NURSING CARE PLAN NO.

Date Identified: November 29, 2008

NURSING OUTCOME
CUES NURSING INTERVENTIONS RATIONALE EVALUATION
DIAGNOSIS CRITERIA

Objective Cues: Risk for infection Short Term Goal: • Assess the client’s • This will serve as a After 8º of nursing
• Has not yet r/t traumatized vital signs baseline data, and interventions, the
taken a skin tissue 2º Within 8º of will help us identify patient was able to
bath due to cesarean section nursing any abnormalities identify measures
beliefs interventions, the if one of these to prevent
• Nails were patient will be signs are altered. infection as
untrimmed able to identify manifested by
several dirt interventions to • Assess for any • Signs and client’s
underneath prevent/reduce localized signs and symptoms reflect verbalization of:
• Guards her the risk of symptoms of the severity of the “Muinom nakog
abdomen infection infection. underlying daghan tubig,
frequently condition mukaon nakog
as seen mga pagkaon na
• Stress to patient the • Hand washing is taas ug protina
importance of proper known to be a first para dali ra mayo
Long Term Goal: hand washing line defense akong samad.
specially when in against infections Manghugas ko ug
Within 3 days of contact with wound maayo sa kamot
nursing aron dili musamot
interventions, the • Encourage to • Increasing fluid akong samad.”
patient will be
increase fluid intake intake and eating
able to
at least 8 oz per hour of foods rich in
demonstrate
and eat protein-rich protein will
lifestyle changes
foods such as meat facilitate wound
to promote safe
and beans healing
environment
• Encourage to take • This is done to
adequate rest decrease tissue
periods demands thus
preventing fatigue
 • To eradicate
• Emphasize the infection causing
necessity of taking microorganisms
antibiotics AS
DIRECTED

COLLABORATIVE:

• Administer anti-
infectives per
prescription
 NURSING CARE PLAN NO.5

Date Identified: November 29, 2008

NURSING OUTCOME
CUES NURSING INTERVENTIONS RATIONALE EVALUATION
DIAGNOSIS CRITERIA

Objective Cues: Risk for Short Term Goal: INDEPENDENT After 8º of

• Patient has constipation r/t INTERVENTIONS: nursing
not yet post pregnancy Within 8º of • This is to interventions, the
eliminated 2° cesarean nursing • Ascertain normal determine the patient was able
since section interventions, the bowel functioning of normal bowel to identify
delivery patient will be the patient, about how pattern measures to
• Absence of able to many times a day prevent infection
bruit sounds demonstrate does she defecate as manifested by
• Normal behaviors or • To increase the client’s
pattern of lifestyle changes • Encourage intake of bulk of the stool verbalization of:
bowel has to prevent foods rich in fiber such and facilitate the “Muinom nakog
not yet developing as fruits passage through daghan tubig ug
returned problem the colon mukaon nakog
mga prutas aron
• To promote moist makalibang
• Promote adequate soft stool nakog insakto..”
fluid intake. Suggest
Long Term Goal: drinking of warm
fluids, especially in the
Within 3 days of morning to stimulate
nursing peristalsis • To stimulate
interventions, the
contractions of the
patient will be
• Encourage ambulation intestines and
able to maintain
such as walking within prevent post
usual pattern of
individual limits operative
bowel functioning
complications
 • To avoid stress on
the cesarean
• However, since she incision/ wound
has had cesarean, also
encourage adequate
rest periods

COLLABORATIVE:

• Administer bulk-
forming agents or stool
softeners such as • To promote
laxatives as indicated defecation
or prescribed by the
physician
 NURSING CARE PLAN NO.2

Date Identified: November 29, 2008

NURSING OUTCOME
CUES NURSING INTERVENTIONS RATIONALE EVALUATION
DIAGNOSIS CRITERIA

Subjective Cues: Deficient Short Term Goal: INDEPENDENT After 8º of nursing

Knowledge r/t INTERVENTIONS: interventions, the
• “Kana rang lack of interest in Within 8º of patient was able to
commercial learning nursing • Identify motivating • Client may need identify measures
na gatas interventions, the factors for the patient visualizations to to prevent
akong patient will be such as provision of increase her infection as
ginapatotoy able to visual aids about interest manifested by
nako sa participate in breastfeeding client’s
akong learning process verbalization of:
kamagulang • Involve client in “Patotoyon na
an..” sharing her thoughts • Provides time for nako akong anak
Objective Cues: about breastfeeding patient to share nga dili mag gamit
Long Term Goal: her perceptions ug gi-commercial
• Patient • Encourage patient in na mga gatas..”
knows Within 3 days of indulging herself in • Done to determine
minimal nursing discussions about whether she has
information interventions, the breastfeeding interest in altering
about patient will be her current
breastfeedin able to exhibit manners
g but takes increased interest
it for and assume • Also done to instill
granted responsibility for
realizations for her
• Client own learning and
• Emphasize to patient second born child
appears begin to look for the significance of
uninterested information and breastfeeding to • To let her
when ask questions infants understand why it
information is more effective
is discussed to have feeding
from the breasts
than bottle-feeds.

DEPENDENT
INTERVENTIONS:
• Refer patient to
support groups in
enhancing breast
feeding techniques
 NURSING CARE PLAN NO.3

Date Identified: November 29, 2008

NURSING OUTCOME
CUES NURSING INTERVENTIONS RATIONALE EVALUATION
DIAGNOSIS CRITERIA
Subjective Cues: Acute Pain r/t Short Term Goal: INDEPENDENT After 8º of
incision at the INTERVENTIONS: nursing
• “Magsakit lower abdomen Within 8º of • Any alterations interventions,
usahay ang nursing • Assess the vital signs occurring in v/s may the patient was
tahi..” interventions, the indicate presence of able to identify
Objective Cues: patient will be pain measures to
able to report prevent infection
• Guards the pain as relieved • Let patient rate pain • To determine the as manifested
area of or controlled in a scale of 1-5, degree or severity of by client’s
incision having 5 as the pain verbalization of:
frequently highest possible pain, “Nawala naman
• Grimace of and one as the pud ang sakit..”
face Long Term Goal: lowest
• Pain scale • These activities may
Within 3 days of • Encourage patient to divert the patient’s
rate of 2 out
nursing use diversional attention from
of 5
interventions, the activities such as perceiving pain
patient will be reading of
able to verbalize magazines, watching
methods that television\ or
provide relief listening to radio • To promote
relaxation
• Teach breathing and
coughing exercises • To prevent further
stress or fatigue to
• Promote adequate the wound
rest periods
• Analgesic inhibit the
DEPENDENT: pain receptor
• Administer mechanism
analgesics as ordered
NURSING CARE PLAN NO.1

Date Identified: November 29, 2008

 NURSING OUTCOME
CUES NURSING INTERVENTIONS RATIONALE EVALUATION
DIAGNOSIS CRITERIA

Subjective Cues: Imbalanced Short Term Goal: INDEPENDENT

Nutrition: More INTERVENTIONS:
• Thick skin than Body Within 2 weeks of • To identify the
folds were requirements r/t nursing • Ascertain patient’s patient’s pattern
noted excessive intake interventions, the knowledge about of eating
located near in relationship to patient will be appropriate food
the armpit metabolic need able to intake
demonstrate • To increase
• Patient’s appropriate • Set goals with the patient’s
weight is lifestyle changes patient in motivation
more than including establishing
the normal behaviors on nutritious dietary
weight of a eating patterns, intake • Helps client
pregnant food determine realistic
woman, quality/quantity • Discuss with client motivating factors
about 183 and exercise the possibility of
lbs program weight loss • Patient might have
the ideas of these
• Frequently food groups but
complains • Discuss with patient might be taking it
about Long Term Goal:
the nutritious foods for granted
hunger that could help her
Within 2 months
body and mind
of nursing
function well such as
interventions, the
the emphasis of the • To help lose weight
patient will be
Go, Grow and Glow and keep the body
able to attain
foods in tone to promote
desirable body
weight with optimum
• Encourage patient to functioning of the
optimum
maintenance of establish a routinely body systems
health exercise program by
herself • Rendering good
information about
what to avoid will
 • Encourage patient to help patient
avoid eating foods identify the right
rich in cholesterol kind of foods to
and sodium that may eaten. Healthful
increase the and nutritious
tendency of obesity
and other health
problems such as
cardiovascular
dysfunctioning and
obesity • Seeking for
professional help
DEPENDENT may help the
INTERVENTIONS: patient achieve
her goals
• Refer patient to
dieticians and
exercise programs of
these independent
interventions fail