NURSING CARE PLAN # 3

Name Alma Avila Reason for Admission uterine contraction with cough x 3weeks
Age 35 Sex F Medical Impression G4P3(3003)Pu37weeks AOG cephalic on labor, CAP

PLANNING NURSING INTEVENTIONS

NURSING OUTCOME
ASSESSMENT CUES RATIONALE EVALUATION
DIAGNOSIS IDENTIFICATION INTERVENTIONS
(with references)
Subjective: Infant’s altered Goal: Independent: After 2 days of nursing
-The patient verbalized nutrition: less than After 2 days of nursing intervention the goal
that “dili ko pwede body requirements intervention, the a. Discuss to the a. It will allow the patient was partially met. The
magpatotoy niya kay related to bottle mother will be able to: patient the to have a better mother was able to:
tungod sa ako ubo”. feeding importance of understanding about
1. Breast feed the breastfeeding breastfeeding. It will -Breastfeed her child
baby as soon and its benefits help them achieve -Understand and know
as her cough to the mother their goal. the importance of
Objective: Scientific bases: secondary to and child. breastfeeding in the
-Observes that the Newborn’s primary CAP is gone first years of infant’s
baby is bottle fed. source of food intake is b. Discourage b. It will allow the patient life.
through the breast milk Desired Outcome: bottle feeding to understand the
of their mother. And it 1. Achieve during the first effect on the infant of
is very important to let breastfeeding years of not having exclusive
the infant suck the very 2. Improve health infant’s life. breastfeeding in the
first milk that is status of the first years of infant’s
produced right after infant by life.
delivery which is the reduction or no
colostrum. It is known signs of Collaborative:
as the first milk which infection
contains protection for c. Make referrals c. It will prevent problem
the infant against many to neonatal of malnutrition.
diseases/infections. nutritionists
and lactation
Reference: specialists if
Maternal and Child necessary
Health Nursing, eight
edition volume 1, Flagg Dependent:
and Pilliteri page 311 d. Follows d. To avoid error.
doctor’s order

Reference:
Maternal and Child
Health Nursing, eight
edition volume 1, Flagg
and Pilliteri page 311-
312
 NURSING CARE PLAN # 1
Name Alma Avila Reason for Admission uterine contraction with cough x 3weeks
Age 35 Sex F Medical Impression G4P3(3003)Pu37weeks AOG cephalic on labor, CAP

PLANNING NURSING INTEVENTIONS

NURSING OUTCOME
ASSESSMENT CUES RATIONALE EVALUATION
DIAGNOSIS IDENTIFICATION INTERVENTIONS
(with references)
Poor personal hygiene Goal Independent Within 8 hours of
Objective: related to lack of Within 8 hours of a. Assess the a. Use of rendering appropriate
- Observed the adequate knowledge of rendering appropriate knowledge and assessment of nursing intervention
patient with the importance of nursing intervention, hygiene practice knowledge the goal was partially
long and dirty hygiene and sanitation the patient will be able of the patient. provides met. The client was
fingernails secondary to to: complementary able to:
- Messy hair is ignorance of facts assessment of
also observed about the possible General Objectives data for goal -Improved her
- Unpleasant effects of poor hygiene -Improve Personal and intervention Personal Hygiene as
odor noted Hygiene as evidence planning. evidence by clean
Scientific Basis by clean fingernails fingernails and combed
Personal Hygiene is a and combed hair. b. Provide health b. The patient will hair.
self-care by which teaching about the be - Understand and
people attend to such Specific Objectives importance of knowledgeable know the importance of
functions as bathing, a. Understand good hygiene. and understand personal hygiene.
toileting, general body and know the the importance - Know the risks of
hygiene, and importance of of hygiene. improper hygiene.
grooming. Hygiene is a personal
highly personal matter hygiene. c. Discussed c. Knowing the
determined by possible disease possible disease
individual values and b. Perform health that may acquired can help the
practices. It involves teachings given due to poor patient prevent
care of the skin, feet, to them such as hygiene. this from
nails, oral and nasal combing hair occurring. It will
cavities, teeth, hair, and keeping serve as
eyes, and perineal- the fingernails motivation to the
genital areas. and toe nail client.
 clean and short d. Demonstrate the d. It will help to
Reference c. Know the risks proper trimming of minimize the
Fundamentals of of improper nails and the hand spread of
nursing ninth edition, hygiene. washing technique infection and
Kozier and Erb’s, pp. through using demonstrating it
750 nails, soap, towel will help the
and water. client know the
correct
procedure and
way how to do it.

e. Provide hair care e. It will help the

for client client improve
her appearance
and grooming
and increase
sense of well-
being.

Reference
Fundamentals of
nursing ninth edition,
Kozier and Erb’s, pp.
750-786
 NURSING CARE PLAN # 2
Name Alma Avila Reason for Admission uterine contraction with cough x 3weeks
Age 35 Sex F Medical Impression G4P3(3003)Pu37weeks AOG cephalic on labor, CAP

PLANNING NURSING INTEVENTIONS

NURSING OUTCOME
ASSESSMENT CUES RATIONALE EVALUATION
DIAGNOSIS IDENTIFICATION INTERVENTIONS
(with references)
Subjective: Ineffective airway Goal: Independent: 1. Rapid, shallow After 2 days of nursing
-The patient verbalized clearance related to After 2 days of nursing 1. Assess breathing patterns intervention the goal
that she has a cough retain secretions as intervention, the respirations: and was met the client was
for 3 weeks. evidence by changes mother will be able to: note quality, hypoventilation able to:
in depth and rate of rate, rhythm, directly affects 1. Breathed
respiration 1. Breathe depth, use of gas exchange. normally.
normally. accessory Hypoxia is 2. Partially free
2. Partially free muscles, ease, associated with from
Objective: from and position signs of increased pneumonia.
-Observable coughing pneumonia. assumed for breathing effort. 3. Less mucus
and difficulty of Scientific bases: easy (Matt Vera, BSN, secretion with
breathing Desired Outcome: breathing. R.N.,2017) clear color.
-T: 36.2 Pneumonia is an 4. The vital signs
P: 63 bpm inflammation of the 1. Presence of 2. As oxygenation were stabilized.
R: 25cpm lung parenchyma, mucus 2. Observe color and perfusion
BP: 100/70 mmHg associated with secretion will of skin, become impaired,
alveolar edema and lessen. mucous peripheral tissues
congestion that impair 2. Stabilize vital membranes, become cyanotic.
gas exchange. signs and nail beds, Cyanosis of nail
. noting beds may
presence of represent
peripheral vasoconstriction
cyanosis (nail or the body’s
beds) or response to
central fever/chills;
cyanosis however,
(circumoral). cyanosis of
 earlobes, mucous
membranes, and
skin around the
mouth (“warm
membranes”) is
indicative of
systemic
hypoxemia.
(Matt Vera, BSN,
R.N.,2017)

3. Monitor heart 3. Tachycardia is

rate and usually present as
rhythm and a result of fever
blood and/or
pressure. dehydration but
may represent a
response to
hypoxemia. Initial
hypoxia and
hypercapniaincre
ases BP and HR.
As hypoxia
becomes more
severe, BP may
drop while HR
tends to continue
to be rapid with
dysrhythmias.
(Matt Vera, BSN,
R.N.,2017)

4. Monitor body 4. High fever

temperature (common in
 as indicated. bacterial
pneumonia and
influena) greatly
increases
metabolic
demands and
oxygen
consumption and
alters cellular
oxygenation.
(Matt Vera, BSN,
R.N.,2017)

Collaborative:
1. Referral to 1. For accurate
radiology result and to
technician for x- determine the
ray procedure progress of the
treatment

Dependent:
1. Follows 1. To avoid
doctor’s order medication error
for medication and to achieve
fast recovery.