NURSING CARE PLAN

Client: D.W. Age: 16

Medical Diagnosis: Deficient fluid volume Gender: Female
Prepared by Athena Irish D. Lastimosa From Group 5-A Amojedo, Bacsain, Catalan, Lastimosa, Olivar

Dolores Wellbeing, a 16 y/o student, comes in for consultation with her mother and is 4. Compute for the AOG (Date of consultation is today).
having an unintended pregnancy. The mother stated that lately, her daughter is
experiencing severe nausea and vomited 3-4 times almost every day accompanied by March 1, 2019 – April 24, 2019
lightheadedness, cramping of legs and a feeling of irregular heartbeat. The mother also = 54 days or 7 weeks 5 days
informed the nurse that her daughter is having dysuria for a week, flank pain, spotting and
loss of appetite. During interview, the mother additionally stated that her daughter has 5. Compute for EDC.
been emotionally upset since the boy who got her pregnant disclaims that baby but still has
March 1, 2019 + 280 days
the conviction to take care of herself and her present condition. On assessment of the client,
she is coherent, states her pain is 7 on a scale of 1-10, and minimal blood on her vaginal pad. = December 7, 2018
Her temperature is 380C, Pulse 115 bpm, respiration 20 cpm, BP 140/ 100. LMP is March 1,
2019, height 4’11 and weighs 40 kgs. Laboratory results are as follows: March 1, 2019

Hgb- 9 gm/ dl +9 +7

Hct- 51.4 % = December 8, 2019

WBC in U/A- 12,000 mcL 6. Compute for the BMI.

Na- 114 mmol/L lbs/m2

K-2.5 mmol/ L 17.8 – normal for a 16 year old girl

1.Formulate 3 NCP (ADPIRE) based on priority need. AOG - 54 days or 7 weeks 5 days

2. Formulate long and short term goals. EDC - December 8, 2019

BMI -17.8
3. Identify independent, dependent and collaborative nursing interventions

 Remember to set your priorities and be SMART

 NURSING CARE PLAN
Client: D.W. Age: 16
Medical Diagnosis: Deficient fluid volume Gender: Female
Priority #1 Deficient Fluid Volume
Assessment Diagnosis Planning Intervention Rationale Evaluation
Subjective: Deficient Fluid Volume Short-term: Dependent: Short-term:
The patient’s mother stated that related to electrolyte  patient exhibit signs of  Administration of IV fluids  Fluids are necessary to maintain After 4 hours of nursing
lately, her daughter is experiencing imbalance and increased improvement and other electrolyte hydration status. Determination of the intervention, the
severe nausea accompanied by metabolic rate secondary to  patient will have normal replacements. type and amount of fluid to be replaced  patient exhibited signs of
lightheadedness, cramping of legs infection as evidenced by vital signs. and infusion rates will vary depending improvement and is
and a feeling of irregular high WBC, increased heart on clinical status. normovolemic as evidenced
heartbeat. rate, vomiting and Long-term: Independent: by normal vital signs and
weakness.  Assess lifestyle changes  Urge the patient to drink  Oral fluid replacement is indicated for electrolytes, Sodium and
Objective: that will help prevent or prescribed amount of fluid. mild fluid deficit and is a cost-effective Potassium.
 Weak reduce Deficient Fluid method for replacement treatment.
 Pale Volume. Long-term: After 5 days of
 Vomited 3-4 times almost every  Talk about causative  Educate patient about  Enough knowledge aids the patient to Nursing intervention, the
day factors and behaviors possible cause and effect of take part in his or her plan of care.  Patient demonstrates lifestyle
 AOG - 54 days or 7 weeks 5 days essential to correct fluid fluid losses/decreased fluid changes and knowledge about
 EDC - December 8, 2019 deficit. intake. Deficient Fluid Volume by:
 BMI -17.8  Educate about the  verbalized awareness of
measures that can be  Enumerate interventions to  Patient needs to understand the value of causative factors and
 V/S taken as follows: taken to treat or prevent prevent or minimize future drinking extra fluid during bouts of behaviors essential to correct
T- 38.0 fluid volume loss. episodes of dehydration. diarrhea, fever, and other conditions fluid deficit
P - 115 bpm causing fluid deficits.  knew the measures that can
RR - 20 cpm be taken to treat or prevent
BP - 140/ 100  Emphasize the relevance of  Increasing the patient’s knowledge level fluid volume loss.
maintaining proper will assist in preventing and managing
 Lab results as follows: nutrition and hydration. the problem.
Hgb- 9 gm/ dl
Hct- 51.4 %  Teach family members how  An accurate measure of fluid intake and
WBC in U/A- 12,000 mcL to monitor output in the output is an important indicator of
Na- 114 mmol/L home. Instruct them to patient’s fluid status.
K-2.5 mmol/ L monitor both intake and
output.

Collaborative:
 Refer patient to home  Continuity of care is facilitated by
health nurse or private community resources.
nurse in order to assist
patient, as appropriate.
 Priority #2 Acute Pain
Assessment Diagnosis Planning Intervention Rationale Evaluation
Subjective: Acute pain related to Short-term: Dependent: Short-term:
The mother informed the nurse infection as evidenced by  Patient exhibit signs of  Administration of unusual  Giving the right kind and dosage of a After 4 hours of nursing
that her daughter is having dysuria complains of pain, changes improvement with a methods of handling pain painkiller to the patient is the key for a intervention, the
(painful urination) for a week, flank in autonomic responses. satisfactory pain control requires a doctor’s order. faster way of getting rid of the pain  patient exhibited signs of
pain, spotting and loss of appetite. at a level less than 3 to 4 which is usually prescribed by the improvement and is normal
on a rating scale of 0 to 10 doctor. with less to no pain.
Objective:  Patient will have normal Independent:
 Weak vital signs.  Foresee the need for pain  Preventing the pain is one thing that a Long-term: After 2 days of
 Pale relief. patient experiencing it can consider. Nursing intervention, the
 Flank pain scaling at 7 Long-term: Early intervention may decrease the  Patient demonstrates lifestyle
 Minimal spotting in pad  Assess lifestyle changes total amount of analgesic required. changes and knowledge about
 AOG - 54 days or 7 weeks 5 days that will help prevent or Acute Pain by:
 EDC - December 8, 2019 reduce acute pain.  Acknowledge reports of  Pain can be aggravated with anxiety and  verbalized awareness of
 BMI -17.8  Talk about causative pain immediately. fear especially when pain is delayed. An causative factors and
factors and behaviors immediate response to reports of pain behaviors essential to cope
 V/S taken as follows: essential to cope with may decrease anxiety in the patient. with acute pain
T- 38.0 acute pain. Demonstrated concern for the patient’s  knew the measures that can
P - 115 bpm  Educate about the welfare and comfort fosters the be taken to treat or prevent
RR - 20 cpm measures that can be development of trusting relationship. acute pain.
BP - 140/ 100 taken to treat or prevent
acute pain.  Get rid of additional  Patients may experience an
 Lab results as follows: stressors or sources of exaggeration in pain or a decreased
Hgb- 9 gm/ dl discomfort whenever ability to tolerate painful stimuli if
Hct- 51.4 % possible. environmental, intrapersonal, or
WBC in U/A- 12,000 mcL intrapsychic factors are further stressing
Na- 114 mmol/L them.
K-2.5 mmol/ L

 Teaching cognitive-  These techniques help an individual

behavioral strategies like decrease the pain experience and to
imagery, distraction lessen the stress, tension, subsequently
techniques and relaxation decreasing the pain.
exercises

Collaborative:  Patients who demand pain medications

 Report to the physician at more frequent intervals than
when interventions are prescribed may require higher doses or
unsuccessful and more potent analgesics.
ineffective.

Assessment
Subjective:
The patient is having an
unintended pregnancy and she
went to her check up with her
mother. The mother stated that
lately, her daughter is experiencing
severe nausea and vomited 3-4
times almost every day
accompanied by lightheadedness.
Objective:
 Weak
 Pale
 AOG - 54 days or 7 weeks 5 days
 EDC - December 8, 2019
 BMI -17.8
 V/S taken as follows:
T- 38.0
P - 115 bpm
RR - 20 cpm
BP - 140/ 100
Diagnosis
Nausea related to pregnancy
as evidenced by reports of
severe nausea that leads to
vomiting multiple times a
day.
Priority #3 Nausea
Planning
Short-term:
 The patient will have  Applying acustimulation
decreased severity of
nausea.
 The patient will know
about the correlation of
nausea and pregnancy.
Long-term:
 Assess lifestyle changes
that will help prevent or
reduce nausea.
 Talk about causative
factors and behaviors
essential to avoid nausea.
 Educate about the
measures that can be
taken to treat or prevent
nausea.
Intervention Rationale
Dependent:
 Stimulation of the Neiguan P6
bands or acupressure are acupuncture point on the ventral surface
as ordered by the doctor. of the wrist has been found to control
nausea in some points but should be
ordered by the doctor before
Independent: administering.
 Provide an emesis basin
within easy reach of the  Nausea and vomiting are closely related.
patient. Keep emesis basin out of sight but
within the patient’s reach if nausea has a
psychogenic component.
 Assist the patient in
diagnostic testing  A series of tests may be used to
preparation determine the contributing factor (e.g.,
upper gastrointestinal tract study,
abdominal computed tomography scan.)
 Educate patient about
possible cause and effect  Enough knowledge aids the patient to
of nausea and identify the take part in his or her plan of care and
triggers avoid the triggers herself.
Evaluation
Short-term:
After 3 hours of nursing
intervention, the
 patient exhibited decreased
severity of nausea
 patient understood that
nausea is a part of pregnancy.
Long-term: After 2 days of
Nursing intervention, the
 Patient demonstrates lifestyle
changes and knowledge about
Deficient Fluid Volume by:
 verbalized awareness of
causative factors and
behaviors essential to correct
fluid deficit
 knew the measures that can
be taken to treat or prevent
fluid volume loss.

 Lab results as follows:  Allow the patient to use

Hgb- 9 gm/ dl nausea control techniques
 These methods have helped patients
Hct- 51.4 % such as relaxation, guided
alleviate the condition but needs to be
WBC in U/A- 12,000 mcL imagery, music therapy,
used before it occurs.
Na- 114 mmol/L distraction, or deep
K-2.5 mmol/ L breathing exercises.

Collaborative:
 Caregivers can promote adequate
 Educate the caregiver
hydration and nutritional status by
about appropriate fluid and
acknowledging dietary points to
dietary options for nausea,
consider when nauseated, following the
importance of Changing
prescribed schedule for medications
positions slowly and proper
reduces episodes of nausea and that
administration of
Abrupt or gross movements may
medications.
aggravate the condition.
 Priority #4 Situational Low Self-Esteem
Assessment Diagnosis Planning Intervention Rationale Evaluation
Subjective: Situational Low Self-Esteem Short-term: Independent: Short-term:
The mother stated that her related to teenage  The patient reports  Act as a role model for the  Assume responsibility for own thoughts After 1 session of nursing
daughter has been emotionally pregnancy and rejection as progress in current patient or significant others and actions by using “I think” language in intervention, the
upset since the boy who got her evidenced by loss of situation. in healthy expression of conversations. Patients may want an  patient reported progress in
pregnant disclaims that baby. appetite and feeling feelings or concerns. example of positive measures to display handling her emotions on the
depressed. Long-term: feelings. situation.
Objective:  Assess lifestyle changes
 Weak that will help with self-  Spend time with the patient;  Having enough time for the patient Long-term: After 3 sessions in a
 Pale esteem. set aside enough time so conveys the nurse’s interest in and week of nursing intervention,
 Worried  Verbalizes positive that the encounter is calm acceptance of the patient’s feelings. A the
 AOG - 54 days or 7 weeks 5 days acceptance of self and and deliberate. trusting relationship is an important  Patient demonstrates lifestyle
 EDC - December 8, 2019 situation. factor in building self-esteem. changes and acceptance of
 BMI -17.8 the situation.
 Provide privacy.  Private discussions need to take place in
 V/S taken as follows: a setting where the patient is free to
T- 38.0 express feelings without being
P - 115 bpm overheard.
RR - 20 cpm
BP - 140/ 100  Apply active listening and  These communication methods permit
 Lab results as follows: open-ended questions. the patient to verbalize interests,
Hgb- 9 gm/ dl concerns, worries, and thoughts without
Hct- 51.4 % interruption. This will convey a sense of
WBC in U/A- 12,000 mcL respect for the patient’s abilities and
Na- 114 mmol/L strengths in addition to recognizing
K-2.5 mmol/ L problems and concerns.

 Consider the “normal”  Disturbances in self-esteem are natural

impact of change on self-
esteem. Reassure the
patient that such
modifications often occur in
a variety of emotional or
behavioral responses.
responses to important changes.
Reconstitution of the patient’s self-
esteem occurs as part of the patient’s
adjustment to change.

 Support the patient in his or  The patient needs continuous positive

her attempts to secure
autonomy, reality, positive
self-esteem, sense of
capability, and problem-
solving.
feedback and support to manage
behaviors to promote self-esteem. The
patient will benefit from feedback that
provides a realistic appraisal of his or
her development and strengthens the
effective change made by the patient.
 Give anticipatory direction  The patient requires a view that places
to reduce anxiety and fear if the change in self-esteem within the
interference in self-esteem context of the normal recuperative
is an expected part of the
process.
process of adjustment to
changes in health status.

 Educate the patient to join in

 The patient needs to explore options to
activities anticipated to
improve self-esteem by substituting
result in healthy self-esteem.
negative behaviors with positive actions.

 Present referral information

 Professional and community sources of
about community resources,
support provide the patient with more
self-help groups, and
resources to sustain the work of
professional counseling.
rebuilding positive self-esteem.
Collaborative:
 Present referral information
 Recognition of unfavorable thoughts can
about community resources,
lift the patient to develop new
self-help groups, and
techniques for coping. The patient must
professional counseling.
replace negative beliefs and ideas with
positive thoughts about self.