Nursing Round Plan

Objectives:

The leader of the nursing round

Health assessment

1. Data collecting
1.1. General information
Gender Female age 23 Years old
Ward 2B Labour wars Marital status Married National Thailand
Occupation Housewife Education Not Available
Date of admission 23/09/2017
First diagnosis Antepartum with PPROM (36 weeks pregnancy)
The final diagnosis NL (Normal Labour)

1.2 Illness History

Patients said she had no previous disease history
Patients said the family had no previous history of illness either from the
husband or herself
1.3 Family history and family tree

Patient

1.4 Health assessment based on 11 functional health patterns

1.4.1 Health perception and health management Commented [1]: You may add more info related to
1.4.1.1 Subjective data health perception
1.4.1.2 Objective data
1.4.1.3 Assessment
1.4.1.4 Nursing diagnosis

1.4.2 Nutritional metabolic

1.4.2.1 Subjective data
1.4.2.2 Objective data
1.4.2.3 Assessment
1.4.2.4 Nursing diagnosis

1.4.3 Elimination
1.4.3.1 Subjective data
 1.4.3.2 Objective data
1.4.3.3 Assessment
1.4.3.4 Nursing diagnosis

1.4.4 Activity exercise

1.4.4.1 Subjective data
1.4.4.2 Objective data
1.4.4.3 Assessment
1.4.4.4 Nursing diagnosis
1.4.5 Sleep rest
1.4.5.1 Subjective data
1.4.5.2 Objective data
1.4.5.3 Assessment
1.4.5.4 Nursing diagnosis

1.4.6 Cognitive-perceptual
1.4.6.1 Subjective data
1.4.6.2 Objective data
1.4.6.3 Assessment
1.4.6.4 Nursing diagnosis

1.4.7 Self perception/self concept Commented [2]: I think this info would be health
1.4.7.1 Subjective data perception rather than self perception.
Patient feeling of inadequacy
Patient said she worried about the baby health.
Patient did not know how long she will be in hospital.
1.4.7.2 Objective data
The baby has give phototherapy treatment for his bilirubin
status.
Patient Insomnia because factor new baby (G1P1).
1.4.7.3 Assessment
1.4.7.4 Nursing diagnosis
Dx. Anxiety

1.4.8 Role relationship

1.4.8.1 Subjective data
1.4.8.2 Objective data
1.4.8.3 Assessment
1.4.8.4 Nursing diagnosis

1.4.9 Sexuality reproductive

1.4.9.1 Subjective data
1.4.9.2 Objective data
1.4.9.3 Assessment
1.4.9.4 Nursing diagnosis

1.4.10 Coping-stress tolerance

 1.4.10.1 Subjective data
1.4.10.2 Objective data
1.4.10.3 Assessment
1.4.10.4 Nursing diagnosis

1.4.11 Value-Belief Pattern

1.4.11.1 Subjective data
1.4.11.2 Objective data
1.4.11.3 Assessment
1.4.11.4 Nursing diagnosis

1.2 Physical examination for baby (Review of system)

System Physical examination
General Pale, good tone, strong cry, active, good
Appearance (Color, maturity how about Juanduce?? Formatted: English (United States)

Tone, Cry, Maturity,

Activity)
Skin / Mucous No rash, no hemangioma
Membrane (Rashes,
Birth Mark,
Hemangioma)
Head Ant. Fontanel 1,5 x 1,5 cm, patent suture,
no caput succeaneum
Eyes No cataract, no Discharges
Ear Soft good recoid ears
Oral cavity No nasal flarring no d/c
No Clet lip and palate
Chest & Lung Trachea in midline
Breast build 3 mm
RR 76x/minute, reguler
CVS & Heart No CVS
HR 216x/minute, reguler, no murmur

1.3 Laboratory tests and interpretation

 Date Type of Normal Results Interpretation
test criteria
(26/09/2017)
HCT 40% - 68 % 55% Normal
MB 10 12 15,6 Abnormal
gr/dl gr/dl*

1.4 Treatment for baby

Date/Time Order for One Day Date/Time Order for

Continuation
(27/09/2017) Last assesment : No
Fever
Morning shift :
NBSC
HCT / MB
55/15,6
On single dose
phototherapy
2. Nursing care plan

Date Nursing Objectives/ Nursing activity/ Nursing Rational Evaluation

diagnosis/ Criteria intervention
Data support
(27/09/2017) Dx. Anxiety
Maturational
r/t
and
Patient describes Teaching : Information
about treatment and
Since a cause of anxiety The patient is
own anxiety and cannot always be identified,
stress about baby coping patterns. nursing care plan. the patient may feel as able to identify
treatment. Patient Recognize awareness of though the feelings being the anxiety
demonstrates the patients anxiety. experienced are counterfeit.
Data Support : improved Use presence, touch Acknowledgment of the problem
DS :
Patient feeling of
concentration
and accuracy of
(with permission), patients feelings validates experienced.
verbalization, and the feelings and
inadequacy thoughts. demeanor to remind communicates acceptance The patient can
Patient said she patient patients that they are of those feelings. explain the
worried about the demonstrates not alone and to Being supportive and
baby health. ability to encourage expression approachable promotes cause of his
Patient did not
know how long
reassure self.
Patient know
or clarification of communication. anxiety and
needs, concerns,
she will be in about the unknowns, and
Awareness
environment
of the
promotes
can solve the
DO :
hospital. treatment very
well.
questions. comfort and may decrease problem
Familiarize patient with
independently.
anxiety experienced by the
The baby has give
the environment and patient. Anxiety may
The patient
phototherapy
new experiences or intensify to a panic level if
treatment for his
people as needed. patient feels threatened and
bilirubin status.
Nurse make a plan for unable to control reveals
Patient Insomnia
because factor giving information very environmental stimuli. knowing the

new baby. well to patient. The
information like what is
Providing clear information
to the patient will decrease
mechanism of
phototherapy, when the anxiety level in the treatment to
the therapy will give to patient because through the
baby, how about the clear information can
Date Nursing Objectives/ Nursing activity/ Nursing Rational Evaluation
diagnosis/ Criteria intervention
Data support
procedure, and how
about the indicator.
improve
coping.
the patient's
be performed
You may need to explain on her baby.
about photo therapy in
details for example why the
baby got phototherapy,
what should the mother can
do to help the baby for
example, breastfeeding
without water, close the
baby eyes and so on.
3. Case summary:
A mother came to srinagarind hospital with indication of giving birth, after examination got patient
got membrane rupture early at age 36 weeks gestation. Patients had no previous medical history
and the patient's family also had no history of the disease. The patient stated this was her first
pregnancy. The patient gave birth normally, and after examination no abnormalities were found
in the infant's physical condition. The baby weighs 2.860 grams at birth, 48 cm long body. The next
day the baby's body appeared jaundice and there was a baby's weight loss without fever indication
of 2,700 grams and obtained HCT / MB 55 / 15.6 results. Single-dose therapy photos were
performed until 27 September 2017 while breastfeeding was performed on infants. Patients
expressed concerns about the condition of the baby because of a photo of the therapy, and the
patient sometimes asks how long the therapy will be performed. The nurse conducts an
assessment and establishes an anxiety diagnosis in the patient, and the nurse also carries out the
related intervention by providing information related to the therapy given to the infant.

Reference

Bulechek G.M., Howard K.B., Joanne M.D. (Eds.). (2008). Nursing Intervention Classification (NIC), Fifth
Edition. St. Louis Missouri: Mosby Inc.
Herdman, T.H. & Kamitsuru, S. (Eds.). (2014). NANDA International Nursing Diagnoses: Definitions and
Classification 2015-2017. Oxford: Wiley Blackwell.
Moorhead Sue, Marion Johnson, Meridean L.M., et al. (Eds.). 2008. Nursing Outcomes Classification
(NOC), Fifth Edition. St. Louis Missouri: Mosby Inc.