Nursing Care Plan #1

ASSESSMENT DIAGNOSIS OBJECTIVES INTERVENTION RATIONALE EVALUATION

Subjective: Impaired Short Term Objectives: Independent Interventions: Goal partially met:
comfort
 “Sakit akong At the end of 8 hours of  Instruct in and encourage -To distract attention  Patient reports
related to
bisong kay nursing intervention, use of relaxation and reduce tension pain is reduced
trauma to
naa koy the client will be able techniques, such as yet not fully due
perineum
tinahian ug to: focused breathing, to uncomfortable
during labor
lisod e lihok.” imaging, listening to music. positioning and
and delivery.  Experience a
as verbalized environmental
satisfactory relief  Provide comfort measures
by client. factors
measure (e.g. touch, repositioning of
heat or cold packs, nurse’s -To promote  Shows an
 Reduced grimacing nonpharmacological
presence), quiet interest in
Objective: of face pain management
environment and calm participating
 Irritability  Use of activities activities of
pharmacological recovery
 Positioning  Monitor Vital Signs
and
to avoid pain  Verbalizes
non-pharmacologic
non-pharmacolo
 Grimacing of al pain-relief
gical strategies
Collaborative Interventions: -These are usually
face when strategies
altered in acute pain were performed
moving  Provide for individualized to relieve pain
Long Term Objectives:
physical therapy or
At the end of 16 hours exercise program that can
of nursing intervention, be continued by the client -Promotes active
the client will be able after discharge rather than passive,
to: role and enhance
 Provide pain relief sense of control
 Demonstrate use medication with prescribed
of relaxation skills analgesics such as
and pain diversion mefenamic acid. -Each client has a
activities. right to expect
maximum pain relief.

Nursing Care Plan #2

 ASSESSMENT DIAGNOSIS OBJECTIVES INTERVENTION RATIONALE EVALUATION

Subjective: Disturbed Short Term Objectives: Independent Interventions: Goal Partially Met:
Sleeping Pattern
 “Galisod kog At the end of 8 hours of  Provide bed to sleep -Comfortable  Patient was
Related to
tulog kay saba nursing intervention, beds promote able to
Hospitalization
kaayo ug the client will be able and prolongs determine
(Noise and
igang.” as to: sleep. factors
Uncomfortable
verbalized by affecting sleep
Temperature)  Determine factors
the client. yet due to
that prevent or
-To uncontrollable
inhibit sleep.
compensate happenings in
Objective:  Observe possible  Encourage patient to the lack of the area
ways to promote take a nap sleep. sleeping
 Dark circles pattern is still
sleep.
under eyes disturbed.
 Yawning
 Puffy eyes
Long Term Objectives:
 Dozing during -To promote
the day At the end of 16 hours readiness for
of nursing intervention, sleep and
the client will be able  Minimize sleep improve sleep
to: disturbing factors(such duration and
as reducing talking and quality
 Report an optimal other disturbing noises).
balance of rest and
 activity.
 Identify individually -to minimize
appropriate the disturbance
Collaborative Interventions:
interventions to of sleep
promote sleep.  Inform other nurses to
reduce the time of
checking vital signs.

Nursing Care Plan #3

 ASSESSMENT DIAGNOSIS OBJECTIVES INTERVENTION RATIONALE EVALUATION

Subjective: Excess fluid Short Term Independent Interventions: Goal Met:

volume related Objectives:
 “Naghubag ako  Educate patient the -Knowledge  The client
to childbirth.
tiil. Adto pani At the end of 8 importance of proper heightens was able to
nako hours of nursing nutrition, hydration, compliance with exhibit
nabantayan intervention, the and diet modification. the treatment plan. decreased
paghuman client will be able edema on the
 Elevate edematous -Elevation
nakog to: left lower
extremities, and handle increases venous
panganak.” as extremity, as
• Determine with care. return to the heart
verbalized by evidence by
causative factors. and, in turn,
the mother. the following
decreases edema.
• Experience indicators:
Edematous skin is
decrease
more susceptible -Relate
Objective: discomfort.
to injury. causative factors.
 Pitting edema
-Relate
on the left lower
Long Term methods of
extremity. -Restriction of
Objectives: decreasing
sodium aids in
 Grimacing of discomfort.
At the end of 16 decreasing fluid
face when  Limit sodium intake as retention
hours of nursing
moving left prescribed.
intervention, the
lower extremity.
client will be able
to: -To have specific
interventions
 Exhibit
including
decreased medications.
edema on the
Collaborative Intervention:
left lower
extremity.  Refer to doctor if
severe signs and
symptoms shows.