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Vi. Nursing Care Plan Cues Analysis Nursing Diagnosis Goal / Plan Intervention Rationale Evaluation

The nursing care plan summarizes a patient presenting with acute abdominal pain due to an ectopic pregnancy. The plan includes monitoring vital signs, pain levels, and vaginal bleeding to assess for hemorrhage and determine if rupture has occurred. Nursing interventions focus on relieving pain, monitoring the patient's condition, and providing comfort measures to help the patient cope. The goal is for the patient's pain to be relieved or controlled after 8 hours of nursing care.

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Raisa Robelle Quicho
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312 views2 pages

Vi. Nursing Care Plan Cues Analysis Nursing Diagnosis Goal / Plan Intervention Rationale Evaluation

The nursing care plan summarizes a patient presenting with acute abdominal pain due to an ectopic pregnancy. The plan includes monitoring vital signs, pain levels, and vaginal bleeding to assess for hemorrhage and determine if rupture has occurred. Nursing interventions focus on relieving pain, monitoring the patient's condition, and providing comfort measures to help the patient cope. The goal is for the patient's pain to be relieved or controlled after 8 hours of nursing care.

Uploaded by

Raisa Robelle Quicho
Copyright
© Attribution Non-Commercial (BY-NC)
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as DOCX, PDF, TXT or read online on Scribd
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VI.

NURSING CARE PLAN

CUES ANALYSIS NURSING GOAL / INTERVENTION RATIONALE EVALUATION


DIAGNOSIS PLAN

Subjective: Ectopic Acute pain After 8 hours Independent: After 8 hours of


“Masakit ang pregnancy related to of nursing Nursing
tiyan ko” (My is gestation distention or interventions · Monitor maternal To determine interventions,
tummy hurts) as located rupture of , the patient vital signs. presence of the patient was
verbalized by outside the fallopian tube. will be hypotension relieved or
patient. uterine cavity. relieved or and tachycardia controlled.
The fertilized controlled. caused by
Objective: ovum implants rupture or
outside of the hemorrhage.
· Facial mask of uterus, usually
pain. in the fallopian · Monitor for To further
tube. presence and assess the
· Guarding Predisposing amount of vaginal present
behavior. factors include bleeding. situation
adhesions of indicating
· V/S taken as the tube , hemorrhage.
follows: salpingitis,
T: 36.4 congenital and · Monitor for Increased pain
P: 85 developmental increase and pain and abdominal
R: 22 anomalies of and abdominal distention
Bp: 110/90 the fallopian distension and indicates
tube, previous rigidity. rupture and
ectopic possible
pregnancy, use intraabdominal
of an hemorrhage.
intrauterine
device for
more than 2
years, multiple · Monitor complete · To determine
induced blood count the amount of
abortions, (CBC). blood loss.
menstrual
reflux , and · Provide comfort · Promotes
decreased tubal measure like relaxation and
motility. back rubs, deep may enhance
breathing. patient’s coping
Instruct in abilities by
relaxation or refocusing
visualization attention.
exercises.

-Provide · Diversional
diversional activities aids in
activities. refocusing
attention and
enhancing
coping with
limitations.

Collaborative:

· Administer · To maintain
analgesics as acceptable
indicated. level of pain.

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