COLLEGE OF HEALTH SCIENCES

NURSING DEPARTMENT

NURSING CARE PLAN

NCM 107 RELATED LEARNING EXPERIENCE OB WARD
CARE OF MOTHER, CHLID, ADOLESCENT (WELL CLIENT)

ASSESSMENT DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATION

Subjective Data: Pain related to  Checking the chart of  Upon the assessment finding try  To identify if there is an  Assess for the re
 Pain scale of post operative the patient. to re-assess the patient if the increase or decrease in occurrence of the
3/10 on the procedure  Provide intervention frequency of the pain intensifies the in the pain scale of pain and if possible,
post operative to the existing chief or decrease if it radiates or only the patient. refer for the doctor
site due to CS compliant of the localize area.  Missed take medication to either suggest for
patient.  Ask the patient if he take the can lead to a another pain reliver
and Ligation as
 Monitor progress. pain medication that are discomfort especially if medication or
verbalized by prescribe by the doctor. the anesthesia is being increase the dosage.
 Patient should feel
the mother. comfortable after  Perform a cold compress to ease expelled it effect the
 Minimal lochial series of the pain of the patient. Continue body after the
discharge. intervention. it until the pain at least reduce. operation will be able
 Frequent eating Check for the possible sign or to feel the pain.
of the baby cold burn if too much exposure to  Ice is the natural
(breastfeeding). the cold compress is made. anesthesia so with
 Re-asses after if the existing chief being compress with
Objective Data: complain have a prognosis. ice it would at least
reduce the pain and
 G3P3
inflammation if there is
(L3A0T3P0)
a presence.
 Patients are  Verify if the complaint
Preeclamptic. is being provided with
 Well contracted care.
uterus.
 Mother can sit.
 Good suckling Deficient  Briefly discuss the  Assess the patient or family  To identify what are  Assess for the
reflex Knowledge pre-eclampsia to the member’s understanding of the the prior thought of the retaliation of the
 Good gripping related to Pre- family and to the disease process by providing a patient and the family. information by the
reflex eclampsia patient. thorough explanation about the  If some circumstances patient and should
 Provide simple and disease, etiology of preeclampsia, arise and a possible be absorb the info
 Pinkish in color
direct to the point signs and symptoms, risk factors, immediate attention is about the pre-
 Flexion and explanation of the and the consequences for both needed, verbalization eclamsia.
Extension of complication. the mother if not treated/ of the presenting
the upper and  Family and patient controlled. situation are must.
lower should be able to  Inform the patient to report  Inform and give the
extremities as formulate series of immediately any signs/symptoms possible option and
well as the neck question that would that indicate a worsening of the referrals to the
are good. supply there condition and when to contact specialist for the better
 Initial Vitals curiosity. the healthcare professional. treatment.
Sign: Instruct the client to report any
new onset of headaches, vision
abnormalities.
Mother:
 Educate the patient about the
BP= 120/80 importance of adherence to
RR= 17 bpm treatment plans and keeping
HR= 87 bpm follow-up appointments.
O2= 99%
TEMP:
A= 36.2 C
Baby:
RR= 122 bpm
HR= 30 bpm
TEMP:
A= 35.8 C
 Newborn Care  Assessment of the  Cephalocaudal assessment to the  Early identification of  The patient should
newborn for the newborn, reflexes, to early notify the possible be able to do the
possible post if there are post neonatal complication on the independent care on
neonatal complication. post neonatal patient the succeeding time
complication.  Allowing the mother to watch will be to assess for the and be able to
 Demonstration of during bathing the baby and cord possible early understand the
things that the cleaning. symptoms of such health teaching that
mother needs to  Providing health teaching for disorder and are provided.
know for providing breastfeeding, proper complication.
independent care to positioning, and attachment  For a better teaching of
her newborn baby. during breastfeeding, frequency the certain care to the
 Evaluation of the of in the breastfeeding as well as neonate letting the
the capability of the the diet of the mother. mother or the father do
mother on doing it would be a better
independent care for way to teach the
her baby. patient.
 And provide health  Supplying heath
teaching that are teaching for the patient
related to the are well vitals to
presenting situation facilitate knowledge
of the baby. and quality self care.

SUBMITTED BY: SUBMITTED TO:

JOHN KOBE M. TOMAGAN SHIRRA MAE O. FERNANDEZ

BSN 2 B Clinical Instructor
GROUP 3