Name: XYZ Date of Admission: Oct 23, 2019

Age: 27 y.o Chief Complaint: Labor Pain

Room: 1 (CLMMRH) Attending Physician: Dr. YYY

NURSING CARE PLAN

General Objectives:

Date/ Cues Need Nursing Diagnosis Objectives of Care Interventions Evaluation

Time
10 Subjective: Knowledge deficit Within 4 hrs of Establish Goal Met!
/24 C regarding condition, rendering nursing rapport 10/24/19
/19 “Wala ko kabalo O and treatment care at Corazon ® to gain patient's @
ngaa gaka hulog G related to absence of Locsin Montelibano trust and have a 6:00pm
@ akon mga bata.” N information Memorial Regional good nurse-patient
I Hospital. The relationship. After 8 hrs of
2:00 “Sang nag sakit T patient will be able rendering nursing
pm ang tiyan ko kag I ® Deficient to manifest: 2. Evaluate care at Corazon
nag bleeding ko V knowledge is a state desire/readiness of Locsin Montelibano
nag kadto kami sa E in which cognitive a) Participate patient to learn. Memorial Regional
hospital gin - information or in learning ®Determine Hospital patient was
tagaan lang ko P psychomotor skills process amount or level of able to know and
bulong kag gin E required for health b) Verbalizatio informatin to understand the
inom ko man.” R recovery, n of provide at any possibl condition and
C maintenance, or understandi given moment. treatment regimen as
“wala ko kaagi pa E health promotion ng about her evidenced by:
check-up sa tanan P are lacking. condition 3. Provide an
ko na bata ini T c) Initiation of atmosphere of a.)patient
lang ang last“ U lifestyle respect openness, participated in
A changes and trust ang learning process
“wala ko kabalo L participate collaboration.
 ano to na in treatment ®Important when b.) “Ah. Kabalo nako
bulong.” P regimen. providing kung diin na makuha
As verbalized by A d) Patient is education to ang infection kung
the patient T less anxious patients with hindi ka maninlo sang
T and well different values kalawaswan mo.” As
E rested and beliefs about verbalized by the
Objective: R health and illness. patient
N
- Lack of 4.Assess c.) “Dapat kung mag
source of motivation and masakit ko, magpa-
informatio wilingness of check up ko dayon sa
n patient and doctor kag hindi ko
- Asked caregivers to learn. magpataka lang inom
questions ®Some patient are bulong na wala man
regarding ready to learn as gin resita sang akon
his soon after they are doctor.” As verbalized
condition diagnosed. Others by the patient
- Expresses cope better by
confusion denying or d.) “Sa dason ko na
on the delaying the need busong sigihon ko na
nature of for instruction ang pre natal kag
the mapa ultra sound
condition 5.Assess history of gid.” As verbalized by
- Purchase UTI infection the patient
of over ® To trace the
the source of
counter infection.
drugs
without
consulting
the
physician