EMILIO AGUINALDO COLLEGE

School of Nursing

NURSING CARE PLAN

NAME: Bonilla, Yla Katrina C. PATIENT NAME: D. B. L. AGE: 30 GENDER: F DOB: 3/13/1993 DOA: 3/11/2024 DATE: 03/13/2024
STUDENT #: 21-1-00762 DIAGNOSIS: Seizure; Loss of Consciousness
ASSESSMENT NURSING OUTCOME NURSING INTERVENTION RATIONALE EVALUATION
DIAGNOSIS IDENTIFICATION
Subjective: Risk for Injury Short term Goal:  Assess latch attempts  Identifying specific issues The Goal was met.
 Report of related to seizure as After 8-hours of nursing and identify specific during latch attempts helps Short term Goal:
seizure and evidenced by loss of intervention, the challenges. tailor interventions to After 8-hours of
loss of consciousness mother/newborn will be address the root cause, nursing intervention,
consciousnes able to: promoting successful the mother/newborn
s  Achieve a breastfeeding. was able to:
successful latch  Achieve a
during at least one  Assist parents in  Correct positioning is successful
Objective: breastfeeding positioning the baby crucial for successful latch during at
Vital Signs of: session. correctly during latching. Hands-on least one
BP: 90/60  Verbalize breastfeeding assistance helps parents
breastfeeding
RR: 18 understanding of sessions. gain confidence in
PR: 66 session.
proper positioning the baby
T: 36.6 effectively.  Verbalize
breastfeeding
O2Sat: 99% techniques and understanding
 Sudden positioning.  Conduct health  Empowering parents with of proper
dizziness  Consume an teaching about proper knowledge enhances their breastfeeding
 Blurry of vision adequate volume breastfeeding, breast ability to facilitate techniques
 Loss of of breast milk care and care for the successful breastfeeding, and
consciousness during infant. ensuring a supportive positioning.
 Uncontrollable breastfeeding environment for the baby.  Consume an
body tremors sessions. adequate
 Demonstrate  Alternate the  Every 15minsfor the first volume of
proficiency in breastfeeding from 24hours; but eventually, the breast milk
breastfeeding either breast. best thing to do is to never during
techniques and break the hood latch on; breastfeeding
positioning. the neonate doesn’t start to sessions.
receive fat-and-protein rich
 EMILIO AGUINALDO COLLEGE
School of Nursing

 Show signs of hind milk after 15 mins.  Demonstrate

effective sucking
and swallowing
during
breastfeeding
sessions.
Long term Goal:
After 3 days of nursing
intervention, the patient will
be able to immediate
success in latching
promotes positive
reinforcement for both the
baby and parents,
addressing immediate
nutritional needs and
boosting confidence.
 Collaborate with a  Involving a lactation
lactation consultant for
expert guidance.
proficiency in
breastfeeding
consultant ensures techniques
specialized support, and
offering insights and positioning.
strategies to overcome
 Show signs of
challenges associated with
effective
latching.
sucking and
swallowing
during
breastfeeding
sessions.
Long term Goal:
After 3 days of nursing
intervention, the patient
was able to immediate
success in latching
promotes positive
reinforcement for both
the baby and parents,
addressing immediate
nutritional needs and
boosting confidence.
 EMILIO AGUINALDO COLLEGE
School of Nursing

NURSING CARE PLAN

NAME: Bonilla, Yla Katrina C. PATIENT NAME: G. L. AGE: 52 GENDER: F ROOM NO. 842 DOA: 2/10/24 DATE: 2/20/2024
STUDENT #: 21-1-00762 DIAGNOSIS: S/P Multiple Odontectomy; Closure of Oro Antral Communication; Maxillary Bone Recon with
Endosteal Implant 2/11
ASSESSMENT NURSING OUTCOME NURSING INTERVENTION RATIONALE EVALUATION
DIAGNOSIS IDENTIFICATION
Subjective: Risk for Infection Short term Goal:  Monitor Surgical Sites.  Regular assessment of The goal was met.
“May related to surgical After 1 week of nursing surgical sites allows for Short term Goal:
nararamdaman procedures including intervention, the patient early detection of signs of After 1 week of
parin akong kirot Multiple will be: infection, facilitating prompt nursing intervention,
pero tolerable Odontectomy;  Demonstrate no intervention and preventing the patient was able
naman, inoobserve Closure of Oro Antral signs of infection at the progression of potential to:
nalang ako ng Communication; surgical sites, complications.  Demonstrate no
dalwang araw at Maxillary Bone including absence of signs of infection
pinapainom ng Recon with redness, swelling, or  Instructing the patient on at surgical sites,
antibiotic para di Endosteal Implant  Instruct the patient to
abnormal discharge. meticulous oral hygiene and including
daw mainfection perform meticulous oral
 Verbalize emphasizing aseptic absence of
sabi ni doc” hygiene, including
understanding of practices help minimize the redness,
gentle brushing and
infection prevention risk of infection, promoting swelling, or
Objective: rinsing, to prevent
measures, including optimal wound healing. abnormal
bacterial colonization
 Patient the importance of discharge.
and reduce the risk of
complies oral hygiene and  Verbalize
infection.
with timely reporting of understanding of
prescribed any signs of infection
antibiotic infection.  Co-amoxiclav is prescribed prevention
regimen.  Administer Antibiotics.
to preemptively combat measures,
 Oral Long term Goal: potential bacterial infections including the
hygiene After 1 month of nursing associated with importance of
practices intervention, the patient will: compromised oral mucosa oral hygiene and
are  Consistently practice and exposed bone tissue timely reporting
observed for effective oral following surgical of any signs of
technique procedures. infection.
hygiene, reducing
and
 EMILIO AGUINALDO COLLEGE
School of Nursing

frequency. the risk of oral  Teach the patient

infections. effective oral care
 Over the next three techniques that promote
months, the patient cleanliness without
will remain free from causing trauma to the
complications related surgical sites.
to the surgical Demonstrate proper
procedures, brushing and flossing
including infection, techniques,
implant-related emphasizing gentle
issues, or delayed movements to avoid
healing. irritation.
 Patient Education.
 Gentle oral care practices
are crucial to prevent Long term Goal:
trauma to the surgical sites.  After 1 month of
Proper brushing and nursing
flossing techniques maintain intervention, the
cleanliness while minimizing patient was able
the risk of disrupting the to:
healing process.  Consistently
practice effective
oral hygiene,
reducing the risk
of oral
infections.
 Over the next
 Patient understanding of the three months,
importance of completing the patient will
the full course of antibiotics remain free from
is crucial for treatment complications
efficacy, preventing related to the
antibiotic resistance, and surgical
ensuring a comprehensive procedures,
approach to infection including
prevention. infection,
implant-related
issues, or
delayed healing.