D.

NURSING CARE PLAN

CUES NURSING GOALS/OUTCOMES NURSING IMPLEMENTATION EVALUATION

DIAGNOSIS INTERVENSION
Subjective: Risk for infection At the end of 24 hours  Emphasize the  Instructed the patient to At the end of 24 hours of
“Awun related to of nursing necessity of taking complete the course of nursing intervention, the
gyumuguwa accumulation of blood intervention, the antibiotic as per antibiotic therapy even if patient was be able to
dugo” as fragments. patient will be able to doctor’s order. symptoms improve or  accurately identified
verbalized by the  identify and Rationale: To reduce disappear. and enumerated the
patient. enumerate the bacterial colonization.  Checked the risk factors present for
Translation: risk factors temperature of the infection,
I’m experiencing present for  Assess signs and patient regularly.  clearly stated the
bleeding. infection, and symptoms of infection  Monitored the importance of infection
Objective:  state the especially cleanliness and control, and
 Vaginal importance of temperature. ventilation of the ward  Religiously followed all
bleeding with infection control; Rationale: Elevated regularly. recommended
clots and temperature indicates  Instructed the family to measures for
 Body  Follow all infection. limit the visitor of the minimizing risks of
Temperature recommended client. infection.
of 36.6 measures to  Clean and ventilate  Demonstrated proper  Maintain a normal
 High White minimize risks of room; limit visitors. vaginal care while body temperature of
Blood Cell infection. Rationale: Infection might explaining why it is 36.4.
(24.9) be caused by dirty done in the
 Moderate pain surroundings and bacteria recommended manner.
on the might be transmitted by
abdomen visitors.
 Malnourished
BMI of 17.3  Keep vaginal area
(underweight) clean, by doing the
following
(1) gently wipe from
front to back after
urinating or have a
bowel movement;
(2) Do not use soap or
any solution except
water unless instructed
by healthcare provider;
(4) change sanitary
pads at least every 2
to 4 hours.
Rationale: Superficial
mucous membrane that
lined uterus during
pregnancy will be shed

Doenges, M. E., Moorhouse, M. F., & Murr, A. C. (2016). Nurses pocket guide: diagnoses, prioritized interventions, and rationales. Philadelphia: F.A. Davis Company.
 after abortion. Vaginal
discharge consisting of
this membrane and blood
(lochia) chain of infection
is an effective way to
prevent infection. Using
soap will render the
discharge ineffective.

CUES NURSING GOALS/OUTCOMES NURSING IMPLEMENTATION EVALUATION

DIAGNOSIS INTERVENSION
Subjective: Risk for bleeding After 24 hours of  Assess urinary output,  Instructed the family to At the end of 24 hours of
“Makabuga related to post-surgical nursing interventions, level of consciousness record the input and nursing intervention, the
putman guwaan procedure the patient will be able patient was be able to
Doenges, M. E., Moorhouse, M. F., & Murr, A. C. (2016). Nurses pocket guide: diagnoses, prioritized interventions, and rationales. Philadelphia: F.A. Davis Company.
na isab ako to: or mentation. output of the patient  Actively participate
dugu” --  Identify the risk Rationale: every time the patient in health teaching in
“I’m scared, I factors present for Changes in these signs drinks fluid and excretes order to promote
might bleed bleeding. may be indicative of urine. physical healing.
again.” As  Have minimal signs blood loss affecting  Utilized the Glasgow  Have consistent
verbalized by the of active bleeding. systemic circulation or Coma Scale to assess normal vital signs.
patient.  Engage in local organ function. the level of  Change her
Objective: appropriate consciousness of the behavior in terms of
 Surgical behavior to reduce  Asses the vital signs of patient. seeking help for
intervention the frequency of the patient  Monitored the vital signs self-care
performed bleeding episodes Rationale: regularly.  Reduce the
(dilatation and To evaluate for potential  Monitored the amount of frequency of her
curettage) bleeding pads the patient is using bleeding episodes.
 Vaginal in an hour.
bleeding with  Monitor amount of  Instructed the patient to
clots bleeding. prevent ambulating for
 2 to 3 pads of Rationale: the first 24 hours and
blood To determine the extent maintain bed rest.
of bleeding.  Emphasized the
importance of seeking
 Assess causative help from her family in
factors in contributing to performing self-care
Doenges, M. E., Moorhouse, M. F., & Murr, A. C. (2016). Nurses pocket guide: diagnoses, prioritized interventions, and rationales. Philadelphia: F.A. Davis Company.
 potential in bleeding. activities.
Rationale:  Educate the patient that
To determine the cause of bleeding may occur
bleeding/risk factors. because of the surgical
procedure that was
 Restrict activity and done.
encourage bed rest until
bleeding subside.
Rationale:
To prevent further
bleeding.

CUES NURSING GOALS/OUTCOMES NURSING IMPLEMENTATION EVALUATION

DIAGNOSIS INTERVENSION
Subjective: Alteration in nutrition After 24 hours of  Provide client diet  Instructed the client After 24 hours of nursing
"Makaruwa sadja less than body nursing intervention modifications to eat three times a intervention the patient
ako kumaun requirements related the patient will be able Rationale: day. was be able to
hangkaadlaw" as to poor diet. to To set nutritional goals  Monitored the quality  Recognize the need

Doenges, M. E., Moorhouse, M. F., & Murr, A. C. (2016). Nurses pocket guide: diagnoses, prioritized interventions, and rationales. Philadelphia: F.A. Davis Company.
verbalized by the  Have adequate when client has specific and quantity of food of eating a
patient intake food. dietary needs. the patient is eating. balanced diet.
Translation:  Modify her  Instructed the patient  Eat good quality of
"I only eat twice a dietary plan or  Evaluate total daily to eat a balanced food that are rich in
day " meal pattern. food intake diet which comprises nutrients.
Long term goal Rationale: of protein, grains,  Demonstrate
Objective:  Have a normal To reveal possible cause vegetables and behaviors, lifestyle
 Malnourished Body mass of malnutrition and fruits. changes to regain
 40 Kg body index (18.5) by changes that could be  Instructed the patient and maintain
weight 1 month. made in client’s intake. to drink less water appropriate weight.
 BMI: 17.3  The patient will while eating to
(underweight) gain at least 5  Promote adequate prevent from being
 Pale skin, kg of body and timely fluid intake full after consuming
buccal mucosa, weight. Rationale: To reduce only a small amount
nail bed. possibility of early satiety of food.

 Poor Skin  Emphasize

Turgor importance of well
balance, nutritious
intake
Rationale:
To promote wellness
after discharge.

Doenges, M. E., Moorhouse, M. F., & Murr, A. C. (2016). Nurses pocket guide: diagnoses, prioritized interventions, and rationales. Philadelphia: F.A. Davis Company.
 CUES NURSING GOALS/OUTCOMES NURSING IMPLEMENTATION EVALUATION
DIAGNOSIS INTERVENSION
Subjective: Situational low self- At the end of 24 hours  Assess causative or  Encourage acceptance At the end of 24 hours of
“Byah di kuna esteem related to of nursing contributing factors of of the situation to nursing intervention
kagausan perceived failure at a intervention, the low self-esteem. promote emotional ,patient was able to
manganak Balik” life event as evidenced patient will be able to Rationale: healing by:
-" I think i am not by verbalization of To determine risk factors a.) stating that the  Verbalized the
capable to negative feelings  Demonstrate an that may cause low self- abortion was not her fault importance of
conceive again improvement of self- esteem. and it was an support system.

Doenges, M. E., Moorhouse, M. F., & Murr, A. C. (2016). Nurses pocket guide: diagnoses, prioritized interventions, and rationales. Philadelphia: F.A. Davis Company.
“as verbalized by confidence unforeseeable crisis.  Demonstrate a
the patient.  Verbalized the view  Encourage expression  Accept the patient’s view positive attitude
of herself as an of feelings and on the situation.  Demonstrate an
Objective: important person anxieties.  Allow the patient to improvement of
 Minimal eye  Identify possible Rationale: verbalize her feelings self-confidence
contact when health threats to self Expressing feelings can and anxieties.  Verbalized the view
spoken to help decrease the client’s  Observe the facial of herself as an
 Crying when anxiety. expression, eye contact, important person
asked about gestures, voice, body  Identify possible
the abortion  Note non-verbal movements and posture health threats to
 Withdrawal languages. of the patient. self
facial Rationale:  Educate the patient that
expression Incongruence between having low situational
noted. verbal and nonverbal self-esteem may lead to
 Negative mood needs to be clarified to be anxiety and depression.
sure perceived meaning of  Instruct the family to
communication is always stay with the
accurate. patient and comfort her.

 Determine individual
factors that could
contribute to diminished

Doenges, M. E., Moorhouse, M. F., & Murr, A. C. (2016). Nurses pocket guide: diagnoses, prioritized interventions, and rationales. Philadelphia: F.A. Davis Company.
 self-esteem.
Rationale:
Individual situation related
to low self-esteem may
contribute to depression.

 Active-listen client’s
concerns without
comments or judgments
Rationale:
Promotes trusting situation
in which client is free to be
open and honest with self
and the nurse.

 Determine availability
and quality of family or
significant others
Rationale:
The development of
positive sense depends on
how the person related to

Doenges, M. E., Moorhouse, M. F., & Murr, A. C. (2016). Nurses pocket guide: diagnoses, prioritized interventions, and rationales. Philadelphia: F.A. Davis Company.
 members of the family as
they are in the current
situation.

Doenges, M. E., Moorhouse, M. F., & Murr, A. C. (2016). Nurses pocket guide: diagnoses, prioritized interventions, and rationales. Philadelphia: F.A. Davis Company.
Doenges, M. E., Moorhouse, M. F., & Murr, A. C. (2016). Nurses pocket guide: diagnoses, prioritized interventions, and rationales. Philadelphia: F.A. Davis Company.