NURSING CARE PLAN – CHO

Name of Client: MS. L.B. Age: 21 years-old

Civil Status: Single Sex: Female

Name of Obstetrician: Dr. Teresita Reyes

Diagnostic Impression: Twin pregnancy; Normohydramnios

Obstetric Impression: G2P0T0P1A1L0

Assessment/ Cues Nursing Diagnosis Background Goals and Nursing Evaluation

Knowledge Objectives Interventions and
Rationale

Subjective Data: Disturbed Body Disturbed body NOC: Body Image NIC: Body Image GOAL PARTIALLY
Image related to image is the Enhancement MET
The client verbalizes increase in uterus confusion [and/or
“simula nung size dissatisfaction] in the After 8 hours of I: Establish rapport After 8 hours of
nabuntis ako na- mental picture of nursing intervention, with the client nursing intervention,
conscious na ako sa one’s physical self. the client will be able R: To establish trust the client was able to:
physical appearance to: and cooperation with
ko kasi feeling ko the client.
tumaba ako, lalo na ● Verbalized an
kambal pa ang ● Verbalize an I: Evaluate the understanding of
pinagbubuntis ko”. understanding of client’s knowledge of body changes.
body changes. and anxiety related to
Objective Data: situation: ● Mentioned relief
Height: 153.4 cm ● Mention relief of R: to assess the of anxiety yet still
Weight: 45 kg anxiety and causative factors in progress of
Body Temperature: adaptation to contributing to the adaptation to
Blood Pressure: actual body client’s status. actual body
110/70 image. I: Assess client’s image.
Respiratory Rate: response to changes
Heart Rate: ● Recognize and in body. ● Recognized and
Oxygen Saturation: incorporate body R: Determines the incorporated
image change extent of the body body image
into self-concept image disturbance. change into self-
in an accurate concept in an
manner without accurate manner
negating self- I: Assess client’s without negating
esteem. current adaptation self-esteem.
and progress.
● Acknowledge self R: to determine ● Acknowledged
as an individual coping abilities and herself as an
who has skills. individual who
responsibility for has responsibility
self. for self.
I: Encourage open
communication with
the client.
R: Providing open
communication that is
free from judgement
will allow the client
to feel more
comfortable.

I: Encourage the
client to look or touch
the affected body part
to begin incorporating
changes into body
image.
R: to assist the client
to deal with or accept
issues of self-concept
related to body
image.
I: Encourage
relaxation techniques
routine for the client
such as watching TV,
listening to calm
music, and
meditating.
R: this is to alleviate
the client’s anxiety
towards her body
image changes.

I: Be realistic and
positive during
treatments and setting
goals within the
limitations.
R: Provide
information at the
client’s level of
acceptance and in
small segments to
allow easier
assimilation.