COLEGIO SAN AGUSTIN – BACOLOD

COLLEGE OF HEALTH AND ALLIED PROFESSIONS

NURSING PROGRAMS
NURSING CARE PLAN

Patient’s Name: T. C. Chief Complaint/s: Labor pains

Room/Bed No.: OBW Room 3 Diagnosis/Impression: Normal spontaneous vaginal deliver with laceration
Age: 41 y.o. Attending Physician: XCV

General Objective: To identify and accept positive and negative expressions, feelings, and reactions.

NURSING RATIONALE SPECIFIC OBJECTIVES INTERVENTIONS RATIONALE EVALUATION

CUES
DIAGNOSIS

Subjective: Fatigue related to The patient is After 1 hour of nursing Independent: After 1 hour of
stress anxious about the intervention, the patient will be rendering nursing
“Okay naman condition of her able to alleviate fatigue through >Assess the root cause of To determine the course of intervention. The
bata ko no?” child, since she is total control of emotions. the patient’s anxiety. action to be taken patient met the
Hepa B reactive. goal by:
“Wala pako She frequently >Establish a therapeutic To maximize the
kapanibin.” inquires about the environment. effectiveness of the Verbalizing
condition of her intervention. positive and
“Indi pako baby. She always >Maintain therapeutic optimistic thoughts
mayo carries her baby conversation consistently To avoid worsening the
katindog, since it always and be sensitive to patient’s patient’s condition and Able to take a bath
kasakit pa.” cries whenever feelings. instead, enable the patient and leave the baby
she tries to put to feel a sense of safety. with the father
Objective: her down the bed >Encourage the patient’s
which leads to her partner to provide emotional Family is the best provider Able to have
Vital Signs: having inadequate support. of emotional support. adequate rest
sleep and self-
Pulse of 99 care deficit. Dependent:
bpm
>Administer medications Anxiety might be caused of
Blood according to the doctor’s an underlying condition. Too
pressure of order and refer if the much anxiety might lead to
100/70 anxiety intensifies. worse outcomes like self-
mmHg mutilation.
 WBC count: Collaborative:
6.6 ×
109/L >Obtain and evaluate To determine other factors
laboratory results. affecting the patient’s
Hepa B emotional status.
reactive
>Coordinate with a Unmanageable anxiety can
Perineum psychiatrist if the anxiety only be pacified by a
lacerations intensifies. specialist.