NURSING CARE PLAN

Patient: Duremdes, Susie Anne Marie,Sacol Hospital No: 305863

Age: 24years old Room No: OB- Ward-221
Impression: 39 4/7 weeks A06 Cephalic, Physician: Dr. Miro
teenage pregnancy Nurse Signature: Mulleta, Alona B.,
Diagnosis: Pregnancy uterine full term
delivered spontaneously to a live
baby girl in cephalic presentation

CLINICAL PORTRAIT PERTINENT DATA

ASSESSMENT. HISTORY OF PRESENT ILLNESS.

During my first contact with my patient, she was seen lying in bed beside
her newborn baby boy that was asleep also. After few minutes, she woke up.
She’s conscious, coherent, cooperative and a febrile. In patient’s unit, they have
many things that they brought like pillows, bags, foods and etc. Patient appears
restless.
A case of S,A,M,D, 24 years old, single, Roman Catholic, Filipino, from
Cebu City was admitted for the first time at Visayas Community Medical
Center on July 24, 2009 due to labor pains. Patient is non-diabetic, non-
hypertensive, non-smoker, and non-alcoholic beverage drinker. She has no
known food or drug allergies.

SINIFICANT FINDINGS. CHIEF COMPLAINTS.

Patient verbalized that she was happy after she had given birth with a baby Patient came in for labor pain.
boy. At the same time she was a little bit frustrated because her baby was not
yet in her bedside for the reason that her baby has complication.

VITAL SIGNS TAKEN DURING THE NURSE'S FIRST CONTACT WITH HEALTH HISTORY RELEVANT TO PRESENT ILLNESS.
THE PATIENT.

BP: 120/80 No previous hospitalization.

T: 37.3 degrees Celsius
P: 96 bpm
R: 19 cpm
5 PRIORITIES OF RAW PROBLEM. VITAL SIGN TAKEN DURING ADMISSION.
1.) Pain
2.) Sleepless times BP: 130/90 mmHg
3.) Restlessness T: 36.9 degrees Celsius
4.) Lack of knowledge P: 89 bpm
5.) Anemic R: 21 cpm

Among the 5 problem that are listed, I prioritized 3 problems. That for me, as
what I’ve studied the condition of the patient it is the major problem that needs
attention. And this are: 1.) pain
2.) sleepless times
3.) restlessness
LABORATORY RESULTS:

WBC - 3400 mm3 = 5000-1500 mm3 HCT -38.8% =>33%

NEUT - 32.8 % = 60-85% MCV -78.1 mm3 =80-95 mm3
LYMP - 1.16 % = 15-40% MCH -25.4 pg =27-31 pg
MONO - .063 % = 2-9-8% RDW-SD-16.6% =11-14%
EOS - .013 % = 1-4% RDW-CV-17.3% =11-14%
BASO - .00 % = .5-1% MPV -5.82 fl =7.4-10.4 fl
RBC - 4.79x 106/uL = 5-6.25 x 106/Ul HGB -12.6g/dl =>11g/dl

HBEAg = Non-reactive
Bloodtype = “A” positive
 NURSING CARE PLAN

CUES/ NURSING SCIENTIFIC GOAL AND NURSING ACTIONS AND RATIONALE OF EVALUATION
EVIDENCES DIAGNOSIS BASIS OUTCOME CRITERIA NURSING ORDERS NURSING ORDERS
SUBJECTIVE Alteration in Tissue traumatized After 8 hours of rendering NURSING ACTION: After 8 hours of
CUE: comfort: Pain or injured sends appropriate nursing Perform nursing care and rendering nursing
“sakit ang related to pain impulses to interventions, the client procedures to alleviate pain. intervention, the
akong tinahian tissue trauma 2 the brain. The will be relieved from pain. pain was
kung grabe ko degrees to stimuli are relieved.
molihok” episiotomy transmitted along OUTCOME CRITERIA: NURSING ORDERS:
OBJECTIVE the nerve fibers 1.)Patient will verbalized Independent: 1.)Assessment enables
CUES: and travel along reduction of pain from a 1.)Asses and reassess and the nurse to evaluate
1.)Rates pain the spinal cord and scale of 6/10 to 2/10 (0-no document the clients verbal pain (Doenges, 10th
with an ascend towards the pain; 10-worst possible and non-verbal cues edition; p. 389)
intensity of 6/10 hypothalamus- pain)
on a pain scale, reticular formation. 2.)Assess specifics of pain like 2.)Facilitates diagnosis
0-no pain and Interpretation and the location, characteristics, of problem and
10-worst localization of pain intensity, onset and duration initiation of appropriate
possible pain is thought to occur therapy (Doenges, 10th
2.)Facial at the cerebral edition; p. 389)
grimaced noted cortex, this part of
during changes the brain which 3.)Monitor vital signs 3.)Vital signs are
in position such interprets the altered during acute
as from sitting quantity and pain (Doenges, 10th
to standing quality of pain. edition; p. 389)
3.)Guarding (Guyton, 1999;p.
behavior noted 123) Lacerations 4.)Assist in proper positioning 4.)Enables to
by placing her of the perineum minimized pain if
by hand near the usually occur when assisted (Doenges, 10th
perineal area a woman is placed edition; p. 389)
everytime she in lithotomy 2.)Patient will Independent:
moves position for birth, demonstrate the use of 1.)Encourage use of relaxation 5.)Relieves muscle and
4.)Limited because this relaxation techniques techniques such as deep emotional tension
movements position increases breathing exercises, imagery (Doenges, 10th edition;
observed tension on the and visualization and music p. 389)
5.)Irritability perineum. Perineal
noted lacerations
 CUES/ NURSING SCIENTIFIC GOAL AND NURSING ACTIONS AND RATIONALE OF EVALUATION
EVIDENCES DIAGNOSIS BASIS OUTCOME CRITERIA NURSING ORDERS NURSING ORDERS
6.)Intake of pain are sutured and 3.)Patients will verbalize Independent: 6.)Refocuses attention,
reliever treated as an 3 methods that provide 1.)Provide diversional may enhance coping
(mefenamic- episiotomy repair. pain relief activities like reading abilities (Doenges, 10th
dolfenal) Make certain that magazines, watching a TV edition; p. 389)
the degree of the program and visiting the baby
laceration is at the nursery room
documented,
because afterward 2.)Provide other comfort 7.)Improves circulation,
it is often difficult measures such as back rubs, decrease muscle tension
to distinguish a massage, change of position and anxiety associated
repaired perinel and turning with pain (Doenges,
laceration from an 10th edition; p. 389)
episiotomy repair Dependent:
on insrection. 1.)Administer medication as 8.)To aid in healing to
Lacerations and prescribed by the physician stop the synthesis of
episiotomies tend prostaglandin
to heal in the same (Doenges. 10th edition;
length of time. p. 389)
(Pilliteri,5th
edition; p.661)
 NURSING CARE PLAN

CUES/ NURSING SCIENTIFIC GOAL AND NURSING ACTIONS AND RATIONALE OF EVALUATION
EVIDENCES DIAGNOSIS BASIS OUTCOME CRITERIA NURSING ORDERS NURSING ORDERS
SUBJECTIVE Disturbed The importance of After 8 hours of rendering NURSING ACTION: After 8 hours of
CUE: Sleeping rest throughout the appropriate nursing Perform nursing care and rendering
“kapoy ug Pattern entire puerperium intervention, the patient procedure to make patient fall appropriate
katulugon kaayo related to cannot be stressed will fall asleep. asleep. nursing
ko” evident enough because the intervention, the
OBJECTIVE stressors new born will wake OUTCOME CRITERIA: NURSING ORDERS: patient had slept.
CUES: at least twice a 1.)The patient will Independent:
1.)Drooping eyes night and demands verbalized understanding 1.)Observed parent – infant 1.)Lack of knowledge
observed his/her needs. And of sleep disturbance interactions/provision of of infant cues/problem
2.)Changes in also, if a woman emotional support relationships may
behavior and has discomfort create tension
performance from hemorrhoids, interfering with sleep
(increasing perineal stitches, or (Doenges,10th edition;
irritability, after pains, be sure p. 504)
disorientation, she use pain
listlessness) reliever because if 2.)The patient will 2.)Discuss/implement 2.)Enhance clients
3.)Expressionless not she cannot identify individually Effective age – appropriate ability to fall asleep
face sleep comfortably appropriate intervention bedtime rituals such as (Doenges,10th edition;
4.)Frequent or just sleep. With to promote sleep drinking warm milk, rocking, p. 504)
yawning this it is really hard and story reading
5.)Ptosis of for her to sleep Independent:
eyelid enough especially
6.)Slight band she feels pain and 1.)Determine client/SO’s 3.)Provides opportunity
tremor her responsibility to expectations of adequate sleep to address
7.)Intake of pain take care of her misconceptions/
reliever new born baby or unrealistic expectations
(mefenamic- give his/her (Doenges,10th edition;
dolfenal) demand or needs. p. 504)
(Pilliteri,5th edition;
p.640)
 CUES/ NURSING SCIENTIFIC GOAL AND NURSING ACTIONS AND RATIONALE OF EVALUATION
EVIDENCES DIAGNOSIS BASIS OUTCOME CRITERIA NURSING ORDERS NURSING ORDERS
2.)Assist client to develop 4.)Enhances ability to
individual program of fall asleep that it
relaxation techniques like relieves muscle and
biofeedback, visualizations emotional tension
and progressive muscle (Doenges,10th edition;
relaxation p. 504)

3.)Encourage SO’s to help the 5.)Can make the patient

patient in caring and giving fall asleep when the
the demands of the baby SO’s are there if they
sleep (Doenges,10th
edition; p. 504)

3.)The patient will report Independent: 6.)Determine peak

increased sense of well 1.)Do a chronological chart performance rhythm
being and feeling rested (Doenges,10th edition;
p. 504)

2.)Observed or obtain 7.)Determine usual

feedback from client or SO’s pattern and provide
comparative baseline
(Doenges,10th edition;
p. 504)

Dependent:
1.)Administer pain 8.)Relieve discomfort
medications as prescribed by and take maximum
the physician advantage of sedative
effect (Doenges,10th
edition; p. 504)
 NURSING CARE PLAN
CUES/ NURSING SCIENTIFIC GOAL AND NURSING ACTIONS AND RATIONLE OF EVALUATION
EVIDENCES DIAGNOSIS BASIS OUTCOME CRITERIA NURSING ORDERS NURSING ORDERS
SUBJECTIVE Fatigue related Because labor is After 8 hours of rendering NURSING ACTION: After 8 hours of
CUE: to increased work, it can cause appropriate nursing Perform nursing care and rendering
“wa na jud koy physical a woman to intervention, the patient procedures to help patient gain appropriate
kusog, kapoy exertion deplete her will gain energy. energy. nursing
kaayo” during labor glucose stores. On intervention, the
OBJECTIVE and delivery a clients OUTCOME CRITERIA: NURSING ORDERS: patient gained
CUES: admission to a 1.)The patient will report Independent: energy.
1.)Restlessness birthing room, improved sense of energy 1.)Note daily energy patterns 1.)Helpful in
noted assess the determining pattern/
2.)Drowsiness likehood of timing of activity
observed; glucose depletion (Doenges,10th edition;
lethargic or by asking the time p. 243)
listless of her last meal.
3.)Compromised Although the 2.)Plan care to allow 2.)Maximize
concentration effect of emotion individually adequate rest participation (Doenges,
4.)Decreased on labor is periods. Schedule activities for 10th edition; p. 243)
performance difficult to periods when client has the
5.)Expressionless document, it most energy
face seems that the
6.)Limited cervix dilates 2.)The patient will Independent:
movements or more rapidly and identify basis of fatigue 1.)Evaluate aspect of “learned 3.)Can perpeturate a
limited changing therefore normal and individual areas of helplessness” that may be cycle of fatigue,
of position labor is shortened control manifested by giving up impaired functioning,
observed if a woman is and increased anxiety
7.)Intake of iron neither tense nor and fatigue (Doenges,
supplements frightened. And in 10th edition; p. 243)
(ferrous sulfate) order for the fetus
to be out in the 2.)Discuss lifestyle changes/ 4.)Enables the patient to
placenta of the limitations imposed by fatigue cope with fatigue and
mother, it really state gains energy (Doenges,
needs a lot of 10th edition; p. 243)
force/energy. This
is now the reason
why mothers who
are from the
delivery room,
 CUES/ NURSING SCIENTIFIC GOAL AND NURSING ACTIONS AND RATIONALE OF EVALUATION
EVIDENCES DIAGNOSIS BASIS OUTCOME CRITERIA NURSING ORDERS NURSING ORDERS
they really feel 3.)Assist client to identify 5.)Promotes sense of
weak and tired. appropriate coping behaviors control and improves
(Pilliteri,5th edition; self-esteem (Doenges,
p.593) 10th edition; p.243)

4.)Provide environment 6.)Temperature and level

conducive to relief of fatigue of humidity are known
to affect exhaustion
(Doenges, 10th edition;
p. 243)

3.)The patient will Independent:

participate in 1.)Establish realistic activity, 7.)Enhances
recommended treatment goals with client commitment in
program promoting optimal
outcomes (Doenges, 10th
edition; p.243)

2.)Instruct in methods to 8.)Makes the patient

conserve energy like sitting gain energy/ there’s less
instead of standing during effort (Doenges, 10th
activities/ shower; plan steps edition; p. 243)
of activity before beginning so
that all needed materials are at
hand

Dependent:
1.)Administer supplements as 9.)Enables the patient to
prescribed by the physician gain energy (Doenges,
10th edition; p. 243)