D. Nursing Care Plan Cues Nursing Diagnosis Goals/Outcomes Nursing Intervension Implementation Evaluation Subjective

D.
NURSING CARE PLAN
CUES NURSING GOALS/OUTCOMES NURSING IMPLEMENTATION EVALUATION

DIAGNOSIS INTERVENSION
Subjective: Risk for infection At the end of 24 hours  Assess signs and  Checked the At the end of 24 hours of
“Awun related to of nursing symptoms of infection temperature of the nursing intervention, the
gyumuguwa accumulation of blood intervention, the especially temperature. patient regularly. patient was be able to
dugo” as fragments. patient will be able to Rationale: Elevated  Monitored the
verbalized by the  Have a stable temperature indicates cleanliness and  Maintain a normal
patient. body temperature infection. ventilation of the ward body temperature of
Translation:  Be in an regularly. 36.4.
I’m experiencing environment free  Clean and ventilate  Instructed the family to  Minimize the risk of
bleeding. of pathogens room; limit visitors. limit the visitor of the acquiring infection in
Objective: causing infections Rationale: Infection might client. the environment
 Vaginal  Follow all be caused by dirty  Demonstrated proper  Accurately
bleeding with recommended surroundings and bacteria vaginal care while enumerated the risk
clots measures to might be transmitted by explaining why it is done factors present for
 Body minimize risks of visitors. in the recommended infection.
Temperature infection. manner.  Religiously followed all
of 36.6  Identify the risk  Keep vaginal area recommended
clean, by doing the measures for
Doenges, M. E., Moorhouse, M. F., & Murr, A. C. (2016). Nurses pocket guide: diagnoses, prioritized interventions, and rationales. Philadelphia: F.A. Davis Company
 High White factors present for following: (1) gently  Instructed the patient minimizing risks of
Blood Cell infection. wipe from front to back to complete the infection.
(24.9) after urinating or have a course of antibiotic
 Pain scale of bowel movement; (2) therapy even if
4/10 Do not use soap or any symptoms improve
 Malnourished solution except water or disappear.
unless instructed by
healthcare provider; (3)
Change sanitary pads
at least every 2 to 4
hours.
Rationale:
Superficial mucous
membrane that lined
uterus during pregnancy
will be shed after abortion.
Vaginal discharge
consisting of this
membrane and blood
Doenges, M. E., Moorhouse, M. F., & Murr, A. C. (2016). Nurses pocket guide: diagnoses, prioritized interventions, and rationales. Philadelphia: F.A. Davis Company.
(lochia) chain of infection
is an effective way to
prevent infection. Using
soap will render the
discharge ineffective
 Emphasize the
necessity of taking
antibiotic as per
doctor’s order.
Rationale:
To reduce bacterial
colonization.
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 or mentation. output of the patient patient was be able to
na isab ako to: Rationale: every time the patient  Scored 15 in the
dugu” --  Be free from signs Changes in these signs drinks fluid and excretes Glasgow Coma Scale.
“I’m scared, I of active bleeding may be indicative of urine.  Have normal vital signs
might bleed  Engage in blood loss affecting  Utilized the Glasgow BP – 110/80, RR – 15,
again.” As appropriate systemic circulation or Coma Scale to assess PR – 68, Temp – 36.4
verbalized by the behavior to reduce local organ function. the level of  Reduce the frequency
patient. the frequency of consciousness of the of her bleeding
Objective: bleeding episodes  Asses the vital signs of patient. episodes.
 Surgical the patient  Monitored the vital signs  Change her behavior
intervention Rationale: regularly. in terms of seeking
performed To evaluate for potential  Monitored the amount of help for self-care
(dilatation and bleeding pads the patient is using  Actively participate in
curettage) in an hour. health teaching in
 Vaginal  Monitor the amount of  Instructed the patient to order to promote
bleeding with bleeding. prevent ambulating for physical healing.
clots Rationale:
 2 to 3 pads of To determine the extent the first 24 hours and
blood of bleeding. maintain bed rest.
 Emphasized the
 Restrict activity and importance of seeking
encourage bed rest until help from her family in
bleeding subside. performing self-care
activities.
Rationale:
 Instructed the patient to
To prevent further
stop taking over the
bleeding.
counter medication or
medication that was not
 Prevent the patient from
prescribed by the
taking medication that
doctor.
contain aspirin or
NSAIDs
Rationale:
These drugs decrease
normal platelet
aggregation

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
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
 Have a normal To reveal possible cause vegetables and behaviors, lifestyle
Objective: Body mass of malnutrition and fruits. changes to regain
 Malnourished index (18.5) by changes that could be  Instructed the patient and maintain
 40 Kg body 1 month. made in client’s intake. to drink less water appropriate weight.
weight  The patient will while eating to  Have a body weight
 BMI: 17.3 gain at least 5  Promote adequate prevent from being of 41 kg.
(underweight) kg of body and timely fluid intake full after consuming
weight. Rationale:
 Pale skin, buccal To reduce possibility of only a small amount
mucosa, nail early satiety of food.
bed.  Emphasize
Poor Skin Turgor importance of well
balance, nutritious
intake
Rationale:
To promote wellness after
discharge.

DIAGNOSIS INTERVENTION
Subjective: Situational low self- At the end of 24 hours  Assess causative or  Encourage expression of At the end of 24 hours of
“Byah di kuna esteem related to of nursing contributing factors of fears, negative feelings, nursing intervention
kagausan perceived failure at a intervention, the low self-esteem. about herself ,patient was able to
manganak Balik” life event as evidenced patient will be able to Rationale:  Observe the facial
-" I think i am not by verbalization of  Acknowledge To determine risk factors expression, eye contact,  Verbalized the
capable to negative feelings factors that lead to that may cause low self- gestures, voice, body importance of
conceive again possibility of esteem. movements and posture support system.
“as verbalized by feelings of low self- of the patient.  Demonstrate a
the patient. esteem.  Encourage expression  Encourage acceptance positive attitude
 verbalize of feelings and of the situation to  Demonstrate an
Objective: understanding of anxieties. promote emotional improvement of
 Minimal eye individual factors Rationale: healing by: self-confidence
contact when that precipitated Expressing feelings can a.) stating that the  Verbalized the view
spoken to current situation help decrease the client’s abortion was not her fault of herself as an
 Crying when  Express positive anxiety. and it was an important person
asked about self-appraisal unforeseeable crisis.  Identify possible
the abortion  Identify possible  Note non-verbal  Gave positive feedbacks health threats to
 Withdrawal health threats to self languages. on the patient while self
facial supporting her in
activities.
expression  Receive support Rationale:  Educate the patient

noted. from significant Incongruence between about the harmful effects
 Negative mood others. verbal and nonverbal of negative self-talk such
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 provide
 Support independence emotional support.
in activities of daily
living
Rationale
The patient needs
continuous positive
feedback and support to
manage behaviors to
promote self-esteem
 Determine individual
factors that could
contribute to diminished
self-esteem.
Rationale:
Individual situation related
to low self-esteem may
contribute to depression.
 Determine availability
and quality of family or
significant others
Rationale:
The development of
positive sense depends on
how the person related to
members of the family as
they are in the current
situation.

D. Nursing Care Plan Cues Nursing Diagnosis Goals/Outcomes Nursing Intervension Implementation Evaluation Subjective

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D. Nursing Care Plan Cues Nursing Diagnosis Goals/Outcomes Nursing Intervension Implementation Evaluation Subjective

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D.

NURSING CARE PLAN

CUES NURSING GOALS/OUTCOMES NURSING IMPLEMENTATION EVALUATION

CUES NURSING GOALS/OUTCOMES NURSING IMPLEMENTATION EVALUATION

CUES NURSING GOALS/OUTCOMES NURSING IMPLEMENTATION EVALUATION

expression  Receive support Rationale:  Educate the patient

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