Nursing Care Plan NCP

CLINICAL INSTRUCTOR : Adriel Arman V. Pizarra, DHCM, MAN, RN

CASE STUDY NO. 1 – Kristinelou Marie N. Reyna
CLIENT NAME : Rachel S. Agapito AGE : 23 SEX : F
REASON FOR ADMISSION : Watery Vaginal Discharge
ADMITTING IMPRESSION : G1P0 Pregnancy Uterine, 39 weeks AOG, Cephalic in latent phase of labor / Prelabor Rupture of Membrane PHYSICIAN : Dr. Yu / Dr. Hermogenes

Goals and Nursing

Assessment Nursing Rationale Evaluation
Outcomes Interventio
Diagnosis
ns
BP = - Risk for Anxiety - Client will be able Monitor frequency, Detects
100/60mmHg to report anxiety at duration, and progress and
RR = 19 - Acute Pain R/T manageable level. intensity of uterine screens for an
RR = 100 Stimulation of both contractions. abnormal
beats/min TEMP parasympathetic and - Client will use uterine
= 36.5 sympathetic nerve breathing and Monitor maternal vital response.
O2 SAT = 98% endings, muscle relaxation techniques signs after drug
WEIGHT = 63 KG tension, verbalization effectively and administration. Note Using charts or
proficiently. drug’s effectiveness drawings of the
(+) pain @ lower and the physiological body can both
back “I have pain at - Client will verbalize response. Informed help the patient
my lower back and actual reduction of Dr. Yu after and the nurse in
and pelvic area” pain at the administration. determining
lumbosacral area. specific pain
G1P0 Discuss to the client locations.
LMP : 7/28/2019 - Client will the take home meds
AOG : 39 weeks effectively urinate - Celecoxib 200 mg Knowing client’s
(LMP) EDC : 5/5/20 and defecate ( 1 cap BID x 1 week ) attitudes toward
37 6/7 weeks by 1st UTZ properly. - Cefuroxime 500 pain and reactions
mg ( 1 tab BID x 7 to pain are
SPE : (+) minimal - Client will be able to days ) individual and
witish discharges at to maintain good based on past
posterior fornix area, nutritional intake. Continue to monitor experiences,
foul smell IE : 1 cm, and record fluid input cultural
UE ST -5, - Client will be able and output. background, and
Leaking BOW, to maintain normal self-concept.
Cephalic, posterior, vital signs.
firm, BISHOP score : Monitoring and
1 - Client will be have Recording vital
A : G1P0, 39 weeks a follow up at APS signs, drug
AOG, Cephalic in clinic on May 6, administration,
latent phase of labor, 2020 fluid input and
PROM P : Admit output will help
the physician in
decision making.
 Nursing Care Plan NCP
CLINICAL INSTRUCTOR : Adriel Arman V. Pizarra, DHCM, MAN, RN
CASE STUDY NO. 1 - Daniel Fernandez Student No. 05-1920-09379
NAME : Rachel Agapito AGE : 23 SEX : F
REASON FOR ADMISSION : Watery Vaginal Discharge
ADMITTING IMPRESSION : G1P0 Pregnancy Uterine, 39 weeks AOG, Cephalic in latent phase of labor / Prelabor Rupture of Membrane PHYSICIAN : Dr. Yu / Dr. Hermogenes

Goals and Nursing

Assessment Nursing Diagnosis Rationale Evaluation
Outcomes Interventions

BP = 100/60mmHg
RR = 19
RR = 100 beats/min
TEMP = 36.5
O2 SAT = 98%
WEIGHT = 63 KG

(+) pain @ lower back

“I have pain at my
lower back and and
pelvic area”

G1P0
LMP : 7/28/2019
AOG : 39 weeks (LMP)
EDC : 5/5/20
37 6/7 weeks by 1st UTZ

SPE : (+) minimal

witish discharges at
posterior fornix area,
foul smell IE : 1 cm, UE
ST -5,
Leaking BOW, Cephalic,
posterior, firm, BISHOP
score : 1
A : G1P0, 39 weeks
AOG, Cephalic in latent
phase of labor, PROM
P : Admit
 FDAR CHART
CLINICAL INSTRUCTOR : Adriel Arman V. Pizarra, DHCM, MAN, RN
CASE STUDY NO. 1 - Daniel Fernandez Student No. 05-1920-09379
NAME : Rachel Agapito AGE : 23 SEX : F
REASON FOR ADMISSION : Watery Vaginal Discharge
ADMITTING IMPRESSION : G1P0 Pregnancy Uterine, 39 weeks AOG, Cephalic in latent phase of labor / Prelabor Rupture of Membrane PHYSICIAN : Dr. Yu / Dr. Hermogenes

DATE FOCUS DATA, ACTION AND RESPONSE

DATE FOCUS DATA, ACTION AND RESPONSE
 DRUG STUDY CHART
CLINICAL INSTRUCTOR : Adriel Arman V. Pizarra, DHCM, MAN, RN
CASE STUDY NO. 1 - Daniel Fernandez Student No. 05-1920-09379
NAME : Rachel Agapito AGE : 23 SEX : F
REASON FOR ADMISSION : Watery Vaginal Discharge
ADMITTING IMPRESSION : G1P0 Pregnancy Uterine, 39 weeks AOG, Cephalic in latent phase of labor / Prelabor Rupture of Membrane PHYSICIAN : Dr. Yu / Dr. Hermogenes
DRUG NAME RECEPTOR THEREPEUTIC USES ADVERSE EFFECTS
DRUG NAME RECEPTOR THEREPEUTIC USES ADVERSE EFFECTS
 CAUDO-CEPHALIC ASSESSMENT
NAME : Rachel Agapito AGE : 23 SEX : F
REASON FOR ADMISSION : Watery Vaginal Discharge
ADMITTING IMPRESSION : G1P0 Pregnancy Uterine, 39 weeks AOG, Cephalic in latent phase of labor / Prelabor Rupture of Membrane PHYSICIAN : Dr. Yu / Dr. Hermogenes
INTEGUMENTARY FINDINGS

Skin, Hair, Nail, Skull, Face

EYES AND VISION FINDINGS

Eyebrows, Eyelashes, Eyelids, Bulbar Conjunctiva,Palpebral

Conjunctiva, Sclera, Lacrimal gland, Lacrimal sac, Nasolacrimal
duct, Cornea, Pupils

EAR AND HEARING FINDINGS

Auricles, External Ear Canal,

NOSES AND SINUSES FINDINGS

External Nose, Nasal Cavity

MOUTH AND OROPHARYNX FINDINGS

Teeth, Tongue and floor of the mouth, Tongue movement, Uvula,

Gag Reflex
 CAUDO-CEPHALIC ASSESSMENT
NAME : Rachel Agapito AGE : 23 SEX : F
REASON FOR ADMISSION : Watery Vaginal Discharge
ADMITTING IMPRESSION : G1P0 Pregnancy Uterine, 39 weeks AOG, Cephalic in latent phase of labor / Prelabor Rupture of Membrane PHYSICIAN : Dr. Yu / Dr. Hermogenes
NECK FINDINGS

Head movement, Muscle strength, Lymph Nodes, Thyroid Gland

THORAX AND LUNGS FINDINGS

Anterior Thorax

ABDOMEN FINDINGS

Abdominal movements, Auscultation of bowel sounds

UPPER AND LOWER EXTREMITIES FINDINGS

Muscles, Bones and Joints,

MENTAL STATUS / GROSS MOTOR FUNCTION FINDINGS

Language, Orientation, Attention span, Level of Consciousness,

Walking gait,