APPENDIX B:

NURSING CARE PLAN

Patient’s Name : M.R.C Hospital No. : 111256-2010

Age : 16 years old Room No. : Ward 1-Bed # 11
Impression/ Diagnosis : Chorioamnionitis Physician : Dr. Maglasang

CLINICAL PORTRAIT PERTINENT DATA

HPI:
Received lying on bed, awake, responsive, afebrile, with ease 18 hrs. PTA, noted sudden gush of vaginal water. Thus went to

respirations, with D5LR@ 30 ggts/min infusing well @ right hand, with LHC where I/E was done by a MW, which reveals 3-4 cm cervical

FBC-urobag draining well. Assessed patient to have watery eyes, dry oral dilatation. Patient was admitted and progress of labor was monitored. 7

mucosa, skin warm to touch, diaphoretic, appears weak, lonely, depressed hrs. PTA, patient claimed that she has asked to bear down with fundal

and powerless on daily activities. pushing done and failure to deliver prompted referral then admission.

Noted with facial grimacing and showed guarding position in the Vital signs taken as follows:

abdominal area. T= 37.4ºC RR= 25cpm

HR= 89 bpm BP= 120/90 mmHg
Significant findings of the patient noted as; labored breathing,
Laboratory results:
excessive sweating (diaphoresis), pale, facial grimacing and guarding
Hematology:
position, verbal complaint of pain in the incision site. Leukocyte :25.5 (4.8-10.8)
Hemoglobin :121 (m: 140-180 f: 120-160)
Vital signs taken as follow: Hematocrit :0.372 (m: 0.42-0.52 f: 0.37-0.42)
Platelet :291 (150-400)
T= 37.1 ºC RR=12 cpm
Urinalysis:
HR= 78 bpm BP= 120/90 mmHg Color :yellow Sugar : (-)
Transparency :cloudy Protein : +++
Pain: scale of 6/10 as 10 as the highest level of pain.
 CUES NURSING SCIENTIFIC GOAL & OUTCOME NURSING RATIONALE OF EVALUATION
DIAGNOSIS BASIS CRITERIA ACTIONS & NURSING
NURSING ORDERS
ORDERS

S- Self-care Impaired ability to After 3 days of nursing INDEPENDENT: GOAL MET

“Di pa man kayo ko deficit R/T perform or intervention, the patient - Assess ability - The patient may
ka lihok, mao nga impaired complete activities will be able to perform to carry out only require After 3 days of
dili pasad kaayo ko mobility 2º of daily living, such activities of daily living ADLs, such as assistance with nursing
makabuhat-buhat sa surgical as feeding, independently. feeding some self care intervention the
mga buhaton bako.” incision. dressing, bathing, dressing, measures. patient is able to
as verbalized by the toileting. The Specifically the patient grooming, (Gulanick/Myer perform ADLs
patient. deficit may be the will be able to: bathing and s; 6th such as
result of transient toileting. edition;157) dressing,
O- limitation, such as - Ambulate herself bathing,
- appears weak those one might independently. - Assess the - Different grooming,
and depressed experience while - Dress herself specific cause etiological toileting and
- powerless recuperating from independently. of deficit. factors may ambulating
- restless surgery. The - Bathe and groom require more herself
- difficulty in patient is not failing herself specific independently.
moving at self-care because independently. intervention.
- inability to of a lack in material - Perform toileting (Gulanick/Myer
ambulate resources. tasks s; 6th
independently independently. edition;157)
- V/S taken as (Gulanick/Myers;6th - Verbalize positive
follow: edition;156) outcomes of self- - Assist the - The patient may
care. patient in need to grieve
accepting before
T= 37.1ºC necessary accepting that
HR= 78 bpm amount of dependence is
RR= 12cpm dependence. necessary.
BP= 120/90 mmHg (Gulanick/Myer
s; 6th
edition;157)
- Set short- - Assisting the
range goals patient to set
with the realistic goals
patient. will decrease
frustrations.
(Gulanick/Myer
s; 6th
edition;157)

- Provide - This provides

positive the patient with
reinforcement an external
for all source of
activities positive
attempted; reinforcement
note partial and promotes
achievement. ongoing efforts.
(Gulanick/Myer
s; 6th
COLLABORATI edition;157)
VE:
- Provide - It is possible for
appropriate a patient to
assisted continue
devices for independence in
dressing as this self-care
assessed by activity.
the nurse and (Gulanick/Myer
the s; 6th
occupational edition;157)
therapist.
DEPENDENT:
- Administer - Proper
medications medications
per should be given
physician’s to promote
order. healing.
(Gulanick/Myer
s;6th
edition;157)
 CUES NURSING SCIENTIFIC GOAL & OUTCOME NURSING RATIONALE OF EVALUATION
DIAGNOSIS BASIS CRITERIA ACTIONS & NURSING
NURSING ORDERS
ORDERS

S- Alteration in The client After 3 days of INDEPENDENT GOAL MET

“Sakit pa man ang comfort: experienced pain nursing interventions,
akong tinahian, Pain R/T after the caesarean the patient will be able - Assess pain - Assessment of After 3 days of
maglisod pa sad ko surgical section done to her verbalize decrease characteristics; the pain nursing
og lihok-kihok.” incision to aid her prolonged feeling of pain, from including the experience is interventions, the
verbalized by the secondary to labor. 6/10 to 4/10 in the quality, the first step in patient was able
patient. Caesarean pain scale. severity, planning pain to verbalize
section. Pain is a highly location, onset management decrease feeling
subjective state in Specifically the patient and duration. strategies. of pain from 6/10
which a variety of will be able to: (Gulanick/Mye to 4/10; as
O- unpleasant rs; 6th evidence slight
- facial sensation and a - decrease facial edition;145) decrease in facial
grimacing wide range of grimacing. grimacing,
- guarding distressing factors - elicit guarding - Observe - Some people showed less
behaviour on may be experienced behaviour on the patient’s vital deny the guarding position,
the incision site by the sufferer. It incision site. signs and experience of and ambulation by
- diaphoretic may be a symptom - lessen verbal symptoms pain when it is herself.
- appears weak of injury or illness. complaints of associated with present.
and depressed pain. pain. (Gulanick/Mye
- restless - able to ambulate rs; 6th
- pale (Gulanick/Myers; and perform edition;145)
- V/S taken as 6th edition;144) activities without
follow any pain felt. - Assess for - Different
probable cause etiological
T= 37.1ºC of pain. factors respond
HR= 78 bpm better to
RR= 12cpm different
BP= 120/90 mmHg therapies.
Pain= 6/10 as 10 is (Gulanick/Mye
the highest rs; 6th
level of pain edition;145)
 - Evaluate - It is important
patient’s to help
response to patients
pain express as
medications factually as
aimed to possible.
abolish pain. (Gulanick/My
ers; 6th
edition;145)
- Stress non- - Lessen
pharmacologica patient’s
l methods to exposure to
alleviate pain, medications.
such as; (Gulanick/My
imagery, ers; 6th
distraction edition;146)
techniques.

COLLABORATIVE
: - To give the
- Collaborate to proper
the nutritionist nutrition
for the patient’s needed by the
diet. patient in
pain.
(Gulanick/My
ers; 6th
edition;146)

DEPENDENT: - Pain
- Give analgesics medications
as ordered, are absorbed
evaluating and
effectiveness metabolized
and observing differently in
for any signs patients.
and symptoms (Gulanick/My
of untoward ers; 6th
effect. edition;148)
 CUES NURSING SCIENTIFIC GOAL & OUTCOME NURSING RATIONALE OF EVALUATION
DIAGNOSIS BASIS CRITERIA ACTIONS & NURSING
NURSING ORDERS
ORDERS

S- “Nag sakit jud Situational The client After 3 days of INDEPENDENT: GOAL MET
ang akong dugan low self- experienced this nursing intervention, - Encourage - This exercise
tungod sa pagkawa esteem R/T low self-esteem due the patient will be able patient to list will sometimes After 3 days of
sa akong ika unang sudden loss to the sudden loss to increase her self- past and helpful in nursing
anak.” as verbalized of child. of her first born esteem. current providing the intervention, the
by the patient. child few days after accomplishme patient with patient was able
giving birth. Specifically, the nt: emotional, perspective. to increase her
patient will be able to: social, Gulanick/Myer self-esteem as
Mild to marked interpersonal, s; 6th evidenced by
O- alteration in an intellectual, edition;161) decreased in the
- depressed individual’s view of - decrease vocational and depression she
- powerless herself, including depression felt physical. felt, lessen times
- weak negative self- from the - Take seriously - The patient being powerless,
- lonely evaluation. One’s situation. the patient’s may be aware was able to
- vital signs self-esteem is - elicit reports of of the events converse to the
taken as affected by ability powerlessness changes in self that negatively other patients.
follows: to function in larger and being weak. esteem. affect her self-
world. It may be - elicit loneliness concept.
T= 37.1ºC expressed directly and mingle and Gulanick/Myer
HR= 78 bpm or indirectly. converse to other s; 6th
RR= 12cpm patients. edition;161)
BP= 120/90 mmHg - Determine - Patient may be
(Gulanick/Myers; whether these able to
6th edition;161) feelings have compensate for
resulted in a low- esteem
change in through
patient’s extraordinary
behaviour. performance.
Gulanick/Myer
s; 6th
edition;161)
- Assess for - Unresolved
unsolved grief. grief may
inhibit patient’s
ability to move
beyond the loss
and to accept
themselves as
they are now.
Gulanick/Myer
s; 6th
edition;162)
- Patients may
- Provide need time to
environment express.
conducive to Gulanick/Myer
the expression s; 6th
of feelings. edition;162)

DEPENDENT

- Administer - To be able to
medication to administer the
the patient per prescribed
physician’s drug.
order. Gulanick/Myer
s; 6th
edition;162)