SAINT PAUL UNIVERSITY DUMAGUETE

COLLEGE OF NURSING

IN PARTIAL FULFILLMENT OF THE REQUIREMENT IN

NCM: _________ (RELATED LEARNING EXPERIENCE)

SUBMITTED TO:
Ms. Sharry Mae G. Awayan, RN, MAN
________________________________________

SUBMITTED BY:
Erika Bea A. Paculanang, SN-SPUD
_________________________________________

DATE:
November 21, 2023
____________________

Proposed By: Mrs. Sharry Mae G. Awayan, RN, MAN

 SAINT PAUL UNIVERSITY DUMAGUETE
COLLEGE OF NURSING

NURSING CARE PLAN FORM

Patient’s Name (Initials): AM Admitting Diagnosis/Medical Diagnosis/CC: vaginal spotting abnormal uterine bleeding
secondary to endometrial polyps
Age: 32 Sex: F Physician (Initials): Dr. RVF
Room No: A9-Bed 2 Diet: NPO

SUBJECTIVE OBJECTIVE NURSING SCIENTIFIC ANALYSIS PLANNING INTERVENTIONS RATIONALE EXPECTED

DIAGNOSIS OUTCOME
Patient was Activity planningEarly mobilization Short term plan:  Review the - Underlying  The client
lying on bed, related to early reduces risk of  After 8 client’s health physical will be able
not fully awake ambulation aspostoperative hours of history problems to actively
due to evidenced bycomplications, nursing such as participate
Did not able to anesthesia that D&C surgery accelerates the intervention, fatigue or to the
interview was injected via recovery of functional the patient medication activity or
patient since SAB. When walking capacit, will be able side effects exercises
she was asleep asked to move positively impacts to perform can affect the
as she just got her lower several patient- the post ability to
out from the extremities, she reported outcomes operative angage in
operating room slightly move and reduces hospital exercises to tasks
them. length of stay, thus improve
activity planning as ambulation  Determine - Identifies
well as doing basic  The patient individual individual
Definition: post-operative will be able problems with difficulties
Activities or exercise is needed to to move or planning and EVALUATION
exercises to be avoid complications. walk with follow through
conducted to any with activity
promote fast assistance plan
recovery

Reference:  Perform a - The client

R;, T. R. G. (n.d.). Early complete may have an
mobilization in physical underlying
Proposed By: Mrs. Sharry Mae G. Awayan, RN, MAN
 enhanced recovery examination problems,
after surgery such as
Reference: pathways: Current allergies,
Doenges, M. E., evidence and recent hypertension,
Moorhouse, M. advancements. Journal asthma, or
F., & Murr, A. C. of comparative chronic pain,
(2019). Nurse’s effectiveness research. that are
pocket guide: https://pubmed.ncbi contributing
Diagnoses, .nlm.nih.gov/35045757 to fatigue and
prioritized difficulty with
interventions, undertaking a
and rationales. tasks
F.A. Davis

 Review
medication
- For possible
regimen
side effects
affecting
client’s desire
to become
involved in
any activity

 Identify client’s
personal values
and - Provides
perceptionof information
self including that will be
strengths and
helpful in
weaknesses
planning care
and choosing
goals for this
individual

Proposed By: Mrs. Sharry Mae G. Awayan, RN, MAN

  Assess client’s
ability to
process
information
- Low self-
esteem,
anxiety, and
possibly
difficulty with
thinking may
interfere with
perceptions
 Involve the
client/significant
other (SO) in
planning an - Having the
activity support of
family and
the nurse will
help promote
 Direct the client success
to break down
the desired
activity into - This makes
specific small the activity
steps more
manageable,
and as each
step is
accomplished,
the client
feels more
confident
about her
ability to
Proposed By: Mrs. Sharry Mae G. Awayan, RN, MAN
 finish the task
 Accompany the
client to an
activity of her - Support from
own choosing, the caregiver
eencouraging may enable
participation the client to
together if begin
appropriate participating
and gain
confidence
 Review
treatment goals
and - This helps
expectations of clarify what
client/SOs. has been
discussed and
decisions that
have been
made; it also
provides an
oppurtunity
to change
goals as
needed.

Proposed By: Mrs. Sharry Mae G. Awayan, RN, MAN