NURSING CARE PLAN #4 (Actual Problem)

Scenario:
Mrs. Bogs, 34 years old G1P0 at 28 weeks’ gestation went to the OPD department. Upon assessment, the client verbalizes that she is a
chain smoker since she was a teenager. She also states her desire to quit smoking for the sake of her baby but she is having difficulty to deal
with it because she feels like her body depends on it in order to do ADLs. Upon physical assessment, the nurse observed the client’s expression
of fear while verbalizing his concerns about her future health and the health of the infant. The nurse also observed the sudden change in
emotional behavior of the client whenever she feels the urge to smoke.

Assessment Planning Intervention Rationale Evaluation

S – “gusto ko na tumigil Long term: • Ascertain the client’s • Client may not Long Term
sa paninigarilyo para sa understanding of the current understand situation and Evaluation:
amin ni baby, kaso Supportive-Educative situation and its impact on life and being aware of these
hinahanap-hanap pa rin work. factors is necessary to After 3 to 6
ng katawan ko palagi.” After 3 to 6 months of planning care and months of
as verbalized by the nursing intervention, the identifying appropriate nursing
patient client will be able to interventions. intervention, the
identify ineffective • Active- listen and identify the • Reflecting client’s outcome goals
O- coping behaviors and client’s perceptions of what is thoughts can provide a for the patient
• Chain smoker consequences as happening. forum for understanding have been met
• Shows evidenced by perceptions in relation and the patient
expression of withdrawing himself to reality for planning condition
fear about his from addiction or care and determining improved.
future health substance abuse. accuracy of
• Emotional interventions needed.
outbursts • Determine previous methods of • to identify successful
dealing with life problems techniques that can be
used in the current
situation.
Vital signs: • Assess current functional • Substance abuse impairs
• BP – 120/90 capacity and note how it is ability to deal with what
• T – 37.2 affecting the individual’s coping is happening in current
• Pr - 74 ability. Determine alcohol intake, situation. Identification
• Hr - 18 drug use, smoking habits, and of impaired sleeping and
• spO2 – 98% sleeping and eating patterns. eating patterns provides
clues to extent of
anxiety and impaired
Nursing Diagnosis coping.
• Give updated or additional • Knowledge helps
Ineffective coping information needed about events, reduce anxiety/fear and
related to insufficient cause (if known), and potential allows the client to deal
sense of control as course of illness as soon as with reality
evidenced by possible. Give information about
substance abuse purposes and side effects of
medications/treatments.
• Assist the client in the use of • Learning new skills can
diversion, recreation, and be helpful for reducing
relaxation techniques. stress and will be useful
in the future as the client
learns to cope more
successfully.
• Encourage the client to try new • This provides an
coping behaviors and gradually external locus of
master the situation. Confront the control, enhancing
client when behavior is safety.
inappropriate, pointing out the
difference between words and
actions.
 • Provide for gradual • This enhances
implementation and continuation commitment to plan.
of necessary behavior/lifestyle
changes.

Submitted by: Submitted To:

Ventura, J-Ian Celcris T. Ma’am Gerlita Pio

BSN – 2D (Group 16) Clinical Instructor