Nursing Care Plan
Nursing Care Plan
Nursing Care Plan
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.
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.