scale of 0/10 of the efficacy of
a 2/10 from a
non-
7/10. - Encourage
pharmacological
regular, small
meals. Foods that methods and
can cause eager to pursue
discomfort, such them instead of
as spicy foods and taking
carbonated conventional
beverages, should analgesics.
be identified and
restricted. - Small meals
eliminate gastrin
- maintain a release and
regular sleep distention.
routine.
- Since having
enough sleep is so
vital for your
mental and
physical health, as
well as your
overall quality of
life, proper sleep
hygiene is
essential.

Group Leader:
QUIRIMIT, DARWIN N.
Group Members:
BOCUA, SAMIRAH P.
CORPUZ, JAMAICA MAE
FLORES, PRECIOUS
MONES NICOLE
Instructor:
SIR CHRISTIAN CALUZA

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