LORMA COLLEGES CONTEMPLATE

NCM 107 RELATED LEARNING EXPERIENCE

NURSING CARE PLAN

Students Name: CABADING, Twinkle Mae M. Rotation: 3rd Area: Obstetric Ward

YR LEVEL AND SEC BSN II Lewin Date: March 7,8,9, 2022 Clinical Instructor: Mrs.
Mariflor Ocampo

NURSING Pregnancy Induced Hypertension Medical Diagnosis: High-risk Pregnancy

PROBLEM:
PIORITIZATION: 1st Date: March 7,8,9, 2022

Assessment Nursing Diagnosis Planning Implementation Rationale Evaluation

Subjective: Decreased cardiac Short Term: Independent  To have a Short term goal was
Client complains output related to After 8 hours of  Assess and baseline met after 8 hours of
for severe heart increased systemic nursing monitor vital data. nursing intervention,
burn occurred vascular resistance intervention, the signs as well  To establish blood pressure
suddenly before 1- secondary to PIH, blood pressure will as the weight a trusting decreased.
2 hours as evidenced by decrease. and conduct relationship
accompanied with an average blood physical and let the Long term goal is
three episodes of pressure level of Long Term: examination. woman partially met, the
vomiting and 180/110 mmHg, After 4 days of  Provide voice out cardiac output was
headache. pitting edema and nursing emotional her fears. improved however, it
Objective: periorbital edema. intervention, the support  To have might decrease again
High blood patient will have an  Provide enough rest in the succeeding
pressure was improve cardiac frequent rest and to lower days after discharge.
obtained: 180/110 output through periods with blood
mmHg well-controlled bed rest. pressure
140/90 mmHg blood pressure  Provide calm, levels and
130/80 mmHg level throughout restful improve
the remainder of surrounding, cardiac
her pregnancy. minimize rate.
environmental  To promote
activity or relaxation
noise  To lower
Dependent blood
 Administer pressure
anti- levels.
hypertensive  These
drug as restrictions
prescribed. can help in
Collaborative: alleviating
 Coordinate to the
the nutritionist situation.
for dietary
sodium, fat
and
cholesterol
restictions.
 NURSING Vomitting Medical Diagnosis: High-risk Pregnancy
PROBLEM:
PIORITIZATION: 2nd Date: March 7,8,9, 2022

Assessment Nursing Diagnosis Planning Implementation Rationale Evaluation

Subjective: Nutrition  After 8 Independent  Assessing  Both short
Client complains imbalanced less hours of  Determine the patient and long term
for severe heart than the body nursing causes of with the was met.
burn occurred requirements intervention vomiting. causes of After 8 hours
suddenly before 1- related to nausea the client  Monitor the vomiting will of nursing
2 hours and vomiting. will report weight of the guide the intervention
accompanied with less client. choice of the client will
three episodes of episode of  Instruct the interventions. reported less
vomiting and vomiting. patient to  To make sure episode of
headache. have a bed that her vomiting.
Objective:  After 4 rest. weight is After 4 days
High blood days of  Instruct the appropriate of nursing
pressure was nursing patient to as pregnant. intervention
obtained: 180/110 intervention avoid foods  So that the the client
mmHg the client that might patient will be weight
140/90 mmHg weight will exacerbate able to relax increased.
130/80 mmHg increased. the situation and it helps
Temp-37.0 like to avoid
RR-20 bpm caffeinated vomiting.
PR of 127 bpm. beverages.  To reduce
 The client  Encourage gastric
appears the client to stimulation
uncomforta drink plenty of and vomiting
ble. water. response.
Collaborative  To avoid
 Refer to dehydration
dietrician for  To gradually
modification of stimulate
diet. appetite.
 NURSING Headache Medical Diagnosis: High-risk Pregnancy
PROBLEM:
PIORITIZATION: 2nd Date: March 7,8,9, 2022

Assessment Nursing Diagnosis Planning Implementation Rationale Evaluation

Subjective: Acute pain related  After 1  Perform pain  To  The goal was
Client complains to headache. hour of assessment determine met. After 1
for severe heart nursing and evaluate the hour of
burn occurred intervention characteristic underlying nursing
suddenly before 1- , the client of pain. cause of intervention
2 hours will report  Perform complication the patient
accompanied with decrease of comfort  To promote reported
three episodes of pain. measures pain decreased
vomiting and  After 4 days such as management pain.
headache. of nursing positioning and reduce  After 4 days of
Objective: intervention the patient on tension. nursing
High blood the client a comfortable  It empowers intervention
pressure was will be free position. patient to client reported
obtained: 180/110 from  Assist the provide relieved pain.
mmHg headache. patient to preventive
140/90 mmHg identify ways measures
130/80 mmHg to prevent independentl
Temp-37.0 and relieve y.
RR-20 bpm symptoms.  Radiation
PR of 127 bpm.  Instruct the can
patient to increased
avoid exposur the pain,
e to radiation.  To help
 Administer alleviate the
medication as pain.
ordered.