NURSING CARE PLAN

CUES NURSING DIAGNOSIS OBJECTIVES INTERVENTIONS RATIONALE EVALUATION

S: “Igang og baho, minsan kay Disturbed sleep pattern related to Within my 8 hours of rendering >Establish Trust and Rapport >To gain cooperation After my 8 hours of rendering
tugnaw, di ta katolog og ayo” as environmental factors holistic care, patient shall be able >Monitor v/s and I&O >To have a baseline data holistic care, patient able to
>Provide bedside care >To provide comfort.
verbalized by the patient to verbalize practices that may verbalize practices that may
enhance sleep pattern. >Assist the patient in scheduling rest >Knowledge and proper planning enhance sleep pattern.
O: 3:30 PM> recieved patient breaks throughout day. can help the patient reduce fatigue
lying on bed;concious;coherent during pregnancy and the immediate
with IVF #3 D5 LR, @550cc level postpartum period.
left, flowing @ 30gtts/min drop >Review daily schedule with the >Knowledge of life changes can help
rate, hooked at Left metacarpal patient, and assist the patient to in planning and implementing
vein, infusing well. adjust her sleep schedule to mechanisms to reduce fatigue and
coincide with the infant‟s sleep sleep disturbance.
>weakness noted pattern.
>Restlessness noted
>irritability noted >Assist the patient in identifying >During the immediate postpartum
lifestyle adjustments that period, 2 to 4 weeks
>drowsiness noted may be needed because of changes after birth, it is important for the
>frequent yawning noted in physiologic mother to adjust her
>slihghtly sunken eyebals noted function or needs during experiential sleep cycle to the infant‟s if at all
>Diaporesis noted phases of life possible, in order to
>poor hygiene noted get enough rest and sleep
>with initial v/s:
T=36.5 „C >Teach the patient to experiment This helps the woman n identifying
with restful activities when she individual practices in coping with
PR=69bpm cannot sleep at night rather than postpartum period
lying in bed and thinking about not
RR= 18cpm sleeping

>Discuss with women some factors >This helps her to identify some
BP=140/100mmHg that affects sleeping pattern. possible practices to avoid, limit, or
resolve this factors

>Establishing a bedtime routine >To have a scheduled resting time.

CUES NURSING DIAGNOSIS OBJECTIVES INTERVENTIONS RATIONALE EVALUATION

S: “Murag di man ayo ang tubig Risk for Infection related to Within my 8 hours of >Establish Trust and Rapport >To gain cooperation After 8 hours of rendering
diri, kaya trapo-trapo na lang poor hygiene and rendering holistic care, client >Monitor v/s and I&O >To have a baseline data holistic care, client verbalize
ko...wa nay ligo” as verbalized by environmental factors >Provide bedside care >To provide comfort.
shall verbalize understanding understanding of practices
the patient of practices that may that may decrease risk for
> Use standard precautions and > Protects the patient and family
O: 3:30 PM> recieved patient
decrease risk for infection teach the patient and family the from infection. infection
purpose and techniques of
lying on bed;concious;coherent
standard precautions
with IVF # @ cc level
left, flowing @ gtts/min drop >Teach the patient and family >Provides basic knowledge for
rate, hooked at metacarpal about the infectious process, self-help and selfprotection
vein, infusing well. routes, pathogens, environmental
and host factors, andaspects of
>weakness noted prevention.
>
>Restlessness noted >Maintain adequate nutrition and >Helps prevent disability that
>irritability noted fluid and electrolyte balance. would predispose infection.
>drowsiness noted
>Diaporesis noted >Encourage to increase intake of >To help boost immune system
>poor hygiene noted Vitamin C and OFI
>with initial v/s:
T= >Maintain a neutral thermal >Avoids overheating or
environment. overcooling of room that would
PR= contribute to complications for
the patient.
RR= >Wash your hands thoroughly
between each treatment. Teach >Prevents cross-contamination
BP= the patient the value of frequent and nosocomial infections.
handwashing.
>Promotes tissue perfusion.
>Turn every 2 hours on
[odd/even] hour.
>Mobilizes static pulmonary
>Cough and deep-breathe every secretions, thereby improving
2 hours on [odd/even] hour. gas exchange.
>Provide education for proper > to minimize risk of infection
perineal care
 NURSING CARE PLAN

CUES NURSING DIAGNOSIS OBJECTIVES INTERVENTIONS RATIONALE EVALUATION

S: “Kosog kay motog si baby ba!” Effective breastfeeding Within my 8 hours of >Establish Trust and Rapport >To gain cooperation After my 8 hours of rendering
as verbalized by the patient related to maternal >Monitor v/s and I&O >To have a baseline data
rendering holistic care, holistic care, patient was able
confidence in >Provide bedside care >To provide comfort.
breastfeeding and good
patient shall be able to to verbalize practices that
O: 3:30 PM> recieved patient
oral structure of infant verbalize practices that may >Monitor for factors contributing to >Assessment of the infant‟s ability to may improve breastfeeding
lying on bed;concious;coherent the infant‟s ability suck assists in meeting goals for
improve breastfeeding effectively.
with IVF #3 D5 LR, @550cc level to suck effective breastfeeding.
left, flowing @ 30gtts/min drop effectively
rate, hooked at Left metacarpal >This information dictates how to
> Determine the effect the altered or
vein, infusing well. impaired breastfeeding has on the approach the problem and promote
mother and infant realistic follow-up.
>Good hygiene noted
>Good mother and child bonding
noted > Coordinate the parents‟ visitation
>proper techniques in with the infant to best facilitate >Maintain the mother‟s confidence in
breastfeeding noted successful breastfeeding breastfeeding
>good milk roduction noted
> Assist with plan to manage
> >slihghtly sunken eyebals impaired breastfeeding to best >Supporting her choice for
noted provide support to all involved alternative feeding demonstrates
>Diaporesis noted valuing of her beliefs
>poor hygiene noted >Provide appropriate resources. > to provide successful education
>Improper positioning of infant about the current condition
for breastfeeding noted
>good milk production noted >List the advantages and >Assists the mother to make an
>frequent asking of question disadvantages of breastfeeding for informed decision about
about proper breastfeeding the mother. Breastfeeding
techniques noted
> Observe the mother with the infant > Provides basic information
>with initial v/s: during breastfeeding. Explain and and visible support to assist
T=36.5 „C demonstrate methods to increase with successful breastfeeding.
infant sucking reflex. Demonstrate to
PR=69bpm the mother various positions for
breastfeeding and how to alternate
RR= 18cpm positions with each feeding to
prevent nipple soreness
BP=140/100mmHg
> Ascertain the mother‟s support for > Support from others is essential for
breastfeeding from attaining successful
others breastfeeding.
 NURSING CARE PLAN

CUES NURSING DIAGNOSIS OBJECTIVES INTERVENTIONS RATIONALE EVALUATION

S: “Di talga ako komportable Disturbed sleep pattern related to Within my 8 hours of rendering >Establish Trust and Rapport >To gain cooperation After my 8 hours of rendering
matulog dito, feeling ko kasi ang environmental factors holistic care, patient shall be able >Monitor v/s and I&O >To have a baseline data holistic care, patient able to
>Provide bedside care >To provide comfort.
dumi lalo na sa labas, yung jan to verbalize practices that may verbalize practices that may
sa malapit na area” as verbalized enhance sleep pattern. >Assist the patient in scheduling rest >Knowledge and proper planning enhance sleep pattern.
by the patient breaks throughout day. can help the patient reduce fatigue
during pregnancy and the immediate
O: 3:30 PM> recieved patient postpartum period.
lying on bed;concious;coherent >Review daily schedule with the >Knowledge of life changes can help
with IVF #3 D5 LR, @550cc level patient, and assist the patient to in planning and implementing
left, flowing @ 30gtts/min drop adjust her sleep schedule to mechanisms to reduce fatigue and
rate, hooked at Left metacarpal coincide with the infant‟s sleep sleep disturbance.
pattern.
vein, infusing well.
>Assist the patient in identifying >During the immediate postpartum
>weakness noted lifestyle adjustments that period, 2 to 4 weeks
>Restlessness noted may be needed because of changes after birth, it is important for the
>irritability noted in physiologic mother to adjust her
>drowsiness noted function or needs during experiential sleep cycle to the infant‟s if at all
>frequent yawning noted phases of life possible, in order to
>slihghtly sunken eyebals noted get enough rest and sleep
>Diaporesis noted
>Teach the patient to experiment This helps the woman n identifying
>with initial v/s:
with restful activities when she individual practices in coping with
T=36.5 „C cannot sleep at night rather than postpartum period
lying in bed and thinking about not
PR=69bpm sleeping

RR= 18cpm >Discuss with women some factors >This helps her to identify some
that affects sleeping pattern. possible practices to avoid, limit, or
BP=140/100mmHg resolve this factors

>Establishing a bedtime routine >To have a scheduled resting time.

CUES NURSING DIAGNOSIS OBJECTIVES INTERVENTIONS RATIONALE EVALUATION

S: “Malakas talaga siya dumede” Effective breastfeeding related to Within my 8 hours of rendering >Establish Trust and Rapport >To gain cooperation After my 8 hours of rendering
as verbalized by the patient maternal confidence in holistic care, patient shall be able >Monitor v/s and I&O >To have a baseline data holistic care, patient was able to
breastfeeding and good oral >Provide bedside care >To provide comfort.
structure of infant to verbalize practices that may verbalize practices that may
O: 3:30 PM> recieved patient improve breastfeeding effectively improve breastfeeding
>Monitor for factors contributing to >Assessment of the infant‟s ability to
lying on bed;concious;coherent the infant‟s ability suck assists in meeting goals for effectively.
with IVF #3 D5 LR, @550cc level to suck effective breastfeeding.
left, flowing @ 30gtts/min drop
rate, hooked at Left metacarpal >This information dictates how to
> Determine the effect the altered or
vein, infusing well. impaired breastfeeding has on the approach the problem and promote
mother and infant realistic follow-up.
>Good hygiene noted
>Good mother and child bonding
noted > Coordinate the parents‟ visitation
>proper techniques in with the infant to best facilitate >Maintain the mother‟s confidence in
breastfeeding noted successful breastfeeding breastfeeding
>good milk roduction noted
> Assist with plan to manage
> >slihghtly sunken eyebals impaired breastfeeding to best >Supporting her choice for
noted provide support to all involved alternative feeding demonstrates
>Diaporesis noted valuing of her beliefs
>frequent asking of question >Provide appropriate resources. > to provide successful education
about proper breastfeeding about the current condition
techniques noted
>with initial v/s: >List the advantages and >Assists the mother to make an
T=36.5 „C disadvantages of breastfeeding for informed decision about
the mother. Breastfeeding
PR=69bpm
> Observe the mother with the infant > Provides basic information and
during breastfeeding. Explain and visible support to assist with
RR= 18cpm successful breastfeeding.
demonstrate methods to increase
infant sucking reflex. Demonstrate to
BP=140/100mmHg the mother various positions for
breastfeeding and how to alternate
positions with each feeding to
prevent nipple soreness

> Ascertain the mother‟s support for > Support from others is essential for
breastfeeding from attaining successful
others breastfeeding.
 NURSING CARE PLAN

CUES NURSING DIAGNOSIS OBJECTIVES INTERVENTIONS RATIONALE EVALUATION

S: “First baby ko kasi siya kaya Readiness for Enhanced Parenting Within my 8 hours of rendering >Establish Trust and Rapport >To gain cooperation Within my 8 hours of rendering
gusto maging good parent ako” related to holistic care, patient shall verbalize >Monitor v/s and I&O >To have a baseline data holistic care, patient verbalized
satisfaction with parental role and >Provide bedside care >To provide comfort. satisfaction with parental role and
as verbalized by the patient
practices to take good care of the practices to take good care of the
>Assist the patient in assessing the >Identifies areas that require
O: 3:30 PM> recieved patient infant home environment. strengthening to meet primary needs infant.
lying on bed;concious;coherent
with IVF # D5 LR, @550cc level
>Assist the patient in identifying >Will facilitate aligning the patient
left, flowing @ 30gtts/min drop areas that will strengthen the with appropriate resources
rate, hooked at Left metacarpal parenting role
vein, infusing well.
>Provide information relative to >Provides a knowledge base, and
>Good hygiene noted normal growth and development of assists the patient to know that
>Good mother and child bonding self and the child by sitting and some of the things he or she is
noted talking with the patient experiencing are normal
>proper techniques in >Assist the parent to recognize >Prevents a crisis situation.
breastfeeding noted when stress is becoming distress. Promotes self-knowledge.
>good milk production noted
>with initial v/s: >Discuss with the patient strategies >Self-care is an essential foundation
T=36.5 „C to meet Their emotional needs. for being supportive to others.

PR=69bpm >Provide parents with resources for >Helps the client identify ways to
information and support improve parenting skills.
RR= 18cpm in the early days of parenting

BP=140/100mmHg
 NURSING CARE PLAN

CUES NURSING DIAGNOSIS OBJECTIVES INTERVENTIONS RATIONALE EVALUATION

S: “Lisod kay matolog kay Disturbed sleep pattern related to Within my 8 hours of rendering >Establish Trust and Rapport >To gain cooperation After my 8 hours of rendering
katol.”As verbalized by the itching of the skin holistic care, patient shall be able >Monitor v/s and I&O >To have a baseline data holistic care, patient able to
>Provide bedside care >To provide comfort.
patient to verbalize practices that may verbalize practices that may
enhance sleep pattern. >Assist the patient in scheduling rest >Knowledge and proper planning enhance sleep pattern.
O: 3:30 PM> recieved patient breaks throughout day. can help the patient reduce fatigue
lying on bed;concious;coherent during pregnancy and the immediate
with IVF # @ cc level postpartum period.
left, flowing @ gtts/min drop >Review daily schedule with the >Knowledge of life changes can help
rate, hooked at metacarpal patient, and assist the patient to in planning and implementing
vein, infusing well. adjust her sleep schedule to mechanisms to reduce fatigue and
coincide with the infant‟s sleep sleep disturbance.
>weakness noted pattern.
>Dry skin noted
>frequent scratching of the skin >Assist the patient in identifying >During the immediate postpartum
lifestyle adjustments that period, 2 to 4 weeks
note may be needed because of changes after birth, it is important for the
>low neutrophils and increase in physiologic mother to adjust her
lymphocytes noted on lab results function or needs during experiential sleep cycle to the infant‟s if at all
>Restlessness noted phases of life possible, in order to
>irritability noted get enough rest and sleep
>drowsiness noted
>Diaporesis noted >Teach the patient to experiment This helps the woman n identifying
>poor hygiene noted with restful activities when she individual practices in coping with
>with initial v/s: cannot sleep at night rather than postpartum period
T= lying in bed and thinking about not
sleeping

>Discuss with women some factors >This helps her to identify some
that affects sleeping pattern. possible practices to avoid, limit, or
resolve this factors

>Establishing a bedtime routine >To have a scheduled resting time.

CUES NURSING DIAGNOSIS OBJECTIVES INTERVENTIONS RATIONALE EVALUATION

S: “nangangati ako.” as Risk for Infection related to poor Within my 8 hours of rendering >Establish Trust and Rapport >To gain cooperation After 8 hours of rendering holistic
verbalized by the patient hygiene and breakage of line of holistic care, client shall verbalize >Monitor v/s and I&O >To have a baseline data care, client verbalize
defense understanding of practices that >Provide bedside care >To provide comfort. understanding of practices that
O: 3:30 PM> recieved patient may decrease risk for infection may decrease risk for infection
lying on bed;concious;coherent > Use standard precautions and > Protects the patient and family
with IVF # @ cc level teach the patient and family the from infection.
purpose and techniques of
left, flowing @ gtts/min drop
standard precautions
rate, hooked at metacarpal
vein, infusing well. >Teach the patient and family >Provides basic knowledge for
about the infectious process, self-help and selfprotection
>weakness noted routes, pathogens, environmental
>Dry skin noted and host factors, and aspects of
>frequent scratching of the skin prevention.
note
>low neutrophils and increase >Maintain adequate nutrition and >Helps prevent disability that
lymphocytes noted on lab results fluid and electrolyte balance. would predispose infection.
>Restlessness noted
>irritability noted >Encourage to increase intake of >To help boost immune system
>drowsiness noted Vitamin C and OFI
>Diaporesis noted
>poor hygiene noted >Maintain a neutral thermal >Avoids overheating or
>with initial v/s: environment. overcooling of room that would
T= contribute to complications for
the patient.
PR= >Wash your hands thoroughly
between each treatment. Teach >Prevents cross-contamination
RR= the patient the value of frequent and nosocomial infections.
handwashing.
BP= >Promotes tissue perfusion.
>Turn every 2 hours on
[odd/even] hour.
>Mobilizes static pulmonary
>Cough and deep-breathe every secretions, thereby improving
2 hours on [odd/even] hour. gas exchange.
>Provide education for proper > to minimize risk of infection
perineal care
 NURSING CARE PLAN

CUES NURSING DIAGNOSIS OBJECTIVES INTERVENTIONS RATIONALE EVALUATION

S: “Makatulog man ako ma‟am, Disturbed energy field related to Within my 8 hours of rendering >Establish Trust and Rapport >To gain cooperation After my 8 hours of rendering
pero putol putol kay igang, baho, disease process and holistic care, client shall verbalize >Monitor v/s and I&O >To have a baseline data holistic care, client verbalized
understanding of practices that >Provide bedside care >To provide comfort.
tapos nangatol pa ko.Kaya environmental factors. understanding of practices that
may improve sense of well-being
madalas di ako masyadong and gain more energy. >Assist the client and family to >Early identification assists in may improve sense of well-being
malakas at gusto ko tulog ako ng identify disturbances in providing early intervention and is sleeping when the shift
tulog” as verbalized by the energy field ended.
patient >Monitor energy field with a focus on >Will enhance assessment of
maintaining self-comforting energy field
O: 3:30 PM> recieved patient Activities.
lying on bed;concious;coherent
with IVF # @ cc level >Redirect areas of accumulated
energy, reestablish the energy flow, >Energy transfer or transformation
left, flowing @ gtts/min drop and direct energy to depleted areas can occur without direct physical
rate, hooked at metacarpal contact between two systems.
vein, infusing well. >Do therapeutic touch for no longer
than 10 minutes >Could disrupt the energy field of
>weakness noted the patient
>Dry skin noted >Teach the patient relaxation
exercises using some of the >Relaxation requires the patient to
>frequent scratching of the skin
same techniques as therapeutic stop trying and to step
note touch outside of self and adopt a nontrying
>low neutrophils and increase attitude
lymphocytes noted on lab results
>Restlessness noted >Provide a more conducive
>irritability noted environment for the client to rest >For the client to rest more
>drowsiness noted
>Diaporesis noted >Promote rest and sleep
>poor hygiene noted >To prevent fatigue
>with initial v/s: >Assist the client and family in
providing a private, quiet >Client comfort is increased, and
T=
environment response to intervention is
enhanced.
PR=

RR=

BP=