Cez NCP

Republic of the Philippines
BATANGAS STATE UNIVERSITY

The National Engineering University
Rizal Avenue Ext., Batangas City, Batangas, Philippines 4200
Tel Nos.: (+63 43) 980-0385; loc 1127
Office of the College of Nursing and Allied Health Sciences
Case: RH/ABO incompatibility
ASSESSMENT DIAGNOSIS PLANNING IMPLEMENTATION RATIONALE EVALUATION
Subjective: Self-care deficient related to the Short term goal: IINDEPENDENT Short Term:
impaired physical mobility and
"Hirap akong kumilos at
weakness secondary to the fatigue
After 5 hours of nursing  Changing the position  Assisting the pregnant Goals were met after 5 hours of
nanghihina din po" intervention, frequently woman in finding nursing intervention; the client has
and generalized weakness as
evidence by low respiratory  Monitor the respiratory rate comfortable positions, such experienced improved physical
 The client will experience
respiration. every hour as using pillows for support mobility and the client will report a
improved physical mobility normal respiratory respiration from
Objective:  Encourage regular rest and while sitting or sleeping,
and the client will report a 7 to 15
pacing helps alleviate pressure on
Drowsiness normal respiratory respiration
joints and muscles, reducing
from 7 to 15.
discomfort and improving
DEPENDENT mobility. Proper positioning Long Term:
Vital Signs: can also promote optimal
Long term goal:  Provide supplemental oxygen fetal positioning for labor and Goals were met after 1 week of
Respiratory rate: 7 nursing intervention; the client has
therapy delivery
After 1 week of nursing maintained improved physical
 Administer muscle relaxants
intervention,
 Encourage adequate intake of  Monitoring respiratory rate in mobility and respiration rate at
 The client will maintain fluids and nutritious foods. pregnant women is crucial for permissible boundaries.
improved physical mobility early detection of respiratory
and respiratory respiration at issues, assessment of
permissible boundaries COLLABORATIVE: oxygenation status, and
timely intervention to ensure
 Provide healthy lifestyle the health and safety of both
education the mother and the fetus.
 Encouraging the pregnant

woman to prioritize rest and
pacing activities throughout
the day helps prevent fatigue
and conserves energy, which
can be especially beneficial
Leading Innovations, Transforming Lives, Building the Nation

Tel Nos.: (+63 43) 980-0385; loc 1127
for those experiencing

impaired physical mobility.
Adequate rest periods allow
for muscle recovery and may
alleviate discomfort
associated with prolonged
standing or walking.
 Pregnant women with

impaired physical mobility
may have limited mobility
and reduced ability to
optimize oxygenation through
physical activity. Oxygen
therapy helps meet the
increased oxygen demands of
both the mother and the fetus,
ensuring adequate oxygen
delivery to tissues and organs.
 Muscle relaxants may be used

in conjunction with physical
therapy to enhance the
effectiveness of therapeutic
exercises and interventions
aimed at improving mobility
and function
 Proper nutrition is essential

for maintaining maternal
health during pregnancy,
especially for women with

Tel Nos.: (+63 43) 980-0385; loc 1127
impaired physical mobility

who may have additional
challenges in accessing
nutritious food or preparing
meals. Adequate intake of
nutrients supports maternal
immune function, energy
levels, and overall well-being,
reducing the risk of
complications such as
anemia, infections, or poor
wound healing.
 Empower the patient with

knowledge and skills for self-
care and promoting adherence
to treatment plans,
encouraging healthy
behaviors, and reducing
modifiable risk factors for the
mother and the fetus

Tel Nos.: (+63 43) 980-0385; loc 1127
ASSESSMENT DIAGNOSIS PLANNING IMPLEMENTATION RATIONALE EVALUATION
Subjective: Activity intolerance related to pain Short term goal: IINDEPENDENT: Short Term:
and weakness secondary to the
"Hirap po ako gumalaw galaw, After 8 hours of nursing  Monitor blood pressure every Goals were met after 8 hours of
normal physiological changes of  Allows for early detection
tsaka po paghinga ko po medyo intervention, hour nursing intervention; the client has
the pregnancy as evidenced by of any worsening signs of
hirap din"  Change the position experienced relief from pain and
nausea, difficulty of breathing with  The client will experience decreased blood pressure
frequently weakness and the client will report
pane scale of 4/10 and decreased relief from pain and weakness
 Provide privacy and a normal blood pressure rate from
Objective: blood pressure and the client will report a  Promotes optimal lung
equipment within easy reach 90/60 to 120/90
normal blood pressure rate expansion by reducing
Nausea during personal care pressure on the diaphragm
from 90/60 to 120/90 Long Term:
activities. and improving ventilation
perfusion matching. It also Goals were met after 1 week of
Physical assessment: Long term goal:
DEPENDENT: helps alleviate discomfort nursing intervention; the client has
Difficulty of breathing
After 1 week of nursing associated with breathing maintained balance energy level
Pain scale 4/10  Administer antiemetics
intervention, difficulties and enhances and adequate blood pressure at
 Provide supplemental oxygen permissible boundaries
Vital signs: overall comfort and well-
 The client will maintain therapy
BP: 90/60 being
balance energy level and  Monitor the food and fluid
adequate blood pressure at intakes
acceptable limits  It helps maintain their sense
of control over their body and
COLLABORATIVE: personal space. Having
equipment within easy reach
 Address social determinants ensures efficiency and
of health and nutrition minimizes discomfort or
inconvenience for the mother,
 Provide healthy lifestyle
promoting a smoother and
education
more respectful care process
 Helps alleviate symptoms of

nausea and vomiting, which
are common during
Tel Nos.: (+63 43) 980-0385; loc 1127
pregnancy and can

significantly affect the
woman's quality of life. By
reducing nausea and
vomiting, antiemetics can
improve the woman's ability
to maintain proper nutrition
and hydration, which is
essential for her health and
the health of the developing
fetus.
 To improve oxygenation and

alleviate respiratory distress,
ensuring adequate tissue
oxygenation and preventing
oxygen deficiency
 Help identify triggers for

common pregnancy
symptoms such as nausea,
vomiting, heartburn, and
constipation. By modifying
the diet and fluid intake, it
can offer strategies to
alleviate these symptoms and
improve the mother's comfort
and well-being.
 Lessen barriers to healthcare

access, ensure adequate
nutrition, and address
socioeconomic factors

Tel Nos.: (+63 43) 980-0385; loc 1127
impacting health outcomes

and promotes well-being of
the mother and the fetus
 Providing education on the

risks associated with these
behaviors encourages
pregnant women to make
healthier choices to protect
the health of their unborn
child.

Cez NCP

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Cez NCP

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Republic of the Philippines

BATANGAS STATE UNIVERSITY

Office of the College of Nursing and Allied Health Sciences

Case: RH/ABO incompatibility

ASSESSMENT DIAGNOSIS PLANNING IMPLEMENTATION RATIONALE EVALUATION

 Encouraging the pregnant

Leading Innovations, Transforming Lives, Building the Nation

Office of the College of Nursing and Allied Health Sciences

for those experiencing

 Pregnant women with

 Muscle relaxants may be used

 Proper nutrition is essential

Leading Innovations, Transforming Lives, Building the Nation

Office of the College of Nursing and Allied Health Sciences

impaired physical mobility

 Empower the patient with

Leading Innovations, Transforming Lives, Building the Nation

Office of the College of Nursing and Allied Health Sciences

ASSESSMENT DIAGNOSIS PLANNING IMPLEMENTATION RATIONALE EVALUATION

 Helps alleviate symptoms of

Office of the College of Nursing and Allied Health Sciences

pregnancy and can

 To improve oxygenation and

 Help identify triggers for

 Lessen barriers to healthcare

Leading Innovations, Transforming Lives, Building the Nation

Office of the College of Nursing and Allied Health Sciences

impacting health outcomes

 Providing education on the

Leading Innovations, Transforming Lives, Building the Nation

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