NURSING CARE PLAN 1: (paki-specify nalang dito yung nursing diagnosis)

ASSESSMENT NURSING SCIENTIFIC OBJECTIVES NURSING RATIONALE EXPECTED

DIAGNOSIS EXPLANATION INTERVENTIONS OUTCOME
Short term: Independent: Short term:
Subjective data: Risk for infection Wounds/ cut >after 2 hours of >provided health >to provide >after 2 hours of
>“’di pa ako related to involving injury to nursing teachings about information nursing
naliligo magmula impaired skin soft tissue can intervention proper hand about the intervention
kahapon.” As integrity and vary from minor patient will hygiene to the benefits of patient shall
verbalized by the poor personal tears to severe verbalize patient and patient proper hand verbalize
patient. hygiene crushing injuries importance of SO(s) hygiene. importance of
which can be proper hygiene. proper hygiene.
Objective data: contaminated >instructed patient >to help the be
>incision site with pathogens Long term: to use alcohol- free from the risk Long term:
manifested signs that can cause >after 3 days of based hand rubs if of getting >after 3 days of
of inflammation infection on nursing she is not able to infection nursing
> with vital signs incision site. intervention stand up intervention
as follows patient will no patient will no
BP:110/70 longer be at risk Dependent: longer be at risk
T: 35 of infection. >provided >to provide of infection.
PR: 75 medications as per protection
RR: 18 the physician’s against infectious
order agents
NURSING CARE PLAN 2: (paki-specify nalang dito yung nursing diagnosis)

ASSESSMENT NURSING SCIENTIFIC OBJECTIVES NURSING RATIONALE EXPECTED

DIAGNOSIS EXPLANATION INTERVENTIONS OUTCOME
NURSING CARE PLAN 3: (paki-specify nalang dito yung nursing diagnosis)

ASSESSMENT NURSING SCIENTIFIC OBJECTIVES NURSING RATIONALE EXPECTED

DIAGNOSIS EXPLANATION INTERVENTIONS OUTCOME
NURSING CARE PLAN 4: (paki-specify nalang dito yung nursing diagnosis)

ASSESSMENT NURSING SCIENTIFIC OBJECTIVES NURSING RATIONALE EXPECTED

DIAGNOSIS EXPLANATION INTERVENTIONS OUTCOME
NURSING CARE PLAN 5: (paki-specify nalang dito yung nursing diagnosis)

ASSESSMENT NURSING SCIENTIFIC OBJECTIVES NURSING RATIONALE EXPECTED

DIAGNOSIS EXPLANATION INTERVENTIONS OUTCOME
FDAR 1: (paki-specify nalang dito yung nursing diagnosis)

DATE TIME FOCUS NURSING PROGRESS NOTES

6-2
07/22/19 8AM General Survey D> received patient on bed. Awake, alert and
coherent to time, place, and people. Breast lactating
properly, still tender and firm, uterus still palpable,
urinated once, defecated once; firm stool, with
minimal vaginal bleeding; lochia rubra, with
episiotomy: impaired skin integrity, negative result of
homan’s sign, with no pain in lower extremities, with
stable emotional status and categorized response of
the patient as positive after her delivery.

>practiced early ambulation

>with vital signs as follows

BP:110/70
T: 35
PR: 75
RR: 18

A>established therapeutic relationship

>provided health teachings
>assessed patient’s incision site
>assisted patient in ambulation
>monitored vital signs

R>patient verbalized understanding of health

teachings provided
>manifested no signs and symptoms of infection on
the site of incision
>ambulated without any problem
>manifested normal vital signs
FDAR 2: (paki-specify nalang dito yung nursing diagnosis)
 DATE TIME FOCUS NURSING PROGRESS NOTES

FDAR 3: (paki-specify nalang dito yung nursing diagnosis)

 DATE TIME FOCUS NURSING PROGRESS NOTES

FDAR 4: (paki-specify nalang dito yung nursing diagnosis)

 DATE TIME FOCUS NURSING PROGRESS NOTES

FDAR 5: (paki-specify nalang dito yung nursing diagnosis)

DATE TIME FOCUS NURSING PROGRESS NOTES