NURSING CARE PLAN

ASSESSMENT NURSING SCIENTIFIC BASIS GOAL OF CARE OUTCOMES NURSING RATIONALE EVALUATION
DIAGNOSIS CRITERIA INTERVENTION
S: " Malipong ko Decreased cardiac Pre-eclampsia Short Term: After two days (2) Independent: The goal was
miss unya magsakit output related to results from of my nursing achieved the client
akong tangkugo" as increased systemic defective spiral After 2 hours of my intervention the Assess for vital sign Blood pressure may was able to report
verbalized by the vascular resistance artery remodeling nursing intervention client will be able to especially BP fluctuate and spike decrease blood
patient. as evidenced by an leading to cellular the patient will achieve decrease monitoring every quickly; monitor for pressure and
increased blood ischaemia in the lessen the feeling blood pressure and 1hr. changes and feeling of dizziness
pressure level of placenta, which in of dizziness. return to its normal elevations. after two days of
180/100 turn results in an state. my nursing care as
O: imbalance between After 3 hours of my Pre-eclampsia may evidenced by:
anti- angiogenic nursing Assess for vision progress overtime
and pro-angiogenic Report decrease of
T- 37.3° C intervention the disturbance and or suddenly to
factors. cognitive function blood pressure
BP- 180/100 blood pressure of eclampsia and from 180/100 to
RR- 19 cpm the patient will results in seizures. 120/90
O- 95 % decrease.
Low sodium diet The client
Long Term: and elevation of verbalized that
Provide nutrition feet to reduce she's not feeling
 NURSING CARE PLAN
ASSESSMENT NURSING SCIENTIFIC BASIS GOAL OF CARE OUTCOMES NURSING RATIONALE EVALUATION
DIAGNOSIS CRITERIA INTERVENTION
Subjective Data: Unstable blood Glucose Short Term: After the nursing Independent The patient's blood
glucose level, as accumulates in the intervention: Intervention: glucose level are
"Ang resulta sa ako evidenced by the blood rather than To make the blood Monitor vital signs. To obtain baseline within normal
lab test kay ni saka patient's narrative being absorbed by glucose levels of The patient will data. range.
ako blood sugar." and laboratory test the cells. Unlike the patient within maintain glucose Provide proper For them to gain
as verbalized by the results. type 1 diabetes, normal range. levels education about knowledge about
patient. gestational diabetes 65-100mg/dL. The patient has
nutritional intake. factors contributing
is caused by Long Term: gained adequate
additional
to unstable blood
Objective Data: knowledge
hormones released Dependent glucose levels.
V/S: After four days of Intervention: regarding the
during pregnancy nursing factors that
T: 36.5 that might make intervention, the contribute to
insulin less Administer To manage high
BP: 130/80 patient will reach unstable blood
efficient, a intravenous fluids blood glucose
RR: 19bpm and maintain a glucose levels and
condition known as and insulin levels.
PR: 82bpm glucose level of less how to manage
insulin resistance. additives or oral
BG LEVELS: than 100 mg/dL. A them.
diabetic agents as
 NURSING CARE PLAN

ASSESSMENT NURSING SCIENTIFIC GOAL OF CARE OUTCOMES NURSING RATIONALE EVALUATION

DIAGNOSIS BASIS CRITERIA INTERVENTION
Subjective Data: Risk for Deficient A condition where Short Term: After the 1 Independent The goal of care
Fluid Volume the fluid output day of nursing Intervention: Information and was achieved.
"Kapoy kaayo related to exceeds the fluid After 45 minutes of intervention Instruct patient, knowledge
akong lawas bleeding from intake. It occurs my nursing The patient caregiver, and about condition The client’s urine
ma’am niya uhaw ruptured ectopic when the body intervention the urine output family members are vital to output is greater
sad kaayo permi.” Pregnancy. loses both water patient urine output will be greater regarding fluid patients who will than 30ml/hr. The
and electrolytes will be greater than 30 than 30ml/hr restrictions, as be co-managing vital signs were
Objective Data: from the ECF in mL/hr and normal and skin appropriate. fluids. maintained and
V/S: similar skin turgor. turgor. stabilized. As
proportions. Monitor vital signs. To manage the evidence by:
T: 37.5 Patient’s vital signs and
BP: 90/60 Long Term: signs will Monitor fluid intake. symptoms of  36 ml/hr
RR: 26bpm remain stable fluid deficit. urine ouput
PR: 110bpm After 24 hours of my and/or return Limit sodium intake  Blood
nursing intervention to patient’s as prescribed. Restriction of Pressure
Output: 20ml/hr the patient’s vital baseline sodium aids in from 90/60
signs are maintained Provide proper decreasing fluid mmhg to
1. Patient maintains Patient’s education about retention 110/70
HR 60 to 100 intake and dehydration: mmhg
beats/min. output will progression of Information is  Respiratory
2. Systolic BP stabilize dehydration, key to Rate from
greater than causative factors managing 26bpm to
or equal to Patient will and behaviors problems.
 90 mm HG verbalize essential to correct 18bpm
(or patient’s measures to fluid deficit.  Pulse Rate
baseline) take at home from 110
3. Patient has to maintain Dependent bpm to
balanced hydration/prev Intervention: Fluids are 80bpm
intake and ent  Administer necessary to
output and dehydration parenteral fluids as maintain From the recovery
stable prescribed. hydration Bleeding of
weight. Consider the need status. ruptured ectopic
4. Patient for an IV fluid Determination pregnancy the
demonstrate challenge with an of the type and client verbalizes
s lifestyle immediate infusion amount of fluid that her recovery
changes to of fluids for patients to be replaced stage has been
avoid with abnormal vital and infusion easier as she was
progression signs rates will vary hydrated.
of depending on
dehydration. clinical status.
5. Patient
verbalizes
awareness of
causative
factors and
behaviors
essential to
correct fluid
deficit.
 NURSING CARE PLAN
ASSESSMENT NURSING SCIENTIFIC BASIS GOAL OF CARE OUTCOMES CRITERIA NURSING RATIONALE EVALUATION
DIAGNOSIS INTERVENTION
Subjective: Acute pain related scientific Basis: Short Term:  The client will Independent  It can assist Client should
“Mag lisod kog to biological Urinary tract After 1-3 hours of report satisfactory nursing actions: determine the verbalize
pangihi kay sakit factors such as infections (UTIs) nursing pain control pain Assess the client’s degree of comprehension of
kaayo, unya tulo trauma of the are a severe public interventions, the control at a level previous elimination change and urinary tract
ra“as verbalized by activity of the health problem and patient’s pain will less than 3 to 4 on pattern and note for track the infection, causes
the patient disease process are caused by a be relieved or a scale 0 to 10. the presence of progression of contributing to it,
range of managed. the disease. and how to
frequency, urgency,
Objective: pathogens, but manage the
Febrile most commonly by Long term:
burning sensation, condition; engage
 The client  It may assist
Lower abdominal Escherichia coli, temperature will size, and force of to maintain in actions to avoid
pain Klebsiella After 1-3 days of decrease into 36.7. the urinary stream. renal function, reinfection.
Restlessness pneumoniae, independent inhibit the
Stress Proteus mirabilis, nursing production of The client should
Enterococcus  Client will report Determine the urinary stones, have established a
interventions the
PAIN SCALE: faecalis and absence of pain. presence of pain and avoid regular elimination
client will be able
Staphylococcus noting for location, further pattern, as shown
10/10 saprophyticus.
to achieve a by decreased,
duration, intensity. infection.
High recurrence normal elimination burning feeling,
 NURSING CARE PLAN

ASSESSMENT NURSING SCIENTIFIC GOAL OF CARE OUTCOMES NURSING RATIONALE EVALUATION

DIAGNOSIS BASIS CRITERIA INTERVENTION

Subjective: Risk for Postpartum Short Term:  The client Independent:  To measure  After 8 hours
“ Pila naka semana ineffective haemorrhage  After 6 shows no  Monitor the amount of nursing
ni labay sa akong tissue perfusion as a loss of hours of sign of amount of of blood interventions,
panganak pero related to blood in the nursing bleeding bleeding by loss. the patient
kusog gihapon ang hemorrhage. postpartum intervention and its weighing all was able to
agas sa dugo” as period of more the recovering pads.  Early demonstrate
verbalized by than 500 mL. bleeding is back to its recognition adequate
patient. The average reduced. normal  Frequently of possible perfusion
spontaneous state. monitor adverse and stable
vaginal birth Long term: vital signs. effects vital signs.
Objective: will typically  After 3 allows for
 Restlessness have 500 mL days prompt
 Confusion blood loss. nursing  Massage intervention.
 Irritability intervention the uterus.
 V/S taken the  To help
as follows: bleeding  Provide expel clots
T: 36.8 stop. comfort of blood and
P: 105 measure it is also
R: 24 like back used to
Bp: 150/70 rubs, deep check the
breathing. tone of the
 Instruct in uterus and
relaxation ensure that
or it is clamping
visualization down to
exercises. prevent
excessive
Collaborative: bleeding.
 Administer
oxygen as
indicated.  Encourages
venouse
 Administer return to
medication facilitate
as indicated circulation,
(e.g and prevent
Methergine) further
bleeding.

 Promotes
relaxation
and may
enchance
patients
coping
abilities by
refocusing
attention.

 To supply
adequate
oxygen to
 the fetus
and mother
and prevent
further
complication.

 To promote
contraction
and prevent
further
bleeding.