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Nairobi West EMR
RN
GK
Grace Kamau F · 34y · MRN: NWH-2024-0847
Penicillin T2 Diabetes Hypertension
4 Active Meds In Consultation HIS Record

Care Plan

Acute Pain
NANDA 00132 · Priority: High
Active
Expected Outcomes
  • Patient will report pain level of 4/10 or less within 2 hours of intervention
  • Patient will demonstrate use of non-pharmacological pain management techniques
  • Patient will verbalize understanding of pain medication regimen
Interventions
  • Assess pain using numeric rating scale every 2 hours and PRN
  • Administer Sumatriptan 50mg PO PRN per physician order
  • Maintain dim, quiet environment; minimize stimulation
  • Apply cool compress to forehead as desired by patient
  • Teach relaxation and deep breathing exercises
  • Monitor for medication effectiveness 30 minutes post-administration
Evaluation
10:45 AM — RN Wanjiku: Sumatriptan 50mg administered at 10:15 AM for pain 7/10. Re-assessed at 10:45 — patient reports pain decreased to 5/10. Cool compress applied. Patient resting comfortably in dim room. Will continue to monitor. Next assessment at 12:45 PM.
Disturbed Sleep Pattern
NANDA 00198 · Priority: Moderate
Active
Expected Outcomes
  • Patient will report improved sleep quality (6+ hours) within 48 hours
  • Patient will identify at least 3 sleep hygiene practices to implement at home
  • Patient will demonstrate reduced signs of fatigue
Interventions
  • Assess current sleep patterns and contributing factors
  • Provide sleep hygiene education (consistent schedule, limit screen time, avoid caffeine)
  • Create optimal sleep environment (dim lights, reduce noise, comfortable temperature)
  • Encourage stress management techniques: progressive muscle relaxation, guided imagery
  • Coordinate care activities to minimize nighttime disruptions
Evaluation
11:00 AM — RN Wanjiku: Patient educated on sleep hygiene practices. Patient verbalizes understanding and willingness to implement changes. Reports current sleep of 4-5 hours/night due to work stress and headache. Will provide written sleep hygiene handout before discharge.
Risk for Ineffective Health Maintenance
NANDA 00099 · Priority: High
Active
Expected Outcomes
  • Patient will verbalize understanding of BP and blood glucose targets
  • Patient will demonstrate correct technique for home BP monitoring
  • Patient will identify signs/symptoms that require medical attention
  • Patient will commit to follow-up appointment in 2 weeks
Interventions
  • Educate on importance of medication compliance (Losartan, Metformin, Amlodipine)
  • Teach home blood pressure monitoring technique and target ranges (<140/90)
  • Review diabetic diet principles and importance of regular glucose monitoring
  • Discuss DASH diet recommendations for hypertension management
  • Provide written discharge instructions and medication schedule
  • Confirm follow-up appointment with Dr. Ochieng in 2 weeks
Evaluation
Pending: Patient education session planned for 4:30 PM. Will assess understanding using teach-back method. Written materials to be provided. Follow-up appointment confirmed for 3 March 2025.