NURSING CARE PLAN NO.

NURSING
CUES OUTCOME CRITERIA NURSING INTERVENTIONS RATIONALE EVALUATION
DIAGNOSIS

Subjective Cues: Risk for infection r/t Short Term Goal: • Assess the client’s • This will serve After 8º of
traumatized skin vital signs as a baseline nursing
“Wala pako naligo tissue 2º to Within 8º of nursing data, and will interventions,
kay basin episiotomy interventions, the help us identify the patient was
mabughat ko.” patient will be able any able to identify
to identify abnormalities if measures to
Objective Cues: interventions to one of these prevent
prevent/reduce the signs are infection as
• With risk of infection • Assess for any altered. manifested by
episiotomy localized signs and client’s
wound symptoms of infection. • Signs and verbalization of:
• Has not symptoms “Muinom nakog
taken a bath reflect the daghan tubig,
Long Term Goal: severity of the mukaon nakog
• Stress to patient the underlying mga pagkaon
Within 3 days of importance of proper condition na taas ug
nursing hand washing protina para
interventions, the specially when in • Hand washing dali ra mayo
patient will be able contact with wound is known to be a akong samad.
to demonstrate first line defense Manghugas ko
lifestyle changes to against ug maayo sa
promote safe infections kamot aron dili
• Encourage to increase
environment musamot
fluid intake at least 8 akong samad.”
oz per hour and eat
protein-rich foods such
as meat and beans • Increasing fluid
intake and
eating of foods
rich in protein
• Encourage to take will facilitate
adequate rest periods wound healing
 • Emphasize the
necessity of taking • This is done to
antibiotics AS prevent fatigue
DIRECTED
• To eradicate
infection
COLLABORATIVE: causing
microorganisms
• Administer anti-
infectives per
prescription
 NURSING CARE PLAN NO.2

NURSING
CUES NURSING DIAGNOSIS OUTCOME CRITERIA RATIONALE EVALUATION
INTERVENTIONS

Subjective Cues: Interrupted breast Short Term Goal: After 8º of nursing

feeding r/t infant interventions, the
“Wala lagi ko illness Within 8º of nursing • Assess the • Client may patient verbalized,
nakapatotoy sa interventions, the client’s have “Mas maayo gyud
akong anak kay tua patient will be able perception misconceptions diay kung gatas sa
siya sa NICU. to understand the about or nanay ang ipatotoy.
Nagsuka2x man gud importance of breastfeeding misinformation Mao nalang na ako
to ug gihilantan.” breastfeeding s about buhaton aron dili
breastfeeding masakit akong
Objective Cues: • Discuss to anak.”
• This is to
patient the
• Infant is not by importance of impart the
the mother’s Long Term Goal: proper proper
side breastfeeding, techniques of
• Painful breast Within 3 days of techniques breastfeeding
due to hospital duty, the and the and will help
engorgement patient will be able benefits both her applying it
as verbalized to identify and the mother actually
by the patient demonstrate and the baby
techniques to can gain
sustain lactation
until breast feeding • Instruct • This will
is reinitiated patient to facilitate
increase fluid increase
intake at least production of
8 oz per hour milk

• Frequent
• Encourage
sucking of the
patient to let
infant will
the infant
relieve the
frequently
 suck the engorged
nipple of the breast of the
mother if mother from
received back pain
from NICU

• Instruct • It is important
patient to to maintain
pump milk the
from the nourishment
breast and of the baby by
store it if she continuously
will be away feeding of
breast milk

• To help and
• Encourage guide her in
patient to promoting
attend responsibility
discussions and
such as independency
responsible
parenthood
 NURSING CARE PLAN NO.3

NURSING
CUES NURSING DIAGNOSIS OUTCOME CRITERIA RATIONALE EVALUATION
INTERVENTIONS

Subjective Cues: Situational Low Self- Short Term Goal:

Esteem r/t perceived
“Inahan nako sa failure at life events Within 8º of nursing • Assess client’s • Client’s
kabat sa akong 2º to rape trauma interventions, the perception of perception is
edad..” patient will be able threat to self- more
to demonstrate at worth important than
Objective Cues: least positive what actually
adaptation to happening and
• Verbalized changes as needs to be
negative evidenced by active dealt with
feelings about participation in before reality
self personal can be
• Feared of relationships addressed
responsibility • Actively listen
for problems to client’s • Provides
• Perceived her concerns and opportunity to
situation as fears, develop and
unfair Long Term Goal: verbalization begin a
• Refused to of feeling problem-
Within 3 days of solving
disclose
nursing process, at the
herself about
interventions, the same time
the event that
patient will be able conveys sense
led her to the
to recognize and • Observe non- of caring
present
incorporate change
 situation into self-concept in verbal
• Silent most of accurate manner communicatio • Provides
the time and without negating self n such as information
seemed worth gestures, body about how
withdrawn movements, comfortable
• Frequently etc. the individual
pacing and is with her
stares at beds • Encourage environment
with mother’s patient to
cuddling participate in • To facilitate
infants conversations sense of
• Has difficulty with mothers communicatio
agreeing on inside the n and to
decisions as ward recover
evidenced by intrapersonal
verbalizations • Provide relationships
of: “Ambot. informations
Ambot lang about • The client may
ani.. Tan-awon counseling feel helpless
lang..” organizations specially that
and she doesn’t
institutions utterly know
that will help her family.
her Support
understand networks will
her current somehow
situation facilitate her
recovery

• The infant has

• Emphasize to nothing to do
patient the with her
acceptance of experience
current
situation and
also the
acceptance of
 her baby • Provides
opportunity to
• Encourage her begin
to cooperate incorporating
with actual
discussion of changes in an
physical accepting and
change hopeful
atmosphere

• Spiritual
counseling
• Refer her to provides
spiritual renewal to the
counseling client and at
and/or the same time
organizations establishes
within her faith in her
belief beliefs and
religion