nursing care plans

Nursing Care Plan

Problem Identified: Wound

Nursing Diagnosis: Impaired skin integrity related to altered metabolic state to allergic reactions

Cause Analysi

Cues Objectives Nursing Interventions Rationale EvaluationSubjectives: “daghan kog katol katol sa akongtiil” as stated by the patient.

Objectives: Wound noted

at lower leftleg

Darkening of skin

Lesion o scalp noted

STO:After 1-2 hours of nursing intervention the patient will be able to identify ways to promote healing

LTO: After 8 hours of nursing intervention the patient will be able to demonstrate behaviors to prevent skin breakdown.

Independent Assess skin daily.

Note the color, turgor, circulation and sensation.

Maintain/ instruct in good skin hygiene, such as wash thoroughly and pat dry carefully

Reposition frequently

Encourage out of bed as tolerated

Cover open lesions with sterile dressing

Collaborative Cilostazol 1amp; 2L

( 150mg/mL) OD soln IVTT

Lyrica (pain) 50 mg

Establish cooperative baseline

Maintaining clean, dry skin provides a barrier to infection

Reduces stress on

pressure points, improves blood flow to tissues

STO: After 4hrs of Nursing Interventions, the patient wasslightly relieved from edema as evidenced by shrunken edema in the ankle.

LTO:

After 5 days of giving effective nursing interventions, the patient was free from edema and have a stable vital signs

1 cap BID POReferences: Maternal and Child Health Nursing 6th Edition by Adele Pilliteri and Health Assessment 3rd Edition by Weber and Kelley

Nursing Care Plan

Problem Identified: Urinary Incontinence and Retention

Nursing Diagnosis:Impaired Urinary Elimination: StressIncontinence related to transient loss of tone of the bladderafter the delivery

Cause Analysis: During a vaginal birth, the fetal head exerts a great deal of pressure on the bladder and urethra as it passes on the bladder’s underside. This pressure may leave the bladder with a transient loss of tone that, together with the edema surrounding the urethra, decreases a woman’s ability to sense when she has to void. A woman who has undergone epidural or spinal anesthesia can feel no sensation in the bladder area until the anesthetic has worn off. (Maternal and Child Health Nursing by Adele Pilliteri 6th Edition. Vol. 1 p. 424)

Cues Objectives Nursing Intervention Rationale Evaluation

Subjective:“Hindi konamamalayannanaiihinaako” as stated by the patient.

Objectives: Reports of loss of

sensation in the perineum

STO:

After 8hrs of nursing intervention, the patient

Encouraged the client to void every 2-4hrs

Assessed the amount of urine output

Taught and encouraged to perform Kegel’s exercise

Instruct the patient to have a urine output diary indicating toilet voiding and leaking

Apply perineal pads

-to minimized over distention

-to strengthen the pelvic muscle-allows to identify patterns of voiding on the toilet or involuntarily and precipitating factors

-to avoid leaking urine in the bed

-relieves and

Collaborative: Administer

catheter as indicated

prevent urinary retention

References: Maternal and Child Health Nursing 6th Edition by Adele Pilliteri

Nursing Care Plan

Problem Identified: Fatigue

Nursing Diagnosis: Activity Intolerance related to increased physical exertion after delivery

Cause Analysis:As soon as birth is completed, a woman experiences total exhaustion. All during labor, she worked hard with little or no sleep. Now, she has “sleep hunger”, which may make it difficult for her to cope with new experiences and stressful situations until she has enjoyed a sustained period of sleep. (Maternal and Child Health Nursing by Adele Pilliteri 6th Edition Vol. 1 p. 425)


Subjective:“nakakapagod, tsakawala pa akongsapatnatulog. Kasigawang nag labor akong midnight” as stated by the patient.Objectives:

Prefer to lie in bed always

Appears tired with some weakness

Cooperative when asked but limited in answering

Always asking for assistance when doing something

STO:After6hrs of nursing intervention, the patient will be able to feel rested

LTO:

After 8hrs of complete bed rest, the patient will be able to perform minimal activities like going to the bathroom on her own or walking around the room

Encouraged to a have a complete bed rest for atleast 6hrs

Post (on the door) visiting schedule time

Encouraged the visitors to minimized voices

Assisted to assume a comfortable position (semi-fowlers or side-lying)

Advised the S.O not to let the patient to do heavy things such as lifting.

-to regain strength

-to limit visitors and promote rest of patient

-it may add weakness to the patient

STO:After 6hrs of nursing intervention, the patient was able to feel rested

LTO:

After 8hrs of complete bed rest, the patient was able to perform minimal activities like going to the bathroom on her own or walking around the room


Nursing Care Plan

Problem Identified: Altered Sleep Pattern

Nursing Diagnosis: Disturbed Sleeping Pattern related to Exhaustion from delivery

Cause Analysis: As soon as birth is completed, a woman experiences total exhaustion. All during labor, she worked hard with little or no sleep. Now, she has “sleep hunger”, which may make it difficult for her to cope with new experiences and stressful situations until she has enjoyed a sustained period of sleep. (Maternal and Child Health Nursing by Adele Pilliteri 6th Edition Vol. 1 p. 425)

Cues Objectives Nursing Intervention Rationale EvaluationSubjective:“walatalagaakongtamangtulogkasimga midnight naakona start ng labor taposnanganakakongmadalingaraw” as verbalized by the patient

Objectives: Appears weak Sunken eyeballs Passive when asked Likes to lie on bed always Vital signs:

Bp: 130/80mmHgP: 78 bpmRR: 21T: 36.7 ®C

STO:After 6hrs of nursing intervention, the patient will be able to sleep and feels rested.

LTO:

After 2days of rest and sleep, the patient will regain her strength again.

Posted (on the door) visiting schedule hours

Encouraged to have a complete bed rest 4 at least 6hrs

Placed in a (R) side lying position

Instructed the S.O to refrain from making noises

Assisted needs in order to promote sleep such pillows and bed rituals (listening to preferred music

-to limit visitors

-to regain strength

-to increase tubular reabsorption thus limiting disturbance from frequent urination

by the patient)


Nursing Care Plan

Problem Identified: Constipation

Nursing Diagnosis:Risk for Constipation related to the still-present effect of relaxin on the bowel after delivery

Cause Analysis: Digestion and Absorption begin to be active again soon after birth unless a woman has had a Ceasarian birth. Bowel sounds are active, but passage of stool through the bowel maybe slow because of the still-present effect of relaxin on the bowel. (Maternal and Child Health Nursing by Adele Pilliteri 6th Edition Vol. 1 p. 242)

Cues Objectives Nursing Interventions Rationale EvaluationObjectives:

After 1 hr of nurse-patient interaction, the patient will be able to know the ways on how to prevent constipation

instruct to increase fluid intake(8-10glasses/day)

Encourage to eat foods rich in fiber such pineapple, papaya and oat meals

Encourage ambulation

-water helps improving stool consistency and fiber-rich foods resist enzymatic digestion

-walking increases blood circulation-maximizes use of abdominal muscle and

Demonstrate how to do semi-squating position

Encourage to avoid stopping the urge to defecate

force of gravity-stopping urge to defecate makes more water get absorbed from stool


Nursing Care Plan

Problem Identified: Uterine Infection

Nursing Diagnosis: Risk for Infection(uterine) related to Lochial discharges

Cause Analysis:The layer adjacent to the uterine cavity becomes necrotic and is cast off as a uterine discharge similar to a menstrual flow. This uterine flow, consisting of blood, fragments of decidua, WBC, mucous, and some bacteria, is known as Lochia. (Maternal and Child Health Nursing by Adele Pilliteri 6th Edition Vol. 1 p. 422)


Objectives: Presence of

Lochia discharge(rubra)

T: 36.7®C

After 8hrs of nursing intervention, the patient will be able to know the importance of maintaining cleanliness in the perineal area and will take responsibility of her own hygiene

Check the perineal pad for any foul smelling

Provideperineal care

Instruct how to do proper cleaning of the perineum

Instruct to change pads frequently

Encourage to have a daily shower

Check Vital signs specifically the temperature

-foul smelling indicates infection

-to prevent infection

-to prevent bacterial growth

-prevents bacterial growth and provides comfort

-rise of temperature may indicate infection


Nursing Care Plan

Problem Identified:risk for Self-care Deficit

Nursing Diagnosis: Risk for bathing/hygiene self-care deficit related to exhaustion from childbirth

Cause Analysis: As soon as birth is completed, a woman experiences total exhaustion. All during labor, she worked hard with little or no sleep. Now, she has “sleep hunger”, which may make it difficult for her to cope with new experiences and stressful situations until she has enjoyed a sustained period of sleep. (Maternal and Child Health Nursing by Adele Pilliteri 6th Edition Vol. 1 p. 425)

Cues Objectives Nursing Intervention Rationale EvaluationSubjective:“Walaakongganangmaligo, dahilpagodako”

Objectives: Always lie on bed There are blood

stains in the linen Not well groomed

with unfixed hair

STO:After 2hrs of nursing intervention, the patient will be able to appear clean, dressed and well-groomed

LTO: After 2days of nursing intervention, the patient will take responsibility in her own hygiene

Provide complete bed bath

Discardblood- stained linens and changed it to clean ones

Teach how to properly clean the perineal area

Encouragedaily showering

Encourage the S.O to assist patient when doing perineal care or bathing

Encourage the S.o to maintain cleanliness inside the room

Instruct the S.O to inform nurse when linens are soiled

-promotes comfort


-for independence of her own hygiene

-to promote proper hygiene

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