(Arled) NCP3

Republic of the Philippines
CEBu NORMAL UNIvERSITy

Osmeña Blvd., Cebu City, 6000, Philippines
College of Nursing
Telephone No.: (+63 32) 254
4837 Email: cn@cnu.edu.ph
Website: www.cnu.edu.ph
Theory-based (Betty Neuman)

NURSING CARE PLAN
Assessment 3 points (15%) Goals 4 points (20%) Interventions 5 points (25%) Bibliography 1 point (5%)
Diagnosis 3 points (15%) Theoretical Basis 2 points (10%) Evaluation 2 points (10%) 20 points
Name of Student:
Client’s Initials: A.M.V. Stressor Classification: (Please check)
Age: 25 Gender: F Civil Status: Married Religion: Roman Catholic Physiological (body structure and functions)
Allergies: No known food and drug allergies √ Psychological (mental processes and emotion) Diet:
Diet as Tolerated Socio-cultural (relationships, social expectations) Date
of Admission: September 2, 2021 Spiritual (influence of spiritual beliefs)
Diagnosis/Impression:37 3/7 weeks AOG; G1P0T0P0A0L0M0 Developmental (developmental processes over the lifespan)
NURSING DIAGNOSIS NURSING GOALS NURSING OUTCOME
Assessment Diagnosis Mutual Planning Interventions Actual Evaluation
(Goal attainable within the shift) (with Rationale & Source)
Subjective: Short-term goal: PRIMARY INTERVENTIONS (focuses on Goals are met.
 Client shared that she Interrupted family processes strengthening the flexible line of defense through
has been less intimate as evidenced by change in After one hours of nursing preventing stress and reducing risk factors) After one hour of
with her husband for a intimacy intervention, the client is able to: Promotive: nursing intervention;
couple of months. 1. Verbalize understanding of the the client was able to:
 She stated that she value of sexual intimacy Intervention: Observe patterns of communication 1. Verbalize
fears that having among couples; in the family. understanding of
sexual intimacy would 2. Showcase understanding on the Rationale: This identifies weakness/areas of the significance
affect the status of the safety of the fetus in the concern to be addressed as well as strengths that of sexual
baby. mother’s uterus during sexual can be used in formulating the solution of the intimacy among
intimacy; problem. couples; and
3. Identify other alternatives to Sources: (Doenges, Moorhouse, & Murr, 2012) 2. Showcase
Certification Date: 1 February 2021 SDF-CON-304-070-00

Recertification due date: 24 January 2024 For
verification of the certificate please access
www.gcl-intl.com (Certification check and
Page 1 of 4
type the registration number)
Registration No. 52Q18778

College of Nursing
Theoretical basis: sexual intimacy to improve Intervention: Assess boundaries between the understanding
Objective: relationship satisfaction; and family couple/members. on the safety of
Interrupted family processes refer 4. Display interest in having Rationale: This helps identify specific problems fetus in the
to the breaking in the continuity of sexual intimacy with her that need to be addressed. mother’s uterus
family functioning which fails to husband. Sources: (Doenges, Moorhouse, & Murr, 2012) during sexual
support the well-being of its intimacy;
support (Herdman, & Long-term goal: Intervention: Listen for expressions of despair or 3. Identify other
Kamitsuru, 2018). The people helplessness. alternatives to
that are at risk for interrupted After three days of nursing Rationale: It helps assess the degree of distress and sexual intimacy
family processes are people that interventions, the client will be able inability to handle what is happening. to improve
experience changes in family to: Sources: (Doenges, Moorhouse, & Murr, 2012) relationship
finances, social status, and 1. Exhibit a deeper understanding satisfaction; and
developmental transition such as on the safety of the fetus during Intervention: Acknowledge difficulties and 4. Display interest
pregnancy (Herdman, & sexual intimacy; and realities of the situation. in having sexual
Kamitsuru, 2018). During 2. Display no fear in engaging Rationale: This reinforces that some of degree of intimacy with
pregnancy, some people fear that sexual intimacy with her conflict is to be expected and can be used to her husband.
they pose a risk towards the husband. promote growth.
developing fetus if they have a Sources: (Doenges, Moorhouse, & Murr, 2012) After three days of
sexual intercourse. They fear that nursing intervention,
during copulation, they might Preventive: the client was able to:
physically hurt the baby which 1. Exhibit more
would result in something bad Intervention: Note cultural and/or religious factors depth in
happening to the baby. Contrary to Rationale: Cultural and religious factors may understanding
that belief, the fetus is completely affect perceptions/expectations of the couple. on the fetus’
safe during sexual intimacy. The Sources: (Doenges, Moorhouse, & Murr, 2012) safety during
developing fetus is placed and sexual intimacy;
protected inside the amniotic fluid and
(“Sex During and After 2. Display no fear in

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College of Nursing
Pregnancy”, n.d.). It serves as the SECONDARY INTERVENTIONS (focuses on engaging sexual

primary protection of the fetus and strengthening the internal lines of resistance and intimacy with her
through doing so, it helps the fetus protecting the basic structure through appropriate husband.
develop normally. Aside from the treatment of symptoms)
amniotic fluid, the fetus is also Curative:
protected by the uterine muscles
(“Sex During and After Intervention: Stress the importance of continuous,
Pregnancy”, n.d). Together with the open dialogue between family members.
amniotic fluid, they serve as a Rationale: This helps facilitates ongoing problem-
cushion – protecting the fetus from solving.
physical harm. Sources: (Doenges, Moorhouse, & Murr, 2012)
It is significant for couples to Intervention: Encourage expression and

engage in sexual intimacy acknowledgment of feelings. Do not deny or
religiously as little to none can reassure client/SO that everything will be all
cause a toll on their right.
marriage/relationship. Sexual Rationale: It is helpful to assist the person in
intimacy is a great component of expressing their feelings to help relieve internal
one’s relationship. Lack of it may stress.
result in the person feeling insecure Source: (Martin, 2020)
and anxious (Nwadike, 2021).
According to Impett, Muise, and Intervention: Assist family in setting realistic
Schimmack (2015), having frequent goals.
sexual intimacy may lead to Rationale: This helps the family gain control over
improved communication and the situation.
feelings of closeness within Source: (Martin, 2020)
couples. Moreover, they shared that
the required amount to feel a higher

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College of Nursing
relationship satisfaction is to have TERTIARY INTERVENTIONS (focuses on

sexual intercourse once a week. maintaining wellness or protecting the client system
Other than that, other alternatives in reconstitution through supporting existing strengths and
increasing relationship satisfaction continuing to preserve energy)
includes cuddling, kissing, and Rehabilitative:
affectionate gestures (Nwadike,
2021). Intervention: Refer to classes such as couple’s
therapy.
Rationale: It helps promote positive adaptation
within the family.
Sources: (Doenges, Moorhouse, & Murr, 2012)
Intervention: Identify community resources that

may be helpful in dealing with the situation.
Rationale: This helps the couple achieve mutual
support for reaching a common goal.
Sources: (Martin, 2020)

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College of Nursing
References:
Alivertie, A. & LoMauru, A. (2015). Respiratory physiology of pregnancy. Retrieved 1 September from https://dx.doi.org/10.1183%2F20734735.008615
Cronkleton, E. (2018). Why does breathlessness occur in early pregnancy?. Retrieved 1 September 2021 from https://www.healthline.com/health/shortness-of-breath-early-
pregnancy
Doenges, M., Moorhouse, M. and Murr, A., 2012. Nurse's Pocket Guide Diagnoses, Prioritized Interventions, and Rationales. 14th ed. Philadelphia: F.A. Davis Company, pp.99-102.
Herdman, T. & Kamitsuru, S., (2018). NANDA International, Inc. nursing diagnoses. 11th ed. New York: Thieme Publisher, p.273.
Impett, E., Muise, A., & Schimmack, U. (2015). Sexual frequency predicts greater well-being, but more is not always better. Retrieved 2 September 2021 from
https://journals.sagepub.com/doi/abs/10.1177/1948550615616462
Martin, P. (2020). 8 Asthma nursing care plans. Retrieved 2 September 2021 from https://nurseslabs.com/asthma-nursing-care-plans/7/
Nwadike, V.R. (2021). How does celibacy affect your health?. Retrieved 2 September 2021 from medicalnewstoday.com/articles/326518
Sex During and After Pregnancy. (n.d.). Retrieved 2 September 2021 from https://www.webmd.com/baby/guide/sex-and-pregnancy#1

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College of Nursing
Nursing Care Plan Product Assessment Rubric
CRITERIA Competent Advance Beginner Novice

All subjective and/or objective cues identified are The subjective and/or objective cues identified include The subjective and/or objective cues identified include
Assessment aligned, relevant and sufficient in the formulation of some data that are misaligned, irrelevant but sufficient several data that are misaligned, irrelevant making it
(3) the nursing diagnosis enough in formulating the nursing diagnosis insufficient in the formulation of the nursing diagnosis
(3) (2) (1)
The nursing diagnosis is appropriate based on the cues The nursing diagnosis is appropriate based on the cues The nursing diagnosis is inappropriate based on the cues
and the priority complaints of the patient or of the presented but may not necessarily be the priority presented and does not reflect the patient’s response to
Diagnosis (3) case scenario nursing problem based on the patient’s health situation the illness.
(3) or of the case scenario (1)
(2)
All the concepts, models and theories (at least 3) are The concepts, models and theories include some The concepts, models and theories are irrelevant and do
Theoretical relevant and substantially supports the nursing information that are irrelevant to the patient’s not substantially support the nursing diagnosis in
Basis (2) diagnosis in relation to the patient’s case case, relation to the patient’s case
(2) however, the data (less than 3) still adequately supports (1)
the nursing diagnosis in relation to the patient’s case (1.5)
Goal/s set is/are specific, measurable, attainable, Goal/s set missed 1-2 elements but the statements are Goal/s set missed 3 or more elements and the
Goals/Goal realistic and time-bounded. Includes both short-term aligned to the identified nursing problem. Goal setting statements are not aligned to the identified nursing
Setting and long-term goals and are aligned to the identified considers both short term and long-term care. problem.
(4) nursing problem. (3) (2)
(4)
All interventions are related and responsive to the Interventions include some data that are unrelated and Interventions include several data that are unrelated
Interventions identified needs and sufficient to help attain the unresponsive to the identified needs, however, the and unresponsive to the identified needs which results
(5) goal. (5) identified interventions are sufficient to help attain the goal. in the non-attainment of the set goal/s.
(4) (3)
The subjective/objective data are aligned, relevant and The subjective/objective data include information that are The subjective/objective data include information that
Evaluation adequate to assess the attainment of the outcome misaligned, irrelevant but adequate enough to assess the are misaligned, irrelevant and are inadequate to assess
(2) criteria. attainment of the outcome criteria. the attainment of the outcome criteria.
(2) (1.5) (1)
At least 3 updated (within 8 – 10 years), accurate and Less than 3 updated (within 8 – 10 years), accurate and References provided are not updated, inaccurate,
References
credible references are provided using APA Format credible references are provided using APA Format (0.5) unreliable or no references provided
(1) (1) (0)
Total Score
Name and Signature of the Faculty

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Republic of the Philippines

CEBu NORMAL UNIvERSITy

Theory-based (Betty Neuman)

Certification Date: 1 February 2021 SDF-CON-304-070-00

Registration No. 52Q18778

Certification Date: 1 February 2021 SDF-CON-304-070-00

Registration No. 52Q18778

Pregnancy”, n.d.). It serves as the SECONDARY INTERVENTIONS (focuses on engaging sexual

It is significant for couples to Intervention: Encourage expression and

Certification Date: 1 February 2021 SDF-CON-304-070-00

Registration No. 52Q18778

relationship satisfaction is to have TERTIARY INTERVENTIONS (focuses on

Intervention: Identify community resources that

Certification Date: 1 February 2021 SDF-CON-304-070-00

Registration No. 52Q18778

Certification Date: 1 February 2021 SDF-CON-304-070-00

Registration No. 52Q18778

Nursing Care Plan Product Assessment Rubric

CRITERIA Competent Advance Beginner Novice

Name and Signature of the Faculty

Certification Date: 1 February 2021 SDF-CON-304-070-00

Registration No. 52Q18778

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