NURSING CARE PLAN

Name:
Age:

Ms. M.B.O

Hospital No: 108521

35 yrs. old

Room No: ABW 8

Impression/ Diagnosis: Normal Spontaneous Vaginal Delivery

Clinical Portrait

Pertinent Data

Physician: Dr. Atoc

ASSESSMENT:
During my first contact with the patient,
she was
seen lying on
bed, awake conscious and afebrile
without an
IVF. She was
cooperative during care activity made to
her.

HISTORY OF PRESENT ILLNESS:

Prior to admission, the patient was admitted to the hospital due to
vaginal watery discharge. Her vital signs were taken as soon as she
arrived in the hospital with the result of not enlarged antracted
minimal, well coaptaled, 110/70 mmHg and clinically stable. Chief
Complaints: Pregnancy which delivered vaginally alive baby girl .

SIGNIFICANT FINDINGS:
Patient verbalizes that she is in pain due CHIEF COMPLAINTS:
to
episiotomy. She expressed that she is
Patient came in due to vaginal watery discharge.
happy
because she delivered her baby
normally.
HEALTH HISTORY RELEVANT TO PRESENT
VITAL SIGNS TAKEN DURING FIRST
ILLNESS :
CONTACT:
BP- 100/70 mmHg
PR- 97 bpm
T- 35.4 C
RR- 17 cpm
No previous hospitalization.

VITAL SIGNS TAKEN DURING ADMISSION:

NURSING DIAGNOSIS:
1. Impaired Urinary Elimination
BP- 110/70 mmHg
PR- 100 bpm

2. Acute Pain

T- 36.4 C
RR- 22 cpm

3. Activity Tolerance
4. Impaired Skin Integrity
5. Risk for Infection

LABORATORY RESULTS REGARDLESS OF FINDINGS

URINALYSIS

TEST

RESULT

NORMAL
VALUUES

REMAKRS

COLOR

Light
yellow

Straw
amber

APPEARANCE

Slightly
cloudy

Clear

Appearance of urine is
slightly cloudy

pH

6.5

4.6 8.0

pH is within normal
values

SPECIFIC
GRAVITY

1.005

1.005
1.030

/ Color of the urine is

slightly yellow

Specific
within
Values

gravity is
normal

PROTEIN

Negative

Negative

No protein found in
the urine

GLUCOSE

Negative

Negative

No glucose found in
the urine

COMPLETE BLOOD COUNT

TEST

RESULT

NORMAL
VALUES

UNITS

SIGNIFICANT
FINDINGS

WBC

15.0

5 - 10

X10^9L

Leukocytosis

RBC

4.63

4.00 - 5.50

X10^12/L

Normal

HEMOGLOBIN

14.3

12.0 16.0

g/L

Normal

HEMATOCRIT

39.2

37 47

Normal

MCV

84.6

76 96

FL

Normal

MCH

30.9

27 32

Pg

Normal

MCHC

36

32 36

g/ dL

Normal

PLATELET
COUNT

201

150 450

X10^9/L

Normal

NEUTROPHILS

71

45 75

Normal

LYMPHOCYTES

19

20 40

Normal

MONOCYTES

2 10

Normal

EOSINOPHILS

0.0 5.0

Normal

BASOPHILS

0.0 2.0

Normal

NURSING CARE PLAN

CUES

NURSING

SCIENTIFIC GOAL

DIAGNOSIS

BASIS

OUT

AND NURSING
COME ACTIONS

CRITERIA

AND

RATIONALE
OF NURSING
ORDERS

EVALUATION

NURSING
ORDERS

SUBJECTIVE

Hyperthyroi

After

dism is on

hours

Fatigue

Dali ra ko
kapoyon,

hypermetabo

paminaw na
ko nangloya
ko. as

l
ic state with
increased

verbbalized
by

related to

energy

the requirement

client.

OBECTIVE :

s.

over
production
of thyroid

8 Nursing
of action :rend
er

intervention

easures help fatigue

, the portion full

of

nursing
, intervention

sleep

the

patient

was

tolerate energy level deprivation , able

of

which

activities

patient

metabolic

can hours

in including

will be able increasing

to

After

nusring aggrovate

the

reaching

Factor

nursing

hormone,

creates far

Multiple

within

the emotional

level tolerate

of

own activities

ability.
A.Identify
negative

effects.

factors

Hypertroph

performance

affevting

level

to distress

to

display
improved

process

ability

(Doenges :

participate

of ow 200187)

abillity.

in

desired

activities.

Nursing

-Help

orders.

counteract
effects of in
erased
metabolism.

to

-Decreased
Performanc
e.

y and
hyperplasia
of te tyroid

1. Encourage
patient

gland most

-Irritability
-V/S akn as
follows :
Temp :
36.8C

PR

90

bpm
RR : 21 cpm
BP : 120 /80
mmHg

to

restrict

Reduces
activity and
Develope
of the
stimuli that
on
activity rest in bed may
clinical
and
rest as much as aggrovate
manifestatio pattern that possible.
agitetion
,
n
result promotes
hyperactivit
B.

from

optimal

increased

independent

metabolic

independenc

rate.

Excessive
heat
The

quiet

insomia.

and

envirenmat,

womaen level.

sensory

stimuli,

-CAdapt

condition is lifestyle
more often inreasd
in

-Pulse
and cool
room
typically
minimizes
decreased
fatigue.

production.

2.Provide

to

soothing
colors.

is

elevated and
even at rest.
(Nureses
pocket
Guide

13th

Ed . 2013)

than

men

occurs

in

3.
vital

Monitor
signs.

several form.

Nothing

(mosbys

pulse rate at

Pocket

rest

Dictionary ,

when active.

6th
2010)

Edition

and

CUES

NURSING
DIAGNOSIS

SCIENTIFIC
BASIS

GOAL
AND
OUTCOME
CRITERIA

NURSING
ACTIONS
AND
ORDERS

RATIONALE EVALUATIO
OF
N
NURSING
ORDERS

Subjectiv Constipatio
e:
n related to
decreased
Di
ra dietary
kayo
ko intake.
tig
kalibang
sukad pa
sa
ni
aging
adlaw
as
verbalized
by
the
client.
Objective:
Abdominal
pain
-Altered
bowel
sounds
-V/S taken
as follows:

Constipati
on
is
a
very
common
condition
that
affects
people of
all
ages.
When you
are
constipate
d you feel
that
you
are
not
passing
stools
as
often
as
your
normally
do, or that
you
have
to
strain
more than
usual
or
that
you

After
8
hours
of
rendering
appropriat
e nursing
interventio
n
the
patient will
establish
or
regain
normal
pattern of
bowel
functionin
g
specifically
the patient
will
be
able to:

Independe
nt:
1.
Determine
stool color,
consistenc
y,
frequency
and
amount.

-Assist
in
indentifyin
g
causative
or
contributin
g
factors
and
appropriat
e
interventio
ns.

After
8
hours
of
nursing
interventio
s
thr
patient
was
able
was
able
to
establish
or
return
2.
to normal
Auscultate
patters of
bowel
-Bowel
the qowel
movement/ sounds are functionin
sounds
generally
g.
decreased
3.
in
Encourage constipatio
fluid intake n.
of
2500Participate 3000
-Assists in
in
bowel mL/day
improving
program
within
stool
as
cardiac
consistenc
indicated.
tolerance
y.

Temp: 37.
C
PR:
85
bpm
RR:
19
cpm
BP: 120/80
mmHg

unable to
completely
empty
your
bowels.
Constipati
on can also
cause your
stool
hard
,
lumpy
large
or
small. The
severity of
constipatio
n can vary
greatly
many
people
only
experience
constipatio
n
for
a
short
period
of
time with

- verbalize
under
standing
of etiology
and
appropriat
e
interventio
n
or
solutions
for
individual
situation.
Demonstra
te
behaviors
of lifestyle
changes to
prevent
recurrence
of
problem.

4.
Recommen
d avoiding
gas
forming
foods

-Decrease
gastric
distress
and
abdominal
distension.

5.
Assist
perineal
skin
condition
frequently
,
noting
changes or
beginning
breakdown
.

-Prevents
skin
axcoriation
and
breakdown
. (Nurses
Pocket
Guide 13th
Ed
2013)

Collaborati
ve:
administer
medication
s, such as
stool

-Promotes
formation
and
passage of
softer
stool .

no lasting
effects on
their
health.
(Pilitteri
20117:510
)

-Verbalize
her
elimination
pattern.

softeners,
mineral oil
as
indicated.

CUES

NURSING
DIAGNOSIS

SCIENTIFIC
BASIS

GOAL
AND
OUTCOME
CRITERIA

NURSING
ACTIONS
AND
ORDERS

RATIONALE EVALUATIO
OF
N
NURSING
ORDERS

Subjecti Hyperther
ve:
mia related
to
Init
dehydratio
akong
n.
paminaw,
lain akong
lawas
as
verbalized
by
the
patient.
Objectiv
e:
-Flushed
skin
,
warm
to
touch.

Hyperther
mia
or
commonly
known as
fever
is
present
when the
body
temperatu
re
is
higher
than 37C
which can
be
measured
orally, buy
37.7C
if
measured
per
rectum. It
occurs
when the
body
is
invaded by
some
bacteria,vi

After
8
hours
of
nursing
interventio
ns,
the
client/pati
ent will
-Maintain
core
temperatu
re
within
normal
range.
-Client will
be
free
from
febrile
convulsion
s resulting
to
brain
damage
after
1
week
of
nursing

-Encourage
client
to
increase
fluid
intake.
-Apply
tepid
sponge
bath.

-Water
regulates
body
temperatu
re.

-It
could
help
in
reducing
hyperther
mia ; avoid
-Adjust
using
and
alcohol
monitor
and
iced
environme water
ntal
which may
factors like even
room
produce
temperatu chills and
re and bed increase
linens
as clients
indicated.
temperatu
re.
-Provide
cooling
-Room
blanket as temperatu

After
8
hours
of
nursing
interventio
ns,
the
patient
was
able
to
maintain
core
temperatu
re
within
normal
range.

ruses,
or care.
parasites.

Sometimes
the
occurance
of
fever
may
also
be due to
noninfectious
factors
hike injury,
heat
stroke
or
dehydratio
n.
(Pilitteri:2
0017510)

-Client will
be able to
report and
show
manifestar
ions
that
fever
is
relieved.
Temperatu
re
of
36.8C per
axilla
repiratory
rate of 1218 breaths
per
minute,
pulse rate
of
60-75
per

indicated.

re may be
accustome
d to near
normal
body
temperatu
re
and
blankets
and linens
may
be
adjusted
as
indicated
to regulate
temperatu
re
of
client.
-It
is
helpful in
reducing
increased
body
temperatu
re
especially

minute,
stable
blood
pressure.

with
temperatu
re of 3940C
.
(Piliterri :
20017510)
`