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NURSING CARE PLAN

NCM 109 RLE CLINICAL

Wednesday 7:00 AM – 12:00 PM

Submitted by:
REGALA, BIANCA YSABELLE M.
BSN II – B
Group 3
Name: Mrs. Y Sex: Female
Assessment Nursing Planning Intervention Rationale Evaluation
Diagnosis

Subjective: Acute pain After 8 hours of Independent: The goal was partially met.
related to nursing intervention
- Evaluate pain - Provides information about After 8 hours of nursing
increased the patient’s pain wil
regularly (every 2 need for or effectiveness of intervention the reported
“Masakit po ang tahi ko,” as muscle decreased from the
hrs noting interventions. that her pain decreased
verbalized by the patient. contraction. scale of 9/10 to 3/10.
characteristics, from 9/10 to 4/10.
location, and
Objective: intensity (0–10
scale). Emphasize
patient’s
 Vital signs taken as responsibility for
follows: reporting pain/
 BP= 130/80 mmHg relief of pain
 PR= 70 bpm completely.
 RR= 20 cpm
 Temperature= 37⁰
- Assess vital signs, - Changes in these vital signs
 Pain= 9/10
noting tachycardia, often indicate acute pain and
hypertension, and discomfort. Note: Some
increased patients may have a slightly
respiration, even if lowered BP, which returns to
patient denies pain. normal range after pain
relief is achieved.

- Assess location, - Indicates the suitable

nature, and choice of treatment. The
duration of pain, patient awaiting imminent
especially as it cesarean birth may
 relates to the encounter varying degrees of
indication for discomfort, depending on
cesarean birth. the indication for the
procedure, e.g., failed
induction, dystocia.

- Provide additional
comfort measures: - To improve the circulation,
backrub, heat or reduces muscle tension and
cold applications. anxiety associated with pain.
Enhances sense of well-
being.
Collaborative:
- Administer
analgesics as - Analgesics given IV reach
indicated. the pain centers
immediately, providing more
effective relief with small
doses of medication.
Health Teaching:
- Educate proper
relaxation - May help in decreasing
techniques; anxiety and tension,
position for comfort promote comfort and
as possible. Use enhance sense of well-being.
Therapeutic Touch,
as appropriate.
Name: Mrs. Q Sex: Female

Assessment Nursing Goal Intervention Rationale Evaluation

Diagnosis

Subjective: Ineffective After 8 hours of Independent: The goal was met.

breathing effective nursing
“Nurse nahihirapan po - Place patient with - A sitting position After 8 hours of effective
pattern intervention the
akong huminga,” as proper body alignment permits maximum nursing intervention the
related to patient will maintain
verbalized by the patient. for maximum lung excursion and patient shows optimal
increased optimal breathing
breathing pattern. chest expansion. breathing pattern, as
production pattern, as evidenced
evidenced by relaxed
Objective: of mucus. by relaxed breathing,
breathing, absences of
absences of crackles - Encourage
- This method relaxes crackles in both lungs, lip’s
in both lungs, lip’s diaphragmatic color turned pinkish and a
color turned pinkish muscles and
 Vital signs taken as breathing for patients normal urine output of
or reddish and a increases the
follows: with chronic disease. 500mL every 4 hours.
normal urine output. patient’s oxygen
 BP= 100/80 mmHg
level.
 PR= 60 bpm
 RR= 25 cpm
 Temperature= 36.5⁰
- Evaluate the
- This training
 Crackles were present in appropriateness of
improves conscious
both lungs. inspiratory muscle
control of
 Lips slightly cyanotic training.
respiratory muscles
 Urine output: 80 mL for and inspiratory
4 hours; concentrated in
muscle strength.
appearance
- Encourage small - This prevents
frequent meals. crowding of the
diaphragm.

Collaborative:
 - Administer diuretics as
indicated.
- Diuretics promotes
normovolemia by
decreasing fluid
accumulation and
blood volume. Fluid
overload reduces
lung perfusion
leading to
- Administer hypoxemia.
vasodilatiors as
ordered. - These medications
increase venous
dilation and
decrease pulmonary
congestion that will
enhance gas
Health Teaching: exchange.
- Educate the patient
how to sustained deep - These techniques
breaths by: promotes deep
o Using inspiration, which
increases
demonstration:
oxygenation and
highlighting
prevents
slow
atelectasis.
inhalation,
Controlled
holding end
breathing methods
inspiration for
may also aid slow
a few seconds,
respirations in
and passive
patients who are
exhalation
tachypneic.
o Utilizing Prolonged
incentive expiration prevents
spirometer air trapping.
o Requiring the
patient to
yawn
Name: Mrs. R Sex: Female

Assessment Nursing Goal Intervention Rationale Evaluation

Diagnosis

Subjective: Risk for After 8 hours of Independent: The goal was met.
decreased effective nursing
“Nahihilo at nanghihina ako,” - Note skin color, - Cold, clammy, and After 8 hours of effective
cardiac intervention the
as verbalized by the patient. temperature, and pale skin is nursing intervention the
output patient will remains
moisture. secondary to patient remains
related to normotensive, with
compensatory normotensive, with blood
Objective: dcreased blood loss less than
increase in loss less than 800 ml.
venous 800 ml.
return. sympathetic nervous
system stimulation
 Vital signs taken as
and low cardiac
follows:
output and oxygen
 BP= 90/60 mmHg
desaturation.
 PR= 112 bpm
 RR= 23 cpm
 Temperature= 36⁰ - Record intake and - Reduced cardiac
output. If patient is output results in
 Uterus is soft and not acutely ill, measure reduced perfusion
contracted. hourly urine output of the kidneys, with
 Fresh blood discharge on and note decreases a resulting decrease
diaper.
in output. in urine output.
 Restlessness

- Monitor and record - To know the actual

blood loss. blood loss and to
determine the
appropriate
treatment needed
by the patient.
Collaborative:
- Administer oxygen - The failing heart
therapy as may not be able to
prescribed. respond to
increased oxygen
demands. Oxygen
saturation need to
be greater than
90%.
Health Teaching:
- Educate family and
patient about the - Early recognition of
disease process, symptoms facilitates
complications of early problem
disease process, solving and prompt
information on treatment.
medications, need
for weighing daily,
and when it is
appropriate to call
doctor.

- Aid family adapt

daily living patterns - Transition to the
to establish life home setting can
changes that will cause risk factors
maintain improved such as
cardiac functioning inappropriate diet to
in the patient. reemerge.

- Educate patient the

need for and how - Psychoeducational
to incorporate programs including
lifestyle changes. information on
stress management
and health
education have
been shown to
reduce long term
mortality and
recurrence of
myocardial
infarction in heart
patients.