NURSING CARE PLAN TEMPLATE (SCHOOL HEALTH and SAFETY NURSING ROTATION)
NCM107 – CARE OF MOTHER, CHILD AND ADOLESCENT (Well Client)
NCP A
Name of Student: KRC
Name of Patient: Mrs M’s Civil Status: Married
Diagnosis or Clinical Impression: Acute Pain Age: 27 years old Sex: Female
ASSESSMENT NURSING DIAGNOSIS PLAN INTERVENTIONS RATIONALE EVALUATION
(Differentiate (Actual or Potential with (Include Long and Short (At least 5 and include (with scientific evidences as (State whether met,
OBJECTIVE from complete parts) Term Goals plus at least only the MOST needed) partially met or unmet
SUBJECTIVE DATA) 3 outcome criteria) APPROPRIATE for and the supporting
client’s context) outcomes)
- Establish Rapport - To gain trust and The goal set for the
Subjective: Acute pain related to cooperation of the client was:
“I’ve been experiencing uterine contractions with patient. Met
contractions at 7-10 7-10 minutes interval as - Assess degree of Partially Met
minute intervals since 4pm evidence muscle tension. discomfort through - Attitudes and Unmet
which lasted 30 seconds.” verbal and nonverbal reactions to pain are As evidenced by:
cues; note cultural individual and based
“I also hiving “a lot of practices on pain on past experiences,
false labor” and hoped that Long Term Goal: response. understanding
this was “the real thing”. After 8 hours of nursing of physiological At the end of 8 hours of
intervention the patient changes, and cultural nursing interventions the
pain will be relieved and expectations. patient the patient pain
Objective: controlled. Decreasing was be relieved and
intensity of pain from 8/10 - Assess nature and - Cervical dilation controlled by describing
BP= 124/80 mmHg to 3/10. amount of vaginal should be the pain 1/10 in the pain
show, cervical approximately 1.2 scale.
Temp: 36.8οC dilation, effacement, cm/hr in the nullipara
fetal station, and and 1.5 cm/hr in
PR = 94 bpm fetal descent. the multipara; vaginal
RR = 23 Objective: show increases with a
At the end of 15 minutes fetal descent. At the end of 15 minutes
Abdominal contractions of nursing interventions of nursing interventions
the patient will - Time and record the - Monitor the labor the patient demonstrated
4pm onwards; contraction demonstrate use of frequency, intensity, progress and provide use of relaxation skills.
frequency for every 7-10 relaxation skills. and duration of information for the Such as therapeutic
mins. Lasting for 30 uterine contractile client. touch, doing side lying
seconds. pattern per protocol. position and back rubs.
Membranes intact At the end of 15 minutes - Provide information - Allows client to make At the end of 15 minutes
nursing interventions the about available informed choice nursing interventions the
patient will express relief analgesics, usual about means of pain patient expressed relief
obtained from labor pain responses/side control. obtained from labor pain
by the use of childbirth effects (client and by the use of childbirth
techniques learned and fetal), and duration techniques learned and
comfort measures given. of analgesic effect in comfort measures given.
light of current “Hindi na gaano masakit
situation. ma’am”
- Maternal hypotension,
At the end of 15 minutes - Assess BP and pulse the most common At the end of 15 minutes
nursing interventions the every 1–2 min after side effect of regional nursing interventions the
patient will appear regional injection for block anesthesia, may patient had relaxed and
relaxed/resting between first 15 min, then interfere with fetal had been resting between
contractions every 10–15 min for oxygenation. contractions
remainder of labor.
At the end 30 minutes At the end 30 minutes
nursing interventions - Elevate head - Elevating head nursing interventions
patient will be free of approximately 30 prevents block from patient is free of
untoward side effects if degrees, alternate migrating up and untoward side effects as
analgesia/anesthetic agents position by turning causing analgesia/anesthetic
are administered. side to side and use respiratory depression. agents are administered.
of hip roll. Lateral positioning
increases venous
return and enhances
placental circulation.
- Monitor FHR - To assess alterations
variability. that should be
investigated
thoroughly.
- Provide safety - Analgesics alter
measures; e.g., perception, and client
encourage client to may fall trying to get
move slowly, keep out of bed.
side rails up
after drug
administration, and
support legs with
position changes.
- Assist with comfort - Promotes relaxation
measures (e.g., and hygiene; enhances
back/leg rubs, sacral feeling of well-being.
pressure, back rest,
mouth care,
repositioning,
shower/hot tub use,
perineal care, and
linen changes).
- Assist in use of - Facilitates progression
appropriate of normal labor.
breathing and/or
relaxation techniques
and in abdominal
effleurage.
- Administer analgesic - Administering IV
such meperidine drug during uterine
hydrochloride contraction decreases
(Demerol) by IV amount of medication
during contractions, that immediately
as order when reaches the fetus.
needed
Demerol 50 mg with
Phenergan 25 mg IV when
needed.
Submitted by: Evaluated by:
KAYELYN – ROSE C. COMBATE CORY MANUEL
(Signature over Complete Name) (Signature over Complete Name)
NCP B
Name of Student: KRC
Name of Patient: Mrs M’s Civil Status: Married
Diagnosis or Clinical Impression: Risk for infection Age: 27 years old Sex: Female
ASSESSMENT NURSING DIAGNOSIS PLAN INTERVENTIONS RATIONALE EVALUATION
(Differentiate (Actual or Potential with (Include Long and Short (At least 5 and include (with scientific evidences (State whether met,
OBJECTIVE from complete parts) Term Goals plus at least only the MOST as needed) partially met or unmet
SUBJECTIVE DATA) 3 outcome criteria) APPROPRIATE for and the supporting
client’s context) outcomes)
The goal set for the client
Subjective: Risk for maternal infection - Establish Rapport - To gain trust and was:
related rupture of cooperation of the Met
“Pumutok na ang membrane in exposure to patient. Partially Met
Panubigan!” pathogens. Unmet
- Assess the patient from - Must follow sterile As evidenced by:
any signs and procedure during
Objective: symptoms of infection vaginal exams.
while hospitalized
M’s membranes ruptured Long Term Goal: After 8 hours of nursing
After 8 hours of nursing - Promote proper - Serve as first line of intervention the patient
8:42 pm membrane intervention the patient will handwashing by all defense against maintained a free infection
rupture; contraction maintain a free infection as care givers before and infection. as evidenced by normal
frequency for every 4 evidenced by normal vital after patient interaction. vital signs and absence of
minute. Lasting for 40-55 signs and absence of signs signs and symptoms of
seconds and symptoms of infection. - Maintain sterility when - Minimize the rate of infection.
cleaning the site. pathogens introduced to
Vaginal Exam Complete the site.
Short Term Goal:
+2 Station After 2 hours of nursing - Monitor temperature, - Increased temperature After 2 hours of nursing
interventions, patient will pulse, and WBC or pulse greater than interventions, patient will
understand the risk factors count, as indicated. 100 bpm may indicate understand the risk factors
of infection as evidence by: infection. of infection as evidence by:
- Perform perineal care - Helps promote
-Verbalizing understanding per protocol, using cleanliness; prevents -Verbalized understanding
of individual causative or medical asepsis. development of an of individual causative or
risk factors of infection. Remove fecal ascending uterine risk factors of infection.
contaminants infection and “Yes I will do proper
expelled during possible sepsis. hygiene”
pushing; change linens
- Identify interventions to /under pad during - Identify interventions to
prevent or reduce risk of pushing; change prevent or reduce risk of
developing an infection. linens/under pad as - Within 4 hour after developing an infection.
needed. rupture of membranes, Remove fecal contaminants
the client and fetus are expelled during pushing;
- Note date and time of at increased risk for change linens /under
rupture of membranes. ascending tract pad during pushing
infections and possible
sepsis.
- Listing down way/s on - Listing down way/s on
how to promote safe - Use surgical asepsis in - Reduces risk of how to promote safe
environment. preparing contamination environment.
equipment. Clean Proper Hand Hygiene, Use
perineum with sterile aseptic techniques.
water and soap or
surgical disinfectant
just prior to delivery.
- Helps prevent
- Provide aseptic postpartal infection and
conditions for delivery. endometritis.
Submitted by: Evaluated by:
KAYELYN – ROSE C. COMBATE CORY MANUEL
(Signature over Complete Name) (Signature over Complete Name)
