NURSING CARE PLAN
ASSESSMENT NURSING DIAGNOSIS PLANNING INTERVENTION EVALUATION
Subjective: “ Masakit Acute pain related to prineal Short-term goal: - Assess pain level, characteristics Short-term goal: The
pa yung tahi ko” trauma secondary to postpartum Within 4-6 hours the and non-verbal cues every 2-4 patient reported a
- Rates pain 7/10 on status as evidenced by verbal patient will report pain hours. decrease in pain from
a numeric pain scale report of pain (7/10) and reduction from 7/10 to 7/10 to 3/10 after
restlessness. at least 3/10 after - Encourage deep breathing interventions.
Objective: interventions. exercises, relaxation techniques
- Patients appears and guided imagery. Long-term goal: The
restless Long-term goal: patient demonstrated
- No visible crying or Within 48 hours. The - Instruct the patient on proper understanding of pain
severe distress patient will verbalize perineal care including gentle management
effective pain cleansing. techniques and
Vital signs: management and followed perineal care
Bp: 120/90 mmHg demonstrate the - Encourage early ambulation and instructions.
Temp. 36.1 ability to perform self proper positioning.
PR: 80 bpm care activities with
RR:17breaths per minimal discomfort.
minute
O2sat: 98%
NURSING CARE PLAN
ASSESSMENT NURSING DIAGNOSIS PLANNING INTERVENTION EVALUATION
Subjective Data: Risk for Bleeding related to - The patient will - Monitor vital signs (blood - The patient
The patient reports, inadequate knowledge as verbalize an pressure, pulse, temperature) verbalized an
"Maraming dugo ang evidenced by heavy menstrual understanding of the regularly understanding of the
lumalabas sakin flow. normal menstrual menstrual cycle and
(menstrual), hindi
cycle and signs of - Assess menstrual flow and excessive bleeding
tatagal ng isang oras
ang napkin ko kaya
excessive bleeding frequency of changing adult within the expected
adult pampers na ang within one week. diapers time-frame.
gamit ko."
- The patient will - Encourage fluid intake (at least- The patient
Objective Data: identify red flags or 2-3L/day) demonstrated
Vital signs: BP: 120/70 symptoms requiring awareness of warning
mmHg, Temp: 36.7°C medical intervention, - Encourage rest and avoidance of signs that require
PR:61bpm, RR:18 such as excessive strenuous activities medical attention.
breaths per minute bleeding, dizziness,
or prolonged periods. - Educate the patient about the - The patient reported
Patient is using adult
diapers due to heavy normal menstrual cycle and a reduction in fatigue
menstrual bleeding, warning signs of abnormal and maintained
requiring frequent bleeding adequate hydration.
changes.
Prescribed
medications
(Paracetamol 500mg
and Tranexamic Acid
500mg) are available
and taken as
prescribed.
Experiencing mild
fatigue.
NURSING CARE PLAN
ASSESSMENT NURSING DIAGNOSIS PLANNING INTERVENTION EVALUATION
Subjective Data: Grieving related to the loss of a - The patient will - Encourage expression of -The patient
The patient reports, newborn, as evidenced by non- demonstrate emotions without forcing the demonstrated
"First time ko acceptance of death. adaptive coping patient to talk. adaptive coping
namatayan ng baby, strategies. - Assist family members in strategies.
hindi ko alam kung understanding and tolerating the
bakit." - The patient will client’s feelings and behavior. - The patient exhibited
exhibit reduced signs - Promote a safe and hopeful reduced signs of
Objective Data: of intense emotional environment to help the patient intense emotional
Non-acceptance of distress. identify their own inner control. distress.
death - Encourage verbalization of
Vital Signs: thoughts and feelings without
- Blood Pressure: confrontation, especially around
120/80 mmHg the realities of the situation.
- Temperature: - Encourage the expression of
36.3°C anger, fear, and anxiety.
- Pulse Rate: 84 - Support the patient in resuming
bpm involvement in usual activities,
- Respiratory Rate: exercises, and social interactions
15 breaths per within their physical and emotional
minute capabilities.
- Oxygen
Saturation: 97%
NURSING CARE PLAN
ASSESSMENT NURSING DIAGNOSIS PLANNING INTERVENTION EVALUATION
Subjective Data: Ineffective breastfeeding - Encourage early - Assess breastfeeding technique - The mother
The patient reports, related to delayed lactation due and frequent for proper latch and positioning. successfully breastfed
"Wala pa po gatas to cesarean section. breastfeeding every using improved
na lumalabas sa 2-3 hours to - Apply warm compresses before positioning
akin." stimulate milk feeding and perform breast techniques.
supply. massage to promote milk flow.
Objective Data: - Expressed a small
- Delayed milk - Provide breast - Provide nutritional guidance, amount of milk after
production massage and warm encouraging high-protein foods breast massage and
compresses to and adequate fluid intake to pumping.
Vital Signs: promote milk support lactation.
- Blood Pressure: letdown. - The mother
130/80 mmHg - Offer reassurance and emotional verbalized
- Temperature: - Educate the patient support to reduce anxiety about understanding of
37.1°C on proper latch and delayed milk production. techniques to
- Pulse Rate: 97 positioning, enhance milk
bpm especially production.
- Respiratory Rate: considering post-C-
19 breaths per section comfort.
minute
- Oxygen - Provide emotional
Saturation: 95% support and
reassurance
regarding delayed
lactation.
NURSING CARE PLAN
ASSESSMENT NURSING DIAGNOSIS PLANNING INTERVENTION EVALUATION
Subjective Data: Deficient Fluid Volume related - Continue to monitor - Administer fluids as directed by - The patient’s vital
The mother reports to increased fluid loss as the patient’s vital the healthcare provider. signs were regularly
that the 3-year-old evidenced by the patient's signs, particularly monitored, and there
patient is lethargy, restlessness, and the respiratory rate, - Monitor input/output and note was no significant
change in respiratory
experiencing mother’s report of dehydration. temperature, and any changes in urination
rate, temperature, or O2
dehydration and hydration status. frequency or consistency. saturation. The child
appears lethargic. remained stable but
- Educate the mother - Assess the child’s energy level showed slight
on signs of severe and responsiveness to stimuli improvement in
Objective Data: dehydration and regularly. alertness.
Vital Signs: when to seek further - The mother was
- Respiratory Rate: medical help. - Encourage oral hydration if the educated on the signs of
29 breaths per child is able to drink. If not, severe dehydration and
minute - Observe for any consider administering IV fluids to demonstrated
- Temperature: changes in the correct dehydration. understanding by
verbalizing the need to
36.6°C child’s level of
seek further medical
- Oxygen consciousness, and help if these symptoms
Saturation: 96% assess for signs of worsen.
- Pulse Rate: 74 worsening - The child’s level of
bpm dehydration. consciousness
- The child appears remained stable with no
lethargic and signs of further
restless. deterioration, and there
were no additional signs
of worsening
dehydration during the
observation period.
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