Mirana, Pyanka Crystal A.

CMCRP Lec
BSN 2-7 02/13/23

NURSING CARE PLAN

NCP#1 : Hypermesis Gravidarium

ASSESSMENT DIAGNOSIS PLANNING INTERVENTION EVALUATION

Subjective data: Fluid volume Short term: Independent: The goal was
The patient deficit related to After 1 hour of  Assess vital sign and note met, adequate
verbally stated prolonged vomiting nursing the changes in blood fluid volume with
that she was as evidence by intervention, the pressure such as a balanced intake
nauseated and deviations affecting patient will be able hypotension, and and output.
vomited intake-limited oral to verbalize tachycardia. Nausea and
frequently intake understanding of  Assess for signs of vomiting reduce
throughout the causative factors dehydration. and the patient is
day. and purpose of  Monitor nutrition status to now free with the
interventions and prevent further weight loss signs of
The patient feels medications.  Encourage to digest dehydration.
thirsty and had carbohydrates, such as Proper nutrition
lost her appetite. Long term: crackers or baked potatoes has also observed
After 8 hours, the and foods with strong by the patient.
patient will no odors should be eliminated
Objective data: longer vomit from the diet. Taking
• Vomiting repeatedly and the liquids between solid
• Dehydration vital signs will be meals helps to reduce
• Fainting in normal range . gastric distention.
• Hypotension  Provide nurse-patient
• Tachycardia interaction by listening to
• Weight loss patient’s feeling about
pregnancy, child rearing,
and living with constant
nausea.
 Provide health teaching

Dependent:
 Administer IV fluids
 Administer antiemetic
drugs such as Diclegis at
bedtime, transdermal
clonidine, and oral
ondansetron
 Monitor electrolyte levels
and replace, as indicated
NCP#2 : Acute pain related to episiotomy

ASSESSMENT DIAGNOSIS PLANNING INTERVENTION EVALUATION

Subjective data: Acute pain related Short term: Independent: The goal was
The patient to episiotomy as After an hour of  Establish rapport met, the patient
verbally stated evidenced by 3/10 nursing  Assess quality, verbalized
that she felt the pain rating scale intervention, the characteristics and severity decreased
pain in her and grimaced face patient’s pain will of pain. intensity of pain
perineum every be reduced by a  Acknowledge the patient’s from 3/10 to 0/10
time she sat. rating of 0/10 pain experience and and no longer
instead of 3/10. convey acceptance of have grimace
Objective data: patient’s response. upon movement.
• Pointed at her After an hour of  Provide the patient in a Also, the patient
perineum area nursing comfortable environment is relieved from
• The patient rate intervention, the and place her in a pain with positive
the pain 3 (1 patient will comfortable side lying coping
lowest- 10 demonstrate position. mechanism.
highest) comfort and no  Provide health teaching
• Facial grimace longer have about perineum and
• Discomfort grimace upon episiotomy care.
movement.
Dependent:
Long term:  Administer analgesics as
After 4 hours of ordered by the physician.
nursing
intervention,
- The patient will
show relief from
pain with positive
coping
mechanism.
- The patient will
not have
complaints of pain.
NCP#3 : Mastitis

ASSESSMENT DIAGNOSIS PLANNING INTERVENTION EVALUATION

Subjective data: Risk for ineffective Short term: Independent: The goal was
The patient breastfeeding After 8 hours of  Ask the patient to rate the met, the patient
verbalizes having related to nursing pain from 0 to 10, and was able to
difficulty at interruption intervention, the describe the pain she is experienced
latching and starts secondary to patient will be able experiencing. decreased pain,
to have a red, inflammation as to experience  Advise the patient to wear redness and
painful area on her evidence patient decreased pain, a good support bra to swelling in right
right breast reporting pain in redness and support the breasts. breast. Also, the
resulting in right breast swelling in right  Support the patient patient was able
difficulty breast. emotionally and gave her to be free from
breastfeeding. reassure. the signs and
Long term:  Apply warm compress on symptoms of
Objective data: After 3 days of the affected breast. Advise Mastitis and
• Breast has a nursing the mother to do it every resume
hard, tender, red intervention, the 2-4 hours since breast breastfeeding
spot on the right patient will be free massage while with effective
outer area from the signs and breastfeeding can also emptying of the
• Red breast is symptoms of help. breast.
developing mastitis and  Ask the patient to
resume reposition herself in a
breastfeeding with more comfortable
effective emptying position.
of the breast.  Assess the patient’s
knowledge regarding the
process of lactation and
breastfeeding then provide
health teaching

Dependent:
 Administer analgesics and
anti-inflammatory
medications as prescribed
 Ask the patient to re-rate
her acute pain 30 minutes
to an hour after
administering the
analgesic.

Collaborative:
 Make referrals to neonatal
nutritionist and lactation
specialists if necessary.