NURSING CARE PLAN

Name of patient: Mrs. O

Age: 39 years old
Diagnosis: PUFT, Cephalic in labor, t/c Preeclampsia severe: G5P4
Attending Physician: GEMMA PRADO M.D.

NURSING NURSING
ASSESSMENT NEEDS GOALS/ OBJECTIVES RATIONALE EVALUATION
DIAGNOSIS INTERVENTION

Subjective Data: “ Kis-a ga Activity Acute pain After 8 hours of rendering 1. Build rapport > To gain Goal partially met
skit tiyan ko. Hindi pa man and related to labor nursing interventions the - Hildegard Peplau cooperation with the patient is able to report
sakit sakit gid” as exercise pain patient will be able to report patient and SO slight relief of pain as
vdrbalized by the patient pattern relieve of pain >For baseline data evidenced by pain scale
with the pain scale of 6 out 2. Check and >Evaluate patient’s of 4 out of 10.
of 10 monitor vital signs response to pain
- Imogene King >To provide
SPECIFIC OBJECTIVES 3. Assess patient’s comfort
Objective Data: After 8 hours of nursing attitude toward >To provide
 Coherent interventions the patient will pain conducive
 Responsive be able to: - Imogene King environment thus
 Afebrile  Identify cause of preventing from
 Well-oriented pain irritability of the pt.
 Conscious  Report pain is
lessened 4. Provide comfort >To give
 Well-groomed
 Verbalize method measures (back appropriate
 Irritability noted rubbing) intervention
 Restlessness noted that provide relief
 Demonstrate use of - Virginia
 On NPO instructed Henderson
 Grimace noted relaxation skills and
divisional activities 5. Provide quiet >To assist patient to
environment explore methods for
VITAL SIGNS - Dorothy Johnson alleviation of pain.
>To promote
BP: 150/100 mmHg 6. Instruct patient to wellness
RR: 16 cpm report pain as soon
PR: 72 bpm as it begins
- Dorothy Johnson >To promote
TEMPERATURE: 36.3 7. Encourage wellness
degree celcius relaxation
exercises
(instructional)
- Dorothy Johnson
8. Encourage
diversional
activities(socializa
tion with others)
- Hildegard Peplau

9. Encourage
adequate rest
periods
- Virginia
Henderson
10. Discuss with SO
ways in which
they can assist
patient and reduce
precipitating
factors
- Imogene King
 NURSING CARE PLAN
Name of patient: Mrs. O
Age: 39 years old
Diagnosis: PUFT, Cephalic in labor, t/c Preeclampsia severe: G5P4
Attending Physician: GEMMA PRADO M.D.

NURSING GOALS/ NURSING

ASSESSMENT NEEDS RATIONALE EVALUATION
DIAGNOSIS OBJECTIVES INTERVENTION

Subjective: After 8 hours of nursing

“No verbal Cues” Ineffective Tissue intervention the patient
ACTIVITY perfusion r/t will be able to
vasospasm as demonstrate increased
& evidenced by perfusion
increase blood
EXERCISE pressure.

Objective:
>Coherent PATTERN Specific objectives
>Responsive BY After 8 hours of nursing
>Conscious GORDON intervention the patient
>Edema noted at Lower will be able to:
Extremities Rationale: a. Improve
>Pallor Noted circulation
>AFebrile Ineffective Tissue b.
>Cyanosis noted at Lower Perfusion is the
Extremities decrease in oxygen
>NPO Instructed resulting in the
V/S failure to nourish the
BP: 150/100mmHg tissue at the tissue at
Temp: 36.6 OC the capillary level.
PR: 16 CPM
RR:72 BPM
 NURSING CARE PLAN
Name of patient: Mrs. O
Age: 39 years old
Diagnosis: PUFT, Cephalic in labor, t/c Preeclampsia severe: G5P4
Attending Physician: GEMMA PRADO M.D.

NURSING GOALS/ NURSING

ASSESSMENT NEEDS RATIONALE EVALUATION
DIAGNOSIS OBJECTIVES INTERVENTION
Knowledge Deficit General: >Build rapport >to gain pt Goal partially met, has
Subjective: related to Blood -Hildegard Peplau cooperation. slightly acquired
“hindi ko man bal-an ang Pressure as After 8 hours of knowledge about her
pagkaon nga gapataas sang evidenced by “hindi rendering nursing >Check and monitor vital >For baseline data conditions as pt.
blood preasure” ko man bal-an ang interventions the patient signs verbalized “AH AMO
pagkaon nga will be able acquire -Imogene King GALE TO GHA ”
COGNITIVE gapataas sang blood knowledge about her
PERCEPTUAL pressure” condition. >determine the client >to determine
Objective: PATTERN ability/readiness and factors pertinent &
>Coherent Rationale: anticipatory needs the learning process.
>Responsive BY: Specific: -Dorothy Jonhson
>Conscious Knowledge deficit After 8 hours of nursing
>Edema noted at Lower GORDON absence or interventions the patient >provide information >to assess the client
Extremities deficiency of will be able to: relevant only to the motivation.
>Pallor Noted cognitive >participate in nursing situation to prevent
>AFebrile information r/t process. overload.
>Cyanosis noted at Lower >pt. has incapacity to >identify the >identify information what >to established the
Extremities understand her inconvenience to her needs to be remembered. content to included
>NPO Instructed condition. learning and specific - Hildegard Peplau
V/S action to them.
BP: 150/100mmHg >exhibit increase >recognized level of >to developed
Temp: 36.6 OC interest/assume achievement, time factors, learners objectives
PR: 16 CPM responsibility to own short term & long.
RR:72 BPM learning by beginning -Imogene King
to look for information
and ask and question. >discuss topic at a time, >to facilitate
>verbalized avoiding giving to much learning
understanding learning information.
condition. -Imogene King
>initiate necessary
lifestyle changes and >provide mutual goal >to identify
participate in treatment setting & learning contacts. teaching methods to
regimen. -Imogene King be used
>provide asses information > to promoted
for contact person to wellness.
answer questions.
- Hildegard Peplau