Vous êtes sur la page 1sur 17

NURSING CARE PLAN

Assessment Diagnosis Scientific Planning Implementation Rationale Evaluation


Explanation
Subjective: Ineffective Spiral artery Short Term: Independent: Short Term:
“Nahihilo ako at ang tissue perfusion doesn’t widen
sakit ng batok at related to After 4 hours of nursing a.) Establish rapport and - To gain patient’s trust After 4 hours of
explain procedures and and paticipation. nursing intervention,
nanlalabo yung vasoconstriction intervention, the patient
expected outcomes. the goal was partially
mga mata ko.” – as of blood vessels Less blood gets in will be able to; met as evidenced by
verbalized by the secondary to the placenta b.) Assess patient’s general - To note for any the patient;
patient. Pre-eclampsia  Decrease and physical condition. abnormality.
maintain blood c.) Check patient’s V/S. - To establish baseline  Blood
pressure within data. pressure is
Hypo-perfused normal range. still
placenta releases d.) Monitor BP periodically. - Pulses in the leg maybe 140/90mmHg
Objective: (from 140/90mmHg
pro inflammatory e.) Note presence of quality  Verbalized
down to 120/80 mmHg) diminished, implicating
proteins of central and peripheral knowledge of
V/S  Verbalize pulses. effects of disease
T: 36.6 C / axilla knowledge of vasoconstriction and process,
RR: 24 cpm disease venous congestion. individual risk
PR: 95 bpm process, factors, and
BP: 140/90 mmHg Pro inflammatory individual risk treatment
proteins goes to f.) Auscultate heart tones - S3 and S4 heart plan.
factors, and
mother circulation and breath sounds.  Identified
treatment plan. sounds may indicate
signs of
 Pale, cool,  Identify signs of atrial and venous cardiac
and clammy hypertrophy and
cardiac decompensati
skin
decompensation impaired functioning. on.
 Presence of
Pro inflammatory Presence of adventitious
non-pitting
proteins causes breath sounds may
edema on
both lower vasoconstriction Long Term: indicate pulmonary Long Term:
extremities congestion secondary to
 Restlessness After 3 days of nursing developing heart failure. After 3 days of
 Capillary nursing intervention
intervention the patient - Presence of pallor, cool
refill of 2-3 Prolonged g.) Observe skin color, the goal was partially
seconds will: and moist skin and
vasoconstriction moisture, temperature, met as evidenced by
damages  Maintained delayed capillary refill
and capillary refill time. the patient:
LAB endothelial cell maybe due to peripheral
blood pressure
within normal vasoconstriction or  Decreased
 ALT: 74 U/L
range. decreased cardiac blood
 AST: 76 U/L
 LDH: 650 d/L output. pressure but
Endothelial cell (From 140/90 didn’t reach
 Proteinuria:
(30mg/dL) injury mmHg down to the normal
h.) Note independent or - It may indicate heart
120/80 mmHg) general edema. range.
failure, vascular or renal
(BP: 120/90
 Absence of impairment.
paleness, and mmHg)
Blood vessels
cool and i.) Provide a calm
become environment, minimizing - To promote comfort  Absence of
dysfunctional clammy skin and relaxation. paleness, and
 Reduced non- noise, limiting visitors
and length of stay. cool and
pitting edema clammy skin
on both lower j.) Maintain activity - It reduces physical
restrictions (bed rest)  Reduced non-
Causes extremities stress stimuli that affect
and assist patient with pitting edema
 Absence of the blood pressure. on both lower
vasospasm self-care activities.
restlessness extremities
 Normal capillary - It decreases discomfort  Absence of
refill of 1-2 k.) Provide comfort
measures such as and peripheral venous restlessness
Hypertension seconds  Normal
elevation of head or pooling.
positioning in a semi- capillary refill
fowler’s. of 1-2 seconds
l.) Encourage relaxation
- It helps reduce stressful
techniques like guided
imagery and distractions. stimuli, thereby
decreases BP.
m.) Monitor response to - Response to drug is
medications to control dependent on both
blood pressure. individual and the
synergistic effect of the
drug. It is also important
to check for any
untoward signs and
symptoms of the
medications.
n.) Instruct patient on fluid - Low intake of sodium
and diet requirements can assist with decrease
and restrictions of in fluid retention and
sodium. Also, encourage hypertension, thereby
to avoid intake of improving cardiac output
caffeine, cola, and foods like caffeine
chocolates, fats and are cardiac stimulant and
cholesterol. may adversely affect
cardiac function.

Dependent:

o.) Administer medications


like diuretics, alpha and - For pharmacological
beta antagonists, management.
calcium channel
blockers, and
vasodilators.

(Methyldopa 250 mg tab now


then TID)
Assessment Diagnosis Scientific Planning Implementation Rationale Evaluation
Explanation
Subjective: Acute Pain Spiral artery doesn’t Short Term: Independent: Short Term:
““Sumasakit yung related to widen
sa bandang gilid ng inflammation After 30 minutes to 1 a) Monitor patient’s V/S. - Can be altered when After 30 minutes to 1
hour of nursing
tiyan ko, parang or damage to hour of nursing the patient is in pain
intervention, the goal
pinipiga.” – as the cells of the Less blood gets in intervention, the patient b) Assess patient’s general was partially met as
verbalized by the liver secondary the placenta will be able to; physical condition. - To note for any evidenced by the
patient. to Pre- abnormality. patient;
eclampsia  Verbalize c) Listen and respect
methods that client’s expression about  Verbalized
Character: (HELLP - Helps in alleviating
Hypo-perfused provide relief. his condition.
 Squeezing Syndrome)  Follow anxiety and refocusing methods that
pain placenta releases provide relief.
prescribed attention.
pro inflammatory
pharmacological d) Monitor patient’s pain - To rule out worsening  Followed
Onset: proteins
regimen. and note/investigate of underlying condition or prescribed
 January 20,  Demonstrate pharmacologic
changes from previous development of
2019;
use of relaxation reports. complications. al regimen.
sudden
Location: skills and  Demonstrated
 RUQ Pro inflammatory diversional - Pain is a subjective use of
proteins goes to e) Perform a
activities, as experience and must be relaxation
mother circulation comprehensive
Duration: indicated, for described by the patient skills and
assessment of pain to
 Continuous individual include location, in order to plan effective diversional
pain and situation. characteristics, onset, activities, as
getting treatment.
 Report pain is duration, frequency, indicated, for
worse when quality, intensity, and
Pro inflammatory relieved or individual
moving, or precipitating factors of
proteins causes reduced. situation.
doing pain.
vasoconstriction (From pain scale of
physical f) Promote adequate rest, - To prevent fatigue and  Reported pain
8/10 down to 4/10)
activities and provide comfort promote non- is reduced but
such as measures (e.g. touch, didn’t reach
pharmacological pain
walking. repositioning, nurse’s the desired
Prolonged management.
vasoconstriction presence), quiet scale.
Severity: damages endothelial environment. (Pain scale of
 Using the cell g) Instruct, or encourage - Helps reduce pain and 6/10)
Universal use of breathing promote relaxation.
Pain relaxation exercise .
Assessment h) Encourage diversional
Endothelial cell activities such as - To distract attention.
Tool, the
scale is injury listening to music and
8/10- socializing with others.
Severe; The
pain is quite Dependent:
intense and Blood vessels
is causing become
the patient dysfunctional i) Administer pain reliever
to avoid, or medication as ordered - Pharmacological
limit physical by the physician. management to reduce
activity, pain.
also, cannot Causes vasospasm (Paracetamol 500 mg)
concentrate
on anything
except pain.
Narrowed hepatic
Pattern: artery
 “Kapag
gagalaw ako
sumasakit,
pero kapag Hypoperfusion on
nagpapahin the liver
ga ako
nababawasa
n yung Liver inflammation or
sakit.” damage
Associated factors:
 The pain
affects the Acute Pain
activities of
the patient
at home,
“Ang sakit
po, hindi
nga ako
nakapagluto
ng baon
para sa
maga anak
kong
papasok ng
school kasi
pumunta na
agad ako
dito.”

Objective:

V/S
T: 36.2 C / axilla
RR: 25, regular
PR: 88, regular
BP: 140/90 mmHg

 Guarding
behavior in
the RUQ of
the
abdomen
 Facial
grimacing
 Irritability

LAB
 ALT: 74 U/L
 AST: 76 U/L
Assessment Diagnosis Scientific Planning Implementation Rationale Evaluation
Explanation
Subjective: Acute pain Abnormal Short Term: Independent: Short Term:
“Masakit yung tahi related to post- placentation
ko lalo na kapag op surgical After 30 minutes to 1 a.) Check patient’s V/S. - Can be altered when After 30 minutes to 1
gumagalaw ako. incision hour of nursing the patient is in pain hour of nursing
hindi ako secondary to Low prefunded intervention, the patient b.) Assess patient’s general - To note for any intervention, the goal
komportable.” – as Pre-eclampsia placenta will be able to; physical condition. abnormality. was met as
verbalized by the c.) Listen and respect - Helps in alleviating evidenced by the
patient.  Verbalize client’s expression about anxiety and refocusing patient;
Release of cytokines nonpharmacolo his condition. attention.
Character: and other toxins gical methods  Verbalized
 Sharp pain that provide d.) Monitor patient’s pain - To rule out worsening nonpharmacol
relief. and note/investigate of underlying condition or
ogical
Onset: Vasoconstriction and  Follow changes from previous development of
methods that
 Post- platelet activation prescribed reports. complications.
Operation pharmacological provide relief.
(January 21, regimen. e.) Perform a - Pain is a subjective  Followed
2019) Generalized  Demonstrate comprehensive experience and must be prescribed
Location: endothelial and use of relaxation assessment of pain to described by the patient pharmacologic
 Pain from vascular dysfunction skills and include location, in order to plan effective al regimen.
incision characteristics, onset, treatment.
diversional  Demonstrated
duration, frequency,
Impact on fetus: activities, as quality, intensity, and use of
Duration:
indicated, for relaxation
 Continuous undernutrition precipitating factors of
pain and because of utero- individual pain. skills and
getting placental vascular situation. f.) Promote adequate rest, - To prevent fatigue and diversional
worse when insufficiency  Report pain is and provide comfort promote non- activities, as
moving, or relieved or measures (e.g. touch, pharmacological pain indicated, for
doing reduced. repositioning, nurse’s management.
individual
physical Growth restriction to (From pain scale of presence), quiet
fetus that may cause environment. situation.
activities 7/10 down to 5/10)
such as distress g.) Instruct, or encourage - Helps reduce pain and  Report pain is
walking. use of breathing promote relaxation. relieved or
relaxation exercise reduced.
Severity: Age related: h.) Encourage diversional - To distract attention or (Pain scale of
 Using the Possible activities such as divert focus from pain. 5/10)
Universal complication listening to music and
Pain socializing with others.
Assessment
Tool, the Stabilized mother Dependent:
scale is and baby
6/10- i.) Administer pain reliever - Pharmacological
Moderate; medication as ordered management to reduce
Interferes Elective Surgery/CS by the physician. pain.
her
concentratio (Celecoxib 200mg tab BID)
n, and felt Tissue
uncomfortab Injury/Inflammatory
le Cell

Pattern:
 Moving Sense by Nociceptor
makes it
worse, and
relieved, Converted to electro
when lying chemical signals
on bed and
controlled
when given Transmitted to spinal
pain cord by Dorsal Root
medication. Ganglia and then to
the Brain
Associated
factors:
The pain affects: Acute Pain
 “Hindi kasi
ako
masyadong
makatulog
dito sa
hospital at
nararamdam
an ko pa rin
yung sakit
dito sa tyan
ko kapag
gabi lalo
kapag
gagalaw
ako, hindi
ako
komportable
.”

 20-25
minutes of
sleep
disturbance
 (total 4hrs of
sleep with
interruption)

Objective:

V/S
T: 36.7 C / axilla
RR: 16, regular
PR: 86, regular
BP: 120/90 mmHg

 Surgical
incision of
13cm long
and 15
stitches (low
transverse)
 Guarding
behavior on
the
abdomen
 Positioning
(to avoid
pain)
 Facial
grimacing
 Irritability
Assessment Diagnosis Scientific Planning Intervention Rationale Evaluation
Explanation
Subjective: Impaired skin Surgical Short Term: Independent: Short Term:
integrity related intervention (CS)
“Inoperahan ako to post-surgical After 6-8 hours of After 6-8 hours of
a.) Support and instruct
kaninang umaga.” – incision nursing intervention, - Reduces possibility of nursing intervention,
patient in incisional
as verbalized by the the patient will be able support when turning, dehiscence and the goal was met as
patient. Incision on the to; coughing, deep incisional hernia. evidenced by:
lower abdomen breathing and
(low transverse)  Have reduced ambulating.  Reduced risk of
Objective: risk of further b.) Observe incision - Verifies status of further
impairment of periodically, noting healing, provides for impairment of
approximation of
V/S skin integrity. early detection of skin integrity.
wound edges,
T: 36.7 C / axilla Surgery involves  Demonstrate hematoma formation developing complications  Demonstrated
RR: 16, regular cutting/ understanding and resolution, and requiring prompt understanding
PR: 86, regular penetration of and ability to presence of bleeding evaluation and and ability to
BP: 120/90 mmHg care for and drainage. influencing choice of care for
skin surface and
skin layers infection-prone intervention. infection-prone
 Surgical site. - Promotes healing. site.
incision of c.) Provide routine
incisional care, being Accumulation of  Demonstrated
13cm long  Demonstrate
and 15 careful to keep serosanguineous ability to
Impaired skin ability to
stitches (low dressing dry and drainage in perform
integrity perform
transverse) sterile. Assess and subcutaneous layers hygienic
hygienic
 Intact maintain patency of increases tension on measures like
measures like
dressing drains. suture line, may delay proper hand
proper hand
washing and wound healing, and washing and
body hygiene. serves as a medium for body hygiene.
bacterial growth.
Long term: - Reduces pressure on Long term:
d.) Encourage frequent
After 3 days of nursing positional changes, skin, promoting
After 3 days of nursing
intervention the patient inspect pressure peripheral circulation and intervention the goal
will: points, and massage reducing risk of skin was met as evidenced
gently, as indicated. breakdown, Skin barrier by the patient:
 Experience Apply transparent skin
healing of reduces risk of shearing  Experienced
barrier to elbows and
wound/incision heels, if indicated. injury. healing of
and regain skin e.) Encourage intake of - Help boost and support wound/incision
integrity protein-rich and calorie- the immune system and regain skin
 Reduce risk for rich foods. responsiveness. integrity
infection f.) Emphasize the - It serves as a first line  Reduced risk
importance of proper defense against infection for infection
hand/body hygiene
and minimizes the risk of
techniques. Practice
proper hand hygiene contamination and
and teach the patient development of infection.
and SO to do so.
g.) Maintain aseptic - Aseptic technique
technique with any decreases the chances
procedures. Provide of transmitting or
routine wound care, as
spreading pathogens to
appropriate.
the patient.
Dependent:

h.) Emphasized necessity - Antibiotics can be used


of taking antibiotics as a prophylactic
properly as ordered by the treatment
physician.

(Co-amoxiclav 325 mg 1
tab OD)
Assessment Diagnosis Scientific Planning Intervention Rationale Evaluation
Explanation
Subjective: Risk for Spiral artery Short Term: Independent: Short Term:
bleeding related doesn’t widens
“Medyo okay na pero to decreased Within the 8 hours a) Assess and monitor - Increased heart rate
vital signs. Within the 8 hours shift,
nanghihina parin platelet count shift, the patient will and orthostatic changes
ako.” – as verbalized be able to: accompany bleeding. the goal was met as
Less blood gets evidenced by the
by the patient. in the placenta b) Assess patient’s - Bleeding maybe
patient:
general condition and obvious
 Identify check for any signs of (bruises/petechiae
individual risks  Identified
Objective: bleeding. epistaxis, bleeding gums, individual risks
Hypo-perfused and engage in
appropriate abdominal pain, and engage in
placenta releases appropriate
V/S behaviors to hematemesis, melena,
pro inflammatory behaviors to
T: 36.7 C / axilla proteins prevent or hematuria).
reduce prevent or
RR: 16, regular c) Check and monitor - To rule out worsening
frequency of reduce
PR: 86, regular laboratory results of underlying condition or frequency of
BP: 120/90 mmHg bleeding especially the platelet development of
episodes. bleeding
count, PT, Hgb, and complications. episodes.
 Weak-looking Pro inflammatory  Be free of signs Hct.
of bleeding  Free of signs of
 Pale proteins goes to d) Maintain safe bleeding
environment for the - To prevent injury and
palpebral mother circulation
conjunctiva Long term: patient. promote rest and
Long term:
 comfort.
After 3 days of nursing After 3 days of nursing
LAB e) Explain the different - For the patient to intervention the goal
intervention the patient risks for bleeding.
Platelet count: 90 x become knowledgeable was met as evidenced
Pro inflammatory will: f) Explain the different
10 9/L about the disease by the patient:
proteins causes factors to prevent
Hgb: 116 g/L  Maintain process.
vasoconstriction bleeding.  Maintained
Hct: 33% reduced risk of
g) Restrain patient from reduced risk of
Prothrombin time: bleeding as any activities that could
evidenced by bleeding as
20.7 seconds cause bleeding. evidenced by
Prolonged normal platelet
normal platelet
vasoconstriction count and
damages clotting times Dependent: count and
endothelial cell and factors h) Administer appropriate - For pharmacological clotting times
within normal medications as ordered management and factors
range. by the physician. within normal
(coagulation)
range.
Formation of i) Transfused PRBC if - To restore Hgb/Hct
thrombi (body will prescribed. level and to replace (Platelet count: 158 X
use massive blood lost. 10 9/L
amount of Collaborative: PT: 12 seconds)
platelets) j) Communicated need - To assure availability
for platelet support to and readiness of
transfusion center.
platelets when needed.

Blood clots
blocks RBC

RBC gets
destroyed
(hemolysis)

Risk for bleeding


Assessment Diagnosis Scientific Planning Intervention Rationale Evaluation
Explanation
Subjective: Disturbed sleep Elective Short Term: Independent: Short Term:
pattern related Surgery/CS
“Hindi ako makatulog to pain and After 2 hours of nursing a. Determine - Sleep problems can After 2 hours of nursing
presence of
ng maayos dahil discomfort intervention, the patient arise from internal and intervention, the goal
physical or
nararamdaman ko pa secondary to Tissue will be able to; psychological external factors and may was met as evidenced
rin yung sakit dito sa Surgery (CS) Injury/Inflammato stressors. require assessment over by the patient;
tahi ko kapag gabi  Verbalize ways time to differentiate
ry Cell
to improve sleep
lalo na kapag specific causes.  Verbalized
pattern.
gagalaw ako, hindi b. Note - These factors can ways to improve
 Identify
ako komportable.” – environmental reduce patient’s ability to sleep pattern
individually
Sense by factors that such as
as verbalized by the appropriate rest and sleep when
Nociceptor affect sleep. providing quiet
patient. interventions to more rest is needed. activities
promote sleep. - To provide comparative
c. Determine (listening to
patient’s usual baseline and to ascertain music) and
Long term:
Objective: Converted to sleep pattern. intensity and duration of comfort
electro chemical After 3 days of nursing problems. measures
V/S signals intervention the patient d. Observe (proper
will: physical signs of positioning,
T: 36.7 C / axilla
fatigue. deep breathing
RR: 16, regular  Report exercises, back
PR: 86, regular Transmitted to improved sleep e. Recommend - To help the patient rub)
BP: 120/90 mmHg spinal cord by  Report quiet activities have a better rest and  Identified
Dorsal Root increased sense such as sleep. individually
 Total hours of Ganglia and then of well-being. listening to appropriate
sleep at night: to the Brain music. interventions to
4-5hrs with promote sleep.
interruptions f. Provide calm, - To provide a conducive
 Presence of quiet environment for the Long term:
eye bags environment patient to relax.
 Lack of Acute Pain and manage After 3 days of nursing
concentration controllable intervention the patient
sleep-disturbing will:
factors.
- This soothes and
g. Provide comfort  Reported
Affects sleep measures such relaxes the patient. Also t improved sleep
pattern as proper promote physical  Reported
positioning, comfort. increased
deep breathing sense of well-
exercises, back being.
rub. - To promote wellness.
h. Arrange care to
provide
uninterrupted
sleep.
i. Recommend - Because caffeine
limiting intake of inhibits sleep.
caffeine and
chocolate prior
to sleep.

Collaborative:
j.) Refer to sleep - For specific
specialist for treatment interventions and/or
when indicated. therapies.