Giman, Dziohanna Marjuoenh L.

BSN 2-3 / Group 2

NURSING CARE PLAN

Deficient Knowledge
ASSESSMENT DIAGNOSIS PLANNING IMPLEMENTATION / RATIONALE EVALUATION
INTERVENTION

OBJECTIVE : SHORT TERM GOALS: INDEPENDENT INDEPENDENT SHORT TERM GOALS

Risk for infection r/t
● V/S taken as amniotic membrane  After 6 hours of  Establish rapport to the  It is important to After 6 hours of nursing
follows: rupture nursing patient. build trust and interventions, the patient
interventions, the  Assess patient’s vital relationship to was able to:
patient will able to: signs the patient to
T: 36.5 A – Free from any signs
 Assess for the presence understand and
BP: 90/60 mmHg A – Free from any signs communicate and symptoms of infection
or existence of signs and
PR: 96 bpm and symptoms of infection symptoms of infection well. It also such as foul selling/looking
RR: 19 breaths for such as foul smelling or  Perform initial vaginal improves patient vaginal drainage,
minute looking vaginal drainage examination, when the care. tachycardia, and hypo –
O2Sat: 95% throughout rest of contraction pattern  To know any tension throughout rest of
pregnancy. repeat, or maternal deviations from pregnancy. – GOAL MET
Weight: 63 kg
behavior indicates normal range.
B – Patient will identify 3 progress  These factors B – Identified 3 causative
 Abdomen: causative risk factors of represent a risk factors of infections –
 Monitor temperature,
infections. pulse, blood pressure, break in body’s GOAL MET
FH: 34 cm and respiration normal first line
EFW: 3565 g C – Patient will verbalize 5  Monitor change in color, of defense and C – Verbalized %
techniques and lifestyle consistency, and amount may indicate an techniques and lifestyle
FHT: 145 bpm
changes to prevent or of vaginal discharge infection. changes to prevent or
  SPE: reduce risk of infection.  Maintain steril technique  Vaginal exam reduce risk of infection.
(+) minimal whitish in all invasive procedures may be required  GOAL MET
charges at posterior D – Patient will maintain and to confirm
vital signs within normal diagnosis, but D – Maintained vital signs
fornix area, foul smell
range. avoid multiple within normal range.
DEPENDENT digital vaginal  GOAL MET
 IE: E – Patient will have a exams to reduce
1 cm, UEST – 5, follow up ● Administer vitamins or the risk of E – Had a follow up check
Leaking BOW, supplements as infection up – GOAL MET
Cephalic, posterior LONG TERM GOALS prescribed by the  Within 4 hours
firm, BISHOP score: 1 physician. after membrane LONG TERM GOALS
 Stay healthy rupture,
throughout the INTERDEPENDENT chorioamnioniti’s  The patient stayed
 A: pregnancy with the incidence healthy throughout
G1P0, 39 weeks AOG, help of exercise,  Provide a meal plan for increased pregnancy until
Cephalic in latent proper diet, meals pregnant women from a progressively in giving birth.
phase of labor, PROM and vitamins. nutritionist. accordance with
the time
indicated by vital
SUBJECTIVE : signs
 Monitoring will
 Soaked help determine
underwear, any signs of
onset of watery infection of
vaginal vaginal discharge
discharges,  To prevent
associated with introduction of
hypogastric pain pathogens and
radiating to contamination
lumbosacral
area, with DEPENDENT
uterine
contraction ● To have a
every 30 sufficient source
minutes. of vitamins and
support the
development of
the baby.

INTERDEPENDENT

 To stay healthy
during pregnancy
and avoid
complications.