University of St.

La Salle NURSING CARE PLAN

Assessment Actual / Abnormal Findings:

Nursing Diagnosis

Rationale

Desired Outcomes

Nursing Intervention

Justification of Care

Evaluation After 8 hours of nursing intervention, the client was able to: 1. Goal met. The

Hematology Result: Hct- 0.13 L/L Hgb- 41g/L RBC-1.49 10^12/L Pale conjunctiva Pale nail beds General appearance Pale Presence of pain during exertion at the lower back and cervico-uterine area

Impaired tissue integrity R/T cervical intraepithelial lesion AEB severe blood loss, presence of lesion, pain and decreased hematologic count

Predisposing Factors: Exposure to HPV through early sexual intercourse (age of 14) Presence of precursor lesion DNA cell mutation Precipitating Factors: Impaired immune

Definition: Damage to surveillance mucous membrane, corneal, Delayed diagnostic integumentary, or findings of lesion subcutaneous tissues.

After 8 hours of nursing Independent: intervention, the client 1. Identify underlying 1. To identify what are will be able to: condition or tissues involved pathology involved 1. Verbalize in tissue injury. understanding of 2. Identify the specific 2. To identify condition and behaviors, such as causative factors. causative/contribut occupational hazards ing factors. or toxic exposures; sport leisure activity risks; lifestyle 2. Demonstrate choices; or use of behaviors and restraints or lifestyle changes to prosthetic devices. promote healing 3. Note poor hygiene or 3. That may be health practices. and prevent impacting tissue

complications or recurrence.

Strength: Family Support Source: Deonges, M. Weakness: Financial E., Moorhouse, M. F., Support & Lack of & Murr, A. C. knowledge about the (2011). Nurse's Pocket condition Guide: Diagnoses, Prioritized Interventions, and Rationales (12 ed.). Philadelphia: F.A.

Abnormal cellular mutation

Abnormal process of cell proliferation and apoptosis

client was able to verbalize to have enough bed rest for a timely wound healing of the lesion while palliative treatment is given. 2. Goal met. Client E.R was able to demonstrate adequate lifestyle health. changes in terms of 4. Encourage adequate 4. To limit metabolic proper diet and periods of rest and maintenance of demands, sleep. proper hygienic maximize energy practices. available for healing, and meet comfort needs. 5. To optimized 5. Emphasize need healing potential. for adequate nutritional and fluid intake

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After 4 days of nursing intervention, the client Collaborative: 6. Modify or eliminate 6. To assist client to will be able to: Presence of CA cell growth in factors contributing 3. Display minimize the transformation zone to condition, if progressive impairment and to possible. Assist with improvement in promote wound treatment of Damage tissue wound or lesion healing. underlying healing. condition, as
Asymptomatic Intermittent pain, bleeding,

appropriate. 7. Monitor laboratory studies.

After 4 days of nursing intervention, the client was be able to: 3. Goal not met. The client still manifested vaginal spotting, indicating the presence of a lesion.

Impaired tissue integrity.

8. Administer

medications as prescribe by physician.

Source: Johnson, J. Y. (2010). Handbook for Brunner & Suddarth's textbook of medical-surgical nursing. Philadelphia: Wolters Kluwer/Lippincott Williams & Wilkins Medscape: Medscape Access. (n.d.).Medscape: Medscape Access. Retrieved July 25, 2012, from http://emedicine.medscape.co m/article/170283overview#a0104

7. Changes indicative of healing or presence of infection, complications. 8. To promote healing and lessen the symptoms of the condition.

Source: Deonges, M. E., Source: Deonges, M. Moorhouse, M. F., & Murr, A. C. E., Moorhouse, M. (2011). Nurse's Pocket F., & Murr, A. C. Guide: Diagnoses, (2011). Nurse's Prioritized Interventions, Pocket Guide: and Rationales (12 ed.). Diagnoses, Philadelphia: F.A. Davis. Prioritized Interventions, and Rationales (12 ed.). Philadelphia: F.A. Davis.

NCP 3 out of 3