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NURSING CARE PLAN

NCM 109 RLE CLINICAL

Wednesday 7:00 AM – 12:00 PM

Submitted by:
REGALA, BIANCA YSABELLE M.
BSN II – B
Group 3
Name: Mrs. Y Sex: Female

Assessment Nursing Planning Intervention Rationale Evaluation

Diagnosis

Subjective: Acute pain After 8 hours of Independent: The goal was partially met.
related to nursing intervention
- Evaluate pain - Provides information about After 8 hours of nursing
increased the patient’s pain wil
regularly (every 2 need for or effectiveness of intervention the reported
“Masakit po ang tahi ko,” as muscle decreased from the
hrs noting interventions. that her pain decreased
verbalized by the patient. contraction. scale of 9/10 to 3/10.
characteristics, from 9/10 to 4/10.
location, and
Objective: intensity (0–10
scale). Emphasize
patient’s
 Vital signs taken as responsibility for
follows: reporting pain/
 BP= 130/80 mmHg relief of pain
 PR= 70 bpm completely.
 RR= 20 cpm
 Temperature= 37⁰
- Assess vital signs, - Changes in these vital signs
 Pain= 9/10
noting tachycardia, often indicate acute pain and
hypertension, and discomfort. Note: Some
increased patients may have a slightly
respiration, even if lowered BP, which returns to
patient denies pain. normal range after pain relief
is achieved.

- Assess location, - Indicates the suitable choice

nature, and of treatment. The patient
 duration of pain, awaiting imminent cesarean
especially as it birth may encounter varying
relates to the degrees of discomfort,
indication for depending on the indication
cesarean birth. for the procedure, e.g., failed
induction, dystocia.

- Provide additional - To improve the circulation,

comfort measures: reduces muscle tension and
backrub, heat or anxiety associated with pain.
cold applications. Enhances sense of well-
being.

Collaborative:
- Administer - Analgesics given IV reach
analgesics as the pain centers
immediately, providing more
indicated.
effective relief with small
doses of medication.

Health Teaching:
- Educate proper - May help in decreasing
relaxation anxiety and tension, promote
techniques; position comfort and enhance sense
for comfort as of well-being.
possible. Use
Therapeutic Touch,
as appropriate.
Name: Mrs. Q Sex: Female

Assessment Nursing Goal Intervention Rationale Evaluation

Diagnosis

Subjective: Ineffective After 8 hours of Independent: The goal was met.

breathing effective nursing - A sitting position
“Nurse nahihirapan po akong - Place patient with After 8 hours of effective
pattern intervention the permits maximum
huminga,” as verbalized by proper body alignment nursing intervention the
related to patient will maintain lung excursion and
the patient. for maximum breathing patient shows optimal
increased optimal breathing chest expansion.
pattern. breathing pattern, as
production pattern, as evidenced
evidenced by relaxed
Objective: of mucus. by relaxed breathing,
breathing, absences of
absences of crackles - Encourage - This method relaxes crackles in both lungs, lip’s
in both lungs, lip’s muscles and color turned pinkish and a
diaphragmatic
 Vital signs taken as color turned pinkish increases the normal urine output of
breathing for patients
follows: or reddish and a patient’s oxygen 500mL every 4 hours.
with chronic disease.
 BP= 100/80 mmHg normal urine output. level.
 PR= 60 bpm
 RR= 25 cpm
 Temperature= 36.5⁰
- Evaluate the - This training
appropriateness of improves conscious
 Crackles were present in
both lungs. inspiratory muscle control of
 Lips slightly cyanotic training. respiratory muscles
 Urine output: 80 mL for 4 and inspiratory
hours; concentrated in muscle strength.
appearance
- Encourage small - This prevents
frequent meals. crowding of the
diaphragm.
Collaborative:
- Administer diuretics as - Diuretics promotes
indicated. normovolemia by
decreasing fluid
accumulation and
blood volume. Fluid
overload reduces
lung perfusion
leading to
hypoxemia.

- Administer
- These medications
vasodilatiors as
increase venous
ordered. dilation and
decrease pulmonary
congestion that will
enhance gas
exchange.

Health Teaching: - These techniques

- Educate the patient promotes deep
how to sustained deep inspiration, which
breaths by: increases
o Using oxygenation and
demonstration: prevents atelectasis.
highlighting Controlled
slow breathing methods
inhalation, may also aid slow
holding end respirations in
inspiration for patients who are
a few seconds, tachypneic.
Prolonged
 and passive expiration prevents
exhalation air trapping.
o Utilizing
incentive
spirometer
o Requiring the
patient to yawn
Name: Mrs. R Sex: Female

Assessment Nursing Goal Intervention Rationale Evaluation

Diagnosis

Subjective: Risk for After 8 hours of Independent: The goal was met.
decreased effective nursing - Cold, clammy, and
“Nahihilo at nanghihina ako,” - Note skin color, After 8 hours of effective
cardiac intervention the pale skin is
as verbalized by the patient. temperature, and nursing intervention the
output patient will remains secondary to
moisture. patient remains
related to normotensive, with compensatory normotensive, with blood
Objective: dcreased blood loss less than increase in loss less than 800 ml.
venous 800 ml. sympathetic nervous
return. system stimulation
 Vital signs taken as and low cardiac
follows: output and oxygen
 BP= 90/60 mmHg desaturation.
 PR= 112 bpm
 RR= 23 cpm
 Temperature= 36⁰ - Record intake and - Reduced cardiac
output. If patient is output results in
 Uterus is soft and not acutely ill, measure reduced perfusion of
contracted. hourly urine output the kidneys, with a
 Fresh blood discharge on and note decreases resulting decrease in
diaper. urine output.
in output.
 Restlessness
- Monitor and record - To know the actual
blood loss. blood loss and to
determine the
appropriate
treatment needed
by the patient.
Collaborative:
- Administer oxygen - The failing heart may
therapy as not be able to
prescribed. respond to increased
oxygen demands.
Oxygen saturation
need to be greater
than 90%.

Health Teaching:
- Educate family and - Early recognition of
patient about the symptoms facilitates
disease process, early problem
complications of solving and prompt
disease process, treatment.
information on
medications, need
for weighing daily,
and when it is
appropriate to call
doctor.

- Aid family adapt - Transition to the

daily living patterns home setting can
to establish life cause risk factors
changes that will such as
maintain improved inappropriate diet to
cardiac functioning reemerge.
in the patient.

- Educate patient the - Psychoeducational

need for and how to programs including
incorporate lifestyle information on
changes. stress management
and health
education have been
shown to reduce
long term mortality
and recurrence of
myocardial
infarction in heart
patients.