Republic of the Philippines

UNIVERSITY OF NORTHERN PHILIPPINES

Tamag, Vigan City
2700 Ilocos Sur
College of Nursing
Website: www.unp.edu.ph Mail: unp_nursingvc@yahoo.com
CP# 09177148749, 09175785986

Wound: dry, no
discharges
noted
Dressing and
plaster were
clean and fully
covered the
incision site
.
 Republic of the Philippines
UNIVERSITY OF NORTHERN PHILIPPINES
Tamag, Vigan City
2700 Ilocos Sur
College of Nursing
Website: www.unp.edu.ph Mail: unp_nursingvc@yahoo.com
CP# 09177148749, 09175785986

No foul odor
noted on the
site
NURSING CARE PLAN

NURSING SCIENTIFIC NURSING

DATA GOAL/OBJECTIVE RATIONALE EVALUATION
DIAGNOSIS BACKGROUND INTERVENTION
SUBJECTIVE : Anxiety Anxiety: Vague After 8 hours of - to have a good After 8 hours of
“Allah kakaasi met pay (Mild) related uneasy feeling of Nursing Interventions Establish rapport nurse-client Nursing
tay anak ko, kasano to perceived discomfort or patient will appear relationship Interventions
ngatan ket nagubing pay threat of dread relaxed and patient appeared
nga adda Pneumonia infant well- accompanied by comfortable with no - to establish baseline relaxed and
nan Apo.” – as verbalized being as an autonomic signs of anxiety for Monitor Vital comfortable with
data for comparison
by the patient evidenced by response. The infant’s well-being Signs no signs of
distress, source often Provide comfort - providing calm and anxiety for
OBJECTIVE DATA: increased nonspecific or (comfortable comfortable infant’s well-
•Sign of distress tension, unknown to the environment, environment being
(exhaustion, inability to restlessness, individual. A adequate decreases the  GOAL
make eye contact, and feeling of ventilation and anxiety of the MET
difficulty controlling expression of apprehension reduce background patient
emotions) irritability caused by noise)
 Republic of the Philippines
UNIVERSITY OF NORTHERN PHILIPPINES
Tamag, Vigan City
2700 Ilocos Sur
College of Nursing
Website: www.unp.edu.ph Mail: unp_nursingvc@yahoo.com
CP# 09177148749, 09175785986

•increased tension anticipation of

•restlessness danger. It is an Assess
•expression of irritability altering signal - the greater the
Psychological
that warns of patient perceives the
response to event
impending danger threat, the greater
and availability of
and enables the the level of her
support
Vital Signs taken at 8:00 individual to take anxiety
AM measures to deal
Remain with the - Helps reduce
BP: 90/60 with threats.
patient and stay anxiety and shows
PR: 88 bpm
calm. Speak in a caring for the
RR: 22 cpm
slow manner and patient and family
Temperature: 36.1 C
show empathy.
G1P1T1P0A0L1 Let the patient and - The patient may feel
AOG: 40 weeks and 1 day family express that she failed on
inner thoughts and caring for her baby
feelings and feel that she is
weak and
irresponsible.
Family may feel that
they failed in
assisting the patient
and providing
needed support.

- Helps to improve
Support patient’s self-confidence,
expressed coping acceptance and
 Republic of the Philippines
UNIVERSITY OF NORTHERN PHILIPPINES
Tamag, Vigan City
2700 Ilocos Sur
College of Nursing
Website: www.unp.edu.ph Mail: unp_nursingvc@yahoo.com
CP# 09177148749, 09175785986

mechanisms reduces anxiety

- To allow patient and

Allot time for family internalize
privacy and organize their
thoughts and cope
effectively.

NURSING CARE PLAN

NURSING SCIENTIFIC NURSING

DATA GOAL/OBJECTIVE RATIONALE EVALUATION
DIAGNOSIS BACKGROUND INTERVENTION
SUBJECTIVE : Establish rapport
For the patient to cooperate

Monitor Vital To have a baseline data.

 Republic of the Philippines
UNIVERSITY OF NORTHERN PHILIPPINES
Tamag, Vigan City
2700 Ilocos Sur
College of Nursing
Website: www.unp.edu.ph Mail: unp_nursingvc@yahoo.com
CP# 09177148749, 09175785986

OBJECTIVE: Vital signs are usually

Bp: 100/70 mmHg Signs affected when pain is
PR: 87 bpm present.
RR: 20 cpm
Temp: 35.8 °C