NURSING CARE PLAN

Cues Diagnosis Planning Implementation Rationale Evaluation

Subjective Cues Risk for infection related Short term: Independent: Short term:
to premature rapture of Within 8 hours of nursing - Routinely monitor the - As these values can After 4 hours of nursing
- Patient had no amniotic membranes as intervention the patient patient’s lab values such signify underlying intervention the patient
prior medical evidence by vaginal would be able to: as white blood cell infection has:
history and no use bleeding count, serum protein,
of an intrauterine - Demonstrate and serum albumin. - Reported signs and
contraceptive adequate personal symptoms of
device (IUCD) or hygiene. - Monitor the patient for - As these would infection and follow
assisted fertility any physical signs of signify infection screening and
treatments - Report signs and infection such as monitoring
- The patient reports symptoms of swelling, purulent procedures
increasing left- infection and follow discharge or presence of
sided pelvic pain screening and pain from wounds, - Demonstrated
monitoring injuries, catheters or adequate personal
procedures. drains. hygiene
Objective Cues
Long term: - Maintain strict asepsis - decreases the Long term:
- Stable vital signs Within 24 hours of for dressing changes, chances of After 24 hours of nursing
- No signs of nursing intervention the wound care, transmitting or intervention the patient
hypovolemic shock patient would be able to: intravenous therapy, spreading pathogens is:
- Patients had 2 and catheter handling.
weeks of - Be free of signs and - Free of any signs and
intermittent symptoms of - Instruct patient and - Knowledge of ways symptoms of
vaginal bleeding infection. family in performance to reduce or infection
of personal hygiene eliminate germs
practices to protect reduces the
against infection such as likelihood of Goal Met
cleaning the area of the transmission.
procedure.
 - Encourage adequate - It can reduce stress
rest. and boost the
immune system.

Collaborative:
- Refer patient and family - Collaborative care
to social services or enhances the
community resources to recovery of the
assist in managing home patient and reduce
hygiene and nutrition the chance of
contracting infection

Ectopic pregnancy:
A 26-year-old gravida 2 para 1 woman presented to the emergency department with 2 weeks of intermittent vaginal bleeding, increasing left-sided pelvic pain, and a
positive home pregnancy test. Her last known menses was 4 weeks prior, but was shorter than normal, started again 2 days later, and she had been having intermittent
bleeding and pelvic pain since. She had no prior medical history and no use of an intrauterine contraceptive device (IUCD) or assisted fertility treatments. She had delivered
1 child via vaginal delivery 2 years prior and was currently breastfeeding. Her vital signs were stable, and there were no signs of hypovolemic shock.