NURSING CARE PLAN

Assessment Nursing Planning Intervention Rationale Evaluation

diagnosis
Subjective: Ineffective After 2hrs of 1. determined To assess After 2hrs of
nahihilo po peripheral nursing factors related to causative nursing
ako as tissue intervention individual factor of the intervention
verbalized perfusion these should situation. condition. the goal was
by the related to manifest. 2.note baseline To provide partially met as
patient. impaired - increase data and comparison manifested by:
Objective: transport of perfusion continuous with current -slightly skin
Hemoglobi oxygen as -skin normal monitoring of findings. pale in color
n 79 evidenced in color VS -vital sign
(normal by pale -have stable 3. reviewed To serve as a BP-110/70
value: skin, vital sign of laboratory scientific RR-20
123 152) vaginal BP=110-70 studies basis for the PR-90
RBC 2.7 bleeding . 120-80 PR= problem. -the bleeding
(normal 60-100bpm 4. Encouraged To promote was decreased
value 4.5- PR=12-20 to perform range circulation to mild and the
5.5) cpm of motion number of
Hemotocrit -decrease 5. Encouraged To enhance pads used is
0.24 bleeding and early ambulation venous return from 3 to 1
(normal use numbers as tolerated To maximize pad.
value 0.37- of pads from 6. Promoted tissue
0.42) 3 pads to 1 position changes perfusion
Pale skin pad. and discouraged
(+) staying at the
moderate same position
vaginal To increase
bleeding 7. Elevated head gravitational
PR 120 of the bed or blood flow.
BP 100/70 add pillow when
RR - 23 patient is lying To decrease
T 37.5 in bed tension level
8. Demonstrated
and encouraged
the use of
relaxation
techniques suck
us deep
breathing
exercise
Assessment Nursing Planning Intervention Rationale Evaluation
diagnosis
Subjective: Anticipatory After 8hours of Assessed the reaction To determine the The woman and
Nalulungk grieving r/t nursing of patient and support feelings of the her partner begin
ot ako sa loss of intervention person. client and of the verbalizing their
pagkawala pregnancy, the mother and significant other. grief and
ng anak ko. cause of her partner will acknowledge that
At mas abortion and verbalize Provided information To lessen confusion the grieving
aalala ako future grieve and regarding current of patient regarding process last s
kasi ako childbearing acknowledge status as needed. the loss, to clarify several months
ang sinisisi that the and to avoid blame.
ng mister grieving
koas process lasts To relieve
verbalized several months emotions, sharing
by the Encouraged the of feelings to father
patient patient to discuss may encourage
feelings about the support from each
Objective: loss of the baby and other.
-appears to include effects on
be sad. relationship with the
PR 120 father. The grieving period
BP 100/70 following a
RR - 23 Acknowledged the miscarriage usually
T 37 loss and allow lasts 6 to 24months.
grieving To offer
psychological
support for the
Listened mother.
sympathetically to Providing privacy
their concerns. will encourage
them to verbalize
Provided time alone further their
for the couple to concerns.
discuss their feelings To inform
important matters
about future
Discussed the pregnancies so they
prognosis of the will have informed
future pregnancies. choice sand smarter
decisions.
Assessment Nursing Planning Intervention Rationale Evaluation
diagnosis
Subjective: Fluid volume After 8 hours Independent: Independent: After 8 hours of
sobra po deficit of nursing 1.Monitored vital 1.Changes in vital nursing
ako related to intervention, signs, compare with signs may be used intervention,the
naghihinaa excessive the patient will patient normal or for rough estimate patient was
s verbalized blood loss as be able to: previous readings. of blood loose ableto:1.
by the evidenced by 1.Demonstrate 2.Noted patients 2.Symptomatology Demonstrateimpr
patient. vaginal improve fluid individual may be useless in ove fluid balance
Objective: bleeding, balance as physiological gauging severity or as evidenced by
-pallor pallor. evidence by response to bleeding length of bleeding stable vital
-poor skin stable vital such as weakness, episode. signs,good skin
turgor signs, good restlessness and turgor.- Goal
-unable to skin turgor. pallor. partially met
rise on bed 3.Monitored intake 3. Provide
-vaginal and output. guidelines for fluid
bleeding replacement.
PR 120 4.Maintained bed 4.Activity increases
BP 100/70 rest. Scheduled intra abdominal
RR - 23 activities to provide pressure and can
T 37 undisturbed rest predispose to
periods. further bleeding.
5. Monitored Hb, 5. to obtain data
Hct,RBC count