IX.

NURSING CARE PLAN

NCP 1
NURSING NURSING
DATE CUES SCIENTIFIC BASIS GOAL OF CARE RATIONALE EVALUATION
DIAGNOSIS INTERVENTION
November 10, Subjective: Maternal Definition Of The after 3 days of nursing Independent after 3 days of nursing
2020 “Sakit kaayo dinhi Infection Nursing Dx interventions, the  Assess patient’s  To know any interventions, the
dapit sa ubos ubos related to Maternal infections are patient will be able to: vital signs deviations from patient was able to:
sa akong tiyan rupture of a common normal range
ma’am, unya wa ko membrane complication during  free from any signs  free from any signs
kasabot sa akong secondary to pregnancy and in and symptoms of  Assess for the  These factors and symptoms of
gipamati” as chorioamnioniti some cases in can infections such as presence or represent a infections such as
verbalized by the s result to fetal demise. foul smelling, existence of signs break in the foul smelling,
patient. Pregnant women are uterine tenderness, and symptoms of body’s normal uterine tenderness,
more susceptible to weak, restless, infection first line of weak, restless, pale
Objective: the effects of pale and facial defense and may and facial
 Facial infections because the grimacing. indicate an grimacing.
grimacing immune system is infection.
 Fever naturally suppressed  Identify causative  Monitor
 Tachycardia or maybe due to the risk factors of temperature, pulse,  Within 4 hours
 Diaphoretic infectious agents like infections blood pressure, and after membrane  Identify causative
 Appears weak viruses, bacteria or respiration. rupture, risk factors of
 Pale fungi.  Verbalize chorioamnionitis infections
 Uterine techniques and incidence
tenderness lifestyle change to increased  Verbalize
 Foul smelling Pathophysiological prevent further progressively in techniques and
vaginal Basis complications accordance with lifestyle change to
discharge Rupture of membrane the time prevent further
 Maintain vital signs indicated by vital complications
V/S: within normal range  Monitor change in signs.
T: 39.0 ᵒC Susceptible for viral color, consistency,  Maintain vital signs
HR: 121 bpm & Bacterial infection  Understand the and amount of  Monitoring will within normal range
RR: 65 cpm importance of vaginal discharge help determine
BP: 120/90 mmHg follow-up check-up. any signs of  Understand the
Colonization of infections of importance of
pathogens vaginal follow-up check up.
Diagnostic Studies  Maintain sterile discharge.
technique in all
Inflammatory response invasive procedure  To prevent
activated and during perineal introduction of
Blood test care to the patient. pathogens and
 contamination.
Hemoglobin  Educate the patient
110 g/L on the causative
Fever, foul-smelling risk factors of  Having
Hematocrit discharge, tachycardia infection that the knowledge and
0.36 (INFECTION) patient should being aware of
watch out for. causative factors
White blood Rationale of infection
18x10³/mm³ Chorioamnionitis is the reduces
term that has been likelihood of
Segmenters used for decades to transmission.
0.83 describe infection  Discuss the
and/or inflammation of importance of sterile  Knowledge of
Lymphocytes the chorion, amnion, techniques and ways to reduce
0.17 or both caused by lifestyle changes to or eliminate
pathogens. reduce worsening gems reduces
the infection. likelihood of
transmission.
(Gulanick/Myers; 6th  Discuss the take
edition;144) home meds to the  To make sure
patient. the patient’s SO
understands how
and when to take
the medications,
store the
medications and
what is the
medication used
Dependent: for.
 Administer
medications and IV  To determine
fluids mandated by effectiveness of
physician’s orders. therapy or
presence of side
Collaborative: effects
 Refer the patient to
attending physician  It signals
if there is worsening presence of
of the patient’s complications
health condition which needs
immediate
 interventions.

NCP 2
NURSING NURSING
DATE CUES SCIENTIFIC BASIS GOAL OF CARE RATIONALE EVALUATION
DIAGNOSIS INTERVENTION
November 10, Subjective: Impaired mobility Definition Of The After 1 day of Independent: After 1 day of
2020 “Di pa man kayo ko related to surgical Nursing Dx nursing  Assess ability to carry  The patient may nursing intervention,
ka lihok, mao nga incision secondary Impaired ability to intervention, the out ADLs, such as only require the patient was able
dili pasad kaayo ko to chorioamnionitis. perform or complete patient will be able feeding dressing, assistance with to:
makabuhat-buhat sa activities of daily living, to: grooming, bathing some self-care
mga buhaton bako.” such as feeding, and toileting. measures.  Perform
as verbalized by the dressing, bathing,  Perform . activities of daily
patient. toileting. activities of  Assist the patient in  The patient may living
daily living accepting necessary need to grieve independently
Objective: independently amount of before accepting
 Appears Pathophysiological dependence. that dependence is  Increase
weak/Powerless Basis  Increase necessary. strength and
 Inability to Cesarean section strength and function of
ambulate function of  Set short- range goals  Assisting the affected body
independently affected body with the patient. patient to set part
 Limited range Breaking in the part realistic goals will
of motion continuity of skin decrease  Move within
 Reluctance to  Move within frustrations. range of motion
attempt range of
movement Inflammation process motion
 Pain in the triggered  Provide positive  This provides the
incision site reinforcement for all patient with an
activities attempted; external source of
Pain note partial positive
achievement. reinforcement and
promotes ongoing
Limited range of efforts.
motion, slowed
movements and Dependent:  Proper medications
reluctance to attempt  Administer should be given to
movement medications per promote healing.
physician’s order.

Impaired physical
 mobility

Rationale Collaborative:
Post-operative  Provide appropriate
patients may assisted devices for
experience impairment dressing as assessed
 It is possible for a
of mobility; it will affect by the nurse and the
patient to continue
the ADLs, energy, and occupational
independence in
lifestyle of the patient. therapist.
this self-care
activity.
Source:
(Gulanick/Myers;6th
edition;156)
NCP 3
NURSING NURSING
DATE CUES SCIENTIFIC BASIS GOAL OF CARE RATIONALE EVALUATION
DIAGNOSIS INTERVENTION
November 10, Subjective: Situational low self- Definition Of The After 7 days of Independent: After 7 days of
2020 “Nag sakit jud ang esteem related to Nursing Dx nursing  Encourage patient to  This exercise will nursing intervention,
akong dugan sudden loss of child. The client experienced intervention, the list past and current sometimes helpful the patient was able
tungod sa pagkawa this low self-esteem patient will be able accomplishment: in providing the to increase her self-
sa akong ika unang due to the sudden loss to increase her self- emotional, social, patient with esteem.
anak.” as of her first-born child esteem. interpersonal, perspective.
verbalized by the few days after giving intellectual, vocational Specifically, the
patient. birth. Specifically, the and physical. patient was able to:
patient will be able
to:  Take seriously the
Pathophysiological patient’s reports of  The patient may
Objective: Basis changes in self- be aware of the  Decrease
 Depressed Mild to marked  Decrease esteem. events that depression felt
 Powerless alteration in an depression felt negatively affect from the
 Weak individual’s view of from the her self-concept. situation.
 Lonely/sad herself, including situation.
 Looks negative self-  Assess for unsolved  Unresolved grief  Elicit
unmotivated evaluation. One’s self-  Elicit grief. may inhibit powerlessness
 Does not talk esteem is affected by powerlessness patient’s ability to and being
too much. ability to function in and being move beyond the weak.
larger world. It may be weak. loss and to accept
expressed directly or themselves as
indirectly. they are now.  Elicit loneliness
 Elicit loneliness and mingle and
Rationale: and mingle and  Provide environment  Patients may need converse to
Sudden loss of child converse to conducive to the time to express. other patients.
can alter the mother’s other patients. expression of
confidence and self- feelings.
esteem; it will create
guilt, sadness, and Dependent  To be able to
depression if not  Administer medication administer the
treated. to the patient per prescribed drug.
Source: physician’s order.
(Gulanick/Myers; 6th
edition;161)
Collaborative
 Advise pt’s parents to
consultation for a
pediatric specialist

 To give the
appropriate care
for the baby