Broward College
Department of Nursing Technology
PATIENT CARE PLAN
STUDENT ADMISSION DATE
PATIENT INITIALS DN AGE Sex OTHER MEDICAL DX
ADMITTING DX
NURSING DIAGNOSIS
(in priority order)
PATIENT-CENTERED
GOALS
NURSING
INTERVENTION
RATIONALE (With reference page) EVALUATION
ND: Ileostomy
Subjective Data:
1. Pain level is 7/10
2. Patient states “I don’t like this,
this looks ugly”
3. Patient avoids to look the
ostomy
Objective Data:
1. Ostomy in the right upper
quadrant
2. Ostomy content green and
liquid
3. Ostomy pink and moist
Short term goal: Acute pain 1. Assess pain, intensity in the scale 1-10, and
aggravate factors.
2. Assist with range of motion exercises and
ambulation gradually.
3. Administer opioids and analgesics as ordered
1. Post surgery the pain should decrease
gradually, if not assess for signs of
infection and adequate nutrition.
Monitoring the pain is important for the
patient comfort.
2. Promote the recovery from surgery,
avoid edema, helping the circulation and
the bowel movement. Avoid muscular
pain and posterior weakness for not
movement.
3. Decrease pain and comfort the patient,
pain alter vital signs and delay recovery.
Patient’s pain is 3 after 3 days pos-surgery.
Patient can move all the body and can walk 5
minutes every 4 hours.
The long-term goal for this diagnosis is on the following page.
