BULACAN STATE UNIVERSITY

COLLEGE OF NURSING
City of Malolos, Bulacan

INDIVIDUAL NURSING CARE PLAN

Patient’s Initial: C.D.E. Age: 24 y/o Gender: Female Date Handled:December 6, 2021 Medical Diagnosis: __________________________

Chief Complaint: Gush of water Hospital: Bulacan State University Medical Center Ward/Clinical Area: ER Department

NURSING
ASSESSMENT PLANNING INTERVENTION RATIONALE EVALUATION
DIAGNOSIS
Subjective:  Risk for infection Short Term Goal: Independent:  Lack of prenatal care Short Term
related to loss of  After 30-45  Obtain history about prenatal can place both mother Evaluation:
 She states that protective barrier minutes of nursing screening and amount and and fetus at risk.  After 30-45
she is 37 weeks as evidence by interventions the timing of care. minutes of nursing
along and is positive ferns test. client will verbalize interventions the
nervous about understanding of client will verbalize
the gush of water individual risk  Review history of previous  To have baseline of understanding of
she experienced factors or pregnancies for presence of data about the client’s individual risk
so she decided condition(s) that complications, such as condition. factors or
to come to the may impact premature rupture of condition(s) that
labor and pregnancy. membranes (PROM), placenta may impact
delivery triage previa, miscarriage or pregnancy.
area. pregnancy losses due to Goal:
Long Term Goal: premature dilation of the cervix, ✓ Met
 After 1-2 weeks of preterm labor or deliveries, ___ Partially
Objective: nursing previous birth defects, Met
 LMP 37 weeks interventions the hyperemesis gravidarum, or ___ Unmet
along client will engage repeated urinary tract or vaginal
 Vital Signs in necessary infections. Long Term
- HR 85, alterations in Evaluation:
- BP 130/82, lifestyle and will  Instruct the client/SO(s) in  After 1-2 weeks of
- Temp. 98.7, demonstrate techniques to protect the nursing
- O2 Sat 98% techniques to integrity of the skin, care for interventions the
on RA, promote reduction lesions, and prevent spread of client will engage
- RR 18 of risk of infection infection. in necessary
 All reflexes are and well-being alterations in
and comfort.
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 checked and are  Note conditions potentiating  Note conditions lifestyle and will
intact. vascular changes/reduced potentiating vascular demonstrate
 No edema is placental circulation (e.g., changes/reduced techniques to
present and UA diabetes, gestational placental circulation promote reduction
comes back as hypertension, cardiac problems, (e.g., diabetes, of risk of infection
negative. smoking) or those that alter gestational and well-being
 Pt denies any oxygencarrying capacity (e.g., hypertension, cardiac and comfort.
uterus tenderness asthma, anemia, Rh problems, smoking) or
 Fetal Heart Rate is incompatibility, hemorrhage) those that alter oxygen Goal:
present with a rate carrying capacity (e.g., ✓ Met
130 bpm.  Assess for severe, unremitting asthma, anemia, Rh ___ Partially
 The patient is to nausea and vomiting, especially incompatibility,hemorrh Met
be kept overnight when it persists after the first age) ___ Unmet
for monitoring and trimester (hyperemesis  Hyperemesis
complete bed rest. gravidarum gravidarum places the
mother at risk for
substantial weight loss
and fl uid and
electrolyte imbalances,
and exposes the
developing fetus to
acidotic state and
malnutrition.
Development of
hyperemesis
gravidarum may require
hospitalization.
Dependent:
 Emphasize the necessity of  Premature
taking antivirals or antibiotics, discontinuation of
as directed (e.g., dosage and treatment when client
length of therapy). begins to feel well may
result in return of
infection and
 Discuss the importance of not potentiation of drug-
taking antibiotics or using resistant strains.
“leftover” drugs unless
specifically instructed by a  Inappropriate use can
ealthcare provider. lead to development of
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 drug-resistant strains or
secondary infections.

Interdependent/
Collaborative:
 Assist in treatment of
underlying medical
condition(s) that have
potential for causing maternal
or fetal harm.
 Identify danger signals
requiring immediate notifi  Recognizing risk
cation of healthcare provider situations encourages
(e.g., PROM, preterm labor, prompt evaluation and
vaginal drainage or bleeding). intervention, which may
prevent or limit
untoward outcomes.

Student’s Name: Kervin Jude D. Manahan Yr &Sec/Group No. BSN 2B/Group No:4 Clinical Instructor: Ms, Charmaine Dale R. Robles

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