EMILIO AGUINALDO COLLEGE

School of Nursing

NURSING CARE PLAN

NAME: ______________________ PATIENT INITIAL: AGE: DATE:
STUDENT #: DIAGNOSIS: G1P1 35 weeks,preeclamspia without severe features GENDER: F ROOM NO.

ASSESSMENT NURSING DIAGNOSIS PLANNING NURSING INTERVENTION RATIONALE EVALUATION

Subjective: INDEPENDENT High blood pressure, increased The patient appears to be

Postpartum mom states that Anxiety related to stressors
she didn’t sleep for 36
hours. Her baby is staying at status, environment.
NICU for further
evaluation. She wanted to
go home immediately as she
has been admitted to the
hospital for 11 days and she
wait for lab work results and
relief for constipation.
Objective:
Conscious and
coherent,distracted easily
No signs of swelling in lower
extremities
Manageable abdominal pain
Elevated blood pressure
Vital signs:
BP:140/80
Pulse: 119
RR: 16
Ostat: 97
Lab results:
Hematocrit: 35.5
Neutrophils: 0.862
Lymphocytes: 0.110
Monocytes: 0.022
ALAT/GPT: 40.8 U/I
Urine protein: 200
After 1 hour of counselling, the
as evidenced by health patient will have knowledge on
coping stress or anxiety and
apply it.
After 48 hours, the patient
portrays positive attitude, looks
calm and relaxed.
Monitor vital signs of the patient
Listen to the patient’s woes
attentively.
Teach patient breathing exercises
Advise patient on diet and
lifestyle.
DEPENDENT
Administer medication as per
doctor’s order.
COLLABORATIVE
Refer to a specialist
heart rate and pulse can be calm, relaxed talking to the
indication of the body’s response nurses.
to stress. The patient has
preeclampsia and the vital signs The patient will report that
serve as the baseline for the she rest well enough at
severity of disease. night.
Giving assurance to the patient The patient will follow the
by listening and answering her discharge plan.
queries will make the patient
trust and cooperate with nurses
for speedy recovery.
Helps improve blood circulation
and boost mood of the patient.
Drinking milk, avoiding heavy
meals at nightime, walking for 5-
10 minutes can help to sleep
better.
Medications such as melatonin is
can temporarily help to sleep.
If anxiety persist after discharge
from hospital, a specialist can
help diagnose for underlying
problems (insomnia)
 EMILIO AGUINALDO COLLEGE
School of Nursing

NURSING CARE PLAN

NAME: _______________________ PATIENT INITIAL: AGE: DATE:
STUDENT #: DIAGNOSIS: Multiple myoma uteri vs ovarian new growth, non malignant GENDER: F ROOM NO.

ASSESSMENT NURSING DIAGNOSIS PLANNING NURSING INTERVENTION RATIONALE EVALUATION

Subjective: INDEPENDENT The vital signs should return The patient will follow the
The patient has fibroids Acute pain related to After 48 hours, the patient will Monitor vital signs of the patient within normal range or stabilizes discharge plan.
detected in the uterus and TAHBS procedure have knowledge on pain due to blood loss during the
undergoes surgery management surgery.
(TAHBS)
After 3-5 days, the patient will
Objective: able to move freely, have bath Monitor intake and output of the To assess the patient’s digestion
Conscious and coherent and return to regular diet. patient and difficulties in urinating and
peeing. The patient remains in
Vital signs: NPO diet until IV fluids
BP:120/80 discontinued. To assess the
Pulse: 75 bleeding.
RR: 17
Ostat: 99 Advise patient to bed rest and The patient should not lift heavy
Lab results: relaxation techniques objects, the patient should deep
Hemoglobin: 122 breathing exercises, use heating
MCHC: 312 pad to relieve abdominal pain
Platelet: 490
Neutrophils: 0.703 Teach patient on wound dressing Proper wound dressing would
Blood type: “B” RH minimize the risk for infection.
positive DEPENDENT
Administer medication as per
doctor’s order. Medications will help for speedy
recovery process of the patient.
COLLABORATIVE
Follow up OBGYNE for check up Visit the obgyne for follow up
and results check up after surgery.
 EMILIO AGUINALDO COLLEGE
School of Nursing

NURSING CARE PLAN

NAME: _______________________ PATIENT INITIAL: AGE: DATE:
STUDENT #: DIAGNOSIS: G5P5 pelvoabdominal mass vs ovarian new growth, malignant GENDER: F ROOM NO.

ASSESSMENT NURSING DIAGNOSIS PLANNING NURSING INTERVENTION RATIONALE EVALUATION

Subjective: NDEPENDENT The vital signs should return The patient will follow the
The patient has fibroids Acute pain related to After 48 hours, the patient will Monitor vital signs of the patient within normal range or stabilizes discharge plan
detected in the uterus and TAHBSO procedure have knowledge on pain due to blood loss during the
undergoes surgery management surgery.
(TAHBSO)
After 3-5 days, the patient will
able to move freely, have bath Monitor intake and output of the To assess the patient’s digestion
Objective: and return to regular diet. patient and difficulties in urinating and
Conscious and coherent peeing. The patient remains in
Vital signs: NPO diet until IV fluids
BP:110/80 discontinued. To assess the
Pulse: 72 bleeding.
RR: 16
Ostat: 97 Advise patient to bed rest and The patient should not lift heavy
Temp: 36.0 relaxation techniques objects, the patient should deep
Lab results: breathing exercises, use heating
Hemoglobin: 110 pad to relieve abdominal pain
Hematocrit: 36.4
MCH: 25.8 Teach patient on wound dressing Proper wound dressing would
Platelet: 484 minimize the risk for infection.
Eosinophils: 0.054 DEPENDENT
Blood type: “B” RH Administer medication as per
Positive serial number: doctor’s order. Medications will help for speedy
1799-0080495 recovery process of the patient.
COLLABORATIVE
Follow up OBGYNE for check up Visit the obgyne for follow up
and results check up after surgery