Republic of the Philippines

UNIVERSITY OF NORTHERN PHILIPPINES

2700 Tamag, Vigan City

COLLEGE OF NURSING

NURSING CARE PLAN

Patient Name: Remular S.C. Age: 29 years old Sex: Female Date of Admission: December 02, 2023
Chief Complaint: Impaired Physical Mobility Medical Diagnosis: Post Low-transverse Cesarean Section II

Nursing Scientific
Assessment Planning Nursing Intervention Rationale Evaluation
Diagnosis Background
Subjective: Short Term Goal: Independent:
- Pain on the Impaired physical Medical History 1. Initiate patient education and 1. Initiate patient education as some After 2 to 3 hrs. of
mobility related health teachings prefer CS delivery due to lack of effective nursing
surgical site. - Client will identify/use
knowledge, pain, fear, and intervention,
- “Medyo nasakit to pain and Indication of techniques to control pain
2. Monitor and record the client’s misconceptions on vaginal delivery. patient is able to
prescribed cesarean delivery or discomfort.
lang nu tay ability to tolerate activity and use all use techniques to
magaraw garaw movement four extremities 2. Valid and reliable screening
- Client will report control
ading” verbalized restriction as Previous history of procedures and tools to assess the client’s pain/discomfort,
discomfort is minimized.
by the patient. evidenced by LTCS 3. Institute safety measures, like preparticipation in exercise health and appear relaxed
restlessness, - Client would appear encouraging the patient to move screening and risk stratification for and patient is able
facial grimace, For repeat cesarean slowly, keeping the siderails up and exercise testing. to increase strength
Objective: relaxed/resting.
recent surgical section supporting legs during position and function of
- Restlessness changes. 3. Sudden movement may precipitate affected body part.
intervention - Client demonstrates
- Facial grimace hypotension, and safety measures are Goal is partially
(LTCS II), pain Uncomplicated relaxation skills and
- Discomfort with diversional activities. 4. Assist with comfort measures like done to establish rapport with the patient met.
on the surgical cesarean delivery while also promoting comfort.
movement providing back or leg rubs, backrest,
site, discomfort repositioning, perineal care, etc.
- Recent surgical
with movement, Delivery of baby Long Term Goal: 4. Comfort measures minimize
intervention (LTCS
II) and “medyo 5. Before activity, observe for and, if stimulation and promotes relaxation.
nasakit lang nu Presence of surgical - Client achieves timely possible, treat pain with massage,
tay magaraw incision wound healing without heat pack to affected area, or 5. Pain limits mobility and if exacerbated
- Vital signs taken complications by specific movements should be
garaw ading” medication. Ensure that the client is
as follows: not over sedated. temporarily avoided.
Temp: 36.9 °C verbalized by the
- Client can perform
PR: 84 bpm patient. activities of recovery or 6. Administer prescribed medications for
Dependent/Collaborative:
RR: 19 cpm ADLs easily after 6. Administer medications, if pain relieving measures.
BP: 100/80 mmHg childbirth. indicated.
O2 sat: 97% 7. Alternative therapies can be used to
- Client would verbalize 7. Assist with complementary mediate pain.
feeling of increased therapies as indicated, e.g.,
strength and ability to acupressure / acupuncture.
move
References: Nursing Diagnosis Handbook an Evidence-Based Guide to Planning Care by Betty J. Ackley Gail B. Ladwig Mary Beth Flynn Maki. / https://nurseslabs.com/cesarean-birth-nursing-care-plans/

Patient Name: Esmael A. Age: 30 years old Sex: Female Date of Admission: December 11, 2023
Chief Complaint: Scheduled Check-up Medical Diagnosis: G2P1 pu 12 weeks AOG

Assessment Nursing Scientific Planning Nursing Intervention Rationale Evaluation

Student Name: Moises Clerick B. Balloguing Clinical Instructor: Rica Marie B. Valdez
 Republic of the Philippines
UNIVERSITY OF NORTHERN PHILIPPINES
2700 Tamag, Vigan City

COLLEGE OF NURSING

NURSING CARE PLAN

Diagnosis Background
Subjective: Short Term Goal: Independent:
1. Initiate prenatal education and 1. This helps the mother understand the stages
- “Magpapa Readiness for Coitus After 1 to 2 hrs. of
of labor and delivery.
enhanced - State importance of health teachings effective nursing
check-up po ako
childbearing Entry of frequent prenatal 2. Supportive care allows the mother to receive intervention,
ngayon” 2. Institute the importance of patient is able to
process as spermatozoon in care/education the necessary emotional and physical
verbalized by the supportive care assistance throughout pregnancy state importance of
patient. evidenced by the cervix then to
- State knowledge of frequent prenatal
patient’s desire to the fallopian tube 3. Teach pain management 3. Pain management techniques helps the care/education and
anatomic, physiological,
enhance prenatal techniques mother cope with any potential discomfort she knowledge of
Objective: psychological changes may experience
lifestyle and Union of ovum and with pregnancy anatomic,
- expresses desire
enhance spermatozoan 4. Provide patient centered care to let physiological,
to enhance prenatal the mother make decisions that
4. Patient centered care enables the mother to
preparation for Long Term Goal: make her own choices concerning her care. psychological
lifestyle affect her care. changes with
childbirth, and Implantation in the
- expresses desire 5. Pregnant women need information about pregnancy and
to enhance “magpapa uterus - Report appropriate 5. Discuss breastfeeding with a overcoming potential breastfeeding problems report appropriate
preparation for check-up po ako lifestyle choices prenatal: pregnant client, including all the and the physiology of breastfeeding (Laanterä lifestyle choices
ngayon” Embryonic stage Activity and benefits both to the infant and the et al, 2012).
childbirth prenatal. Goal is
verbalized by the starts exercise/healthy nutritional mother partially met.
practices 6. A healthy, varied is of vital importance for
- Vital signs taken patient. optimal birth outcome. (USDA, 2014;
Fetal stage begins Dependent/Collaborative:
as follows: - Client will participate in Williamson & Wyness, 2013).
Temp: 36.7 °C 6. Ensure that pregnant clients have
Childbirth the decision-making an adequate diet and take multi- 7. Social and emotional health problems
PR: 80 bpm process micronutrient supplements during associated with depression in the perinatal
RR: 18 cpm period can lead to poor outcomes for women,
BP: 90/60 mmHg pregnancy.
their infants, and their families (Rollans et al,
O2 sat: 97% 2013)
7. Assess for signs of depression and
make appropriate referral.

References: Nursing Diagnosis Handbook an Evidence-Based Guide to Planning Care by Betty J. Ackley Gail B. Ladwig Mary Beth Flynn Maki. / https://nandadiagnoses.com/readiness-for-enhanced-childbearing-process/

Patient Name: Esmael A. Age: 30 years old Sex: Female Date of Admission: December 11, 2023
Chief Complaint: Scheduled Check-up Medical Diagnosis: G2P1 pu 12 weeks AOG

Nursing Scientific
Assessment Planning Nursing Intervention Rationale Evaluation
Diagnosis Background
Subjective: Short Term Goal: Independent:

Student Name: Moises Clerick B. Balloguing Clinical Instructor: Rica Marie B. Valdez
 Republic of the Philippines
UNIVERSITY OF NORTHERN PHILIPPINES
2700 Tamag, Vigan City

COLLEGE OF NURSING

NURSING CARE PLAN

Objective:

Long Term Goal:

Dependent/Collaborative:

References: Nursing Diagnosis Handbook an Evidence-Based Guide to Planning Care by Betty J. Ackley Gail B. Ladwig Mary Beth Flynn Maki. / https://nandadiagnoses.com/readiness-for-enhanced-childbearing-process/

Student Name: Moises Clerick B. Balloguing Clinical Instructor: Rica Marie B. Valdez