APPENDIX B
NURSING CARE PLAN
CLINICAL PORTAIT
Assessment:
Received patient seen sitting on her bed without IVF infused,
stands erect, clear vocal tone noted. The patient is conscious,
attentive and oriented to time, place, and person and very
cooperative.
Review of Systems:
Head and Neck: normocephalic, hair is evenly distributed, not
extremely dry or oily, no scaled and with symmetrical facial
features. No lesions noted and can breathe freely.
Skin: Warm, good skin turgor, normal capillary refill noted (2
seconds) Free of edema.
Mouth and Pharynx: Breath smells fresh. Lip is pinkish. Upper
teeth override the lower teeth. Oral mucosa is pink, moist,
smooth, and no lesions.
Abdomen: The patient’s abdomen as round and large. No masses
were noted and fundus was at the level of the umbilicus.
Significant Findings:
The patient still feels the pain in her vaginal area. She also
has small amount of vaginal discharges. She can’t sleep well at
night because of the noise of babies. Restlessness noted. She was
not able to defecate.
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PERTINENT DATA
A case of Ms. R, 26 years old, female, single, Roman
Catholic currently residing at Gun-ob,Lapu-Lapu ; admitted at
Lapu-Lapu City District Hospital due to labor pain.
Prior to admission the patient has an appointment going
for a checkup while having her check-up the residence doctor
advised her to go the hospital because of her complain of lower
abdominal pain and blurring of vision, instead of going to the
hospital patient went home and experience pain and vaginal
bleeding and a blurring of vision. The family of the patient has
decided to bring her to the LLCDH hospital.
Upon admission through internal examination it was noted
that the patient is having a baby girl twins. Already 7cm. dilated
with fetal heart beat of 145 bpm. A cephalic presentation via
primary low segment transverse caesarian section 2 degrees to
placenta previa totalis posteriorly located, Vital signs of the
patient showed a pulse rate of 94 beats per minute; respiratory
rate of 44 cycles per minute, with a blood pressure of 150/100
mmHg and a temperature of 38.4 degree celsius through axilla.
Was in labor for 4 hrs.
No history of hypertension and diabetes. No known food
and drug allergies. Non-smoker and non-alcoholic beverage
drinker.
LMP: January 13, 2009
EDC: October 26, 2009
 AOG: 35 weeks

Vital signs taken during first contact with the patient: OB score: G1 P1

Temperature: 36.5 Degrees Celsius RR: 19 breaths per minute Gravida 1 female Cesarean Birth Full-term Sept. 21, 2008
RR: 60 beats per minute BP: 100/80 mmHG

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CUES/EVIDENCES NURSING SCIENTIFIC GOALS AND NURSING RATIONALE EVALUATION
DIAGNOSIS BASIS OUTCOME ACTION &
CRITERIA NURSING
ORDERS
Subjective Alternation in Sutures for an After 8 hrs. of Nursing action: Goal met. After
Cues: comfort: pain episiotomy nursing Render Nursing 8 hours of
“Sakit ako kinataw related to can be sore interventions, the intervention to nursing
inig pangihi nako.” , perineal and painful. patient will be able alleviate pain and intervention, the
as verbalized by the wound Although to verbalize discomforts patient was able
patient. secondary to relatively alleviation of pain to verbalize
episiorrhaphy. small in size, and discomfort. alleviation of
Objective and Nursing Orders: pain and
Cues: episiotomy Outcome discomfort from
a. Guarded can cause Criteria: the scale of 6
behavior considerable Specifically, the reduced to 3 as
noted discomfort patient will be able 10 as the highest
every time because the to: for pain scale.
she moves perineum is
out of an extremely a. Verbalize a. Provide a. Refocuses
bed. tender area. methods Divisional attention may
The muscled that provide activities enhance coping
b. Rates pain of the pain relief. like abilities.
with perineum are reading
intensity involved in books or (Kozier, 2002:
of 6, as 0 many magazines. 847)
has no activities.
pain and Thus, an b. Express of b. Encourage b. Imagery can
10 as the incision in feeling of use of be used to
highest this area comfort. relaxation enhance other
for pain causes a great technique forms of
scale. deal of such as medical &

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 discomfort. guided nursing
c. Grimaced imagery. therapists to
face noted (Pillitteri, improve the
during 2003: 612) body’s
unnecessa response to
ry therapy. Images
movement are meaningful
s. to the patient
need to be
d. (+) used.
episiorrha (Kozier,
py 2002:847).

c. Verbalize c. Asses and c. Facilitate

reduction of determine diagnosis of
pain from 4- the signs pain &
3 scale of of pain initiation of
pain (0 as while appropriate
no pain & 5 taking in therapy
as the considerati (Doenges,
highest). on of the 1997: 38)
location,
characteris
tics,
intensity,
onset, and
its
duration.

d. Use or d. Make time

demonstrate to interact
Diversio-nal and d. Helpful in

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 activities maintain alleviating
such as frequent anxiety &
reading & contact refocusing
walking with the attention.
patient. (Kozier, 2002:
682)
Collaborative
e. Demonstrate a. Administer e. To provide a
pain relief medication medication that
with the use as ordered has systematic
of some by the effect on the
relaxation physician gastrointestinal
technique. (mefenami tract. (Kozier,
c acid) 2002: 1313)

Subjective Constipation Constipation After 8 hrs. of Nursing Action: Goal partially

Cues: related to loss tends to occur nursing intervention Render nursing met. Even
“Wala pa ko kalibang of bowel because of the the patient will be intervention to though the fact
sukad gahapon unya sensation relaxation of able to defecate. resume normal that the patient
sakit kung mosulay secondary to the abdominal bowel movement. was able to
ko ug kalibang.” As post term as wall and the Outcome criteria: defecate one and
verbalized by the evidenced by intestine now Specifically the Nursing Orders: half a cup but
Patient. absence of that it is no patient will be bale Independent: she still needs
stool. longer to: more follow up
Objective compresses of nursing
Cues: by the bulky intervention to
a. Went to the uterus. For a. Regain a. Review a. Fiber absorbs achieve
comfort room bowel normal daily water and resuming her
and tried to movement to pattern of dietary increases stool normal bowel
defecate but occur, the bowel regimen. bulk which pattern.
there room abdominal functioning Encourage stimulates
and tried to wall must intake of peristalsis and

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 defecate but exert pressure. roughage bowel
there was no It its relaxed and evacuation.
stool. state, it is not increase Likewise
strong enough fluid adequate
b. The patient to be intake. amount of fluid
has already effective. will improve
eaten regular (Pillitteri, stool
meals but has 2003: 618) consistency
not defecated ( Kozier,
yet. 2002:1193)

b. Alters diet to b. Encourage b. Fiber absorbs

include the patient water and
adequate to include increases stool
amounts of fiber in the bulk which
fluid and diet. stimulates
fiber. peristalsis and
bowel
evacuation.
Likewise
adequate
amount of fluid
will improve
stool
consistency
( Kozier,
2002:1193)

a. Reestablish c. Encourage c. Stimulates,

normal early peristalsis,
bowel ambulation facilitating
functioning. passage of

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 flatus.
(Doengus,
2002:259)

b. Change diet Collaborative d. Solid foods

d. Begin are not started
progressive until bowel
diet as sounds have
tolerated. returned has
been passed
and danger of
ileus formation
has abated.
(Doenges,
2002:259)

c. Pass stool of a. Administer e. Softens

soft or semi laxatives, stools,
formed stool promotes
consistency softener as normal bowel
without indicated. habits,
straining. decreases
straining.
(Doenges,
2002:260)

Subjective Disturbed Environment After 8 hours of Nursing Action: Goal Met. The
Cues: sleep pattern can promote nursing Render nursing patient was able
“Wala pa kayo ko’u related to or hinder intervention, the intervention to to verbalize
tarong nga tulog ku noise brought sleep. The patient will be able have an optimal satisfaction with
sige ug hilak ako about by cry absence of to verbalize that she sleep pattern. quality and

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anak kada gabii.” As of the usual stimuli can sleep amount of sleep,
verbalized by the newborn. or the satisfactorily. and reported
patient. presence of feelings of being
unfamiliar Outcome rested and
Objective stimuli can Criteria: refreshed after
Cues: keep people Specifically the waking.
from sleep. patient will be able
Restlessness (Kozier, to:
Noted 2002:956)
a. Evaluate a. Obtain a. to determine
Dark circles sleep patter feedback the usual sleep
Under the eyes and from client pattern and
dysfunction regarding provide
Frequent yawning. usual comparative
bedtime, baseline.
rituals, (Doenges,
routines, 2004:474)
number of
hours of
sleep, time
in arising,
and
environme
ntal needs.

b. To assist b. Arrange b. It enables

client to care to patient to sleep
establish provide for uninterruptedly
optimal uninterrupt .
sleep/rest ed periods (Doenges, 2002
pattern. for rest. :338)

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c. To have c. Restrict c . Caffeine
regular intake of may delay
sleeping caffeine- patient’s falling
pattern containing asleep and
foods/ interfere with
fluids. rapid eye
movement
sleep, resulting
in patient not
feeling well
rested
( Doenges,
2002; 338)

d. Fall asleep d. Provides d. d.

within 30 to client’s desired Relaxati
45 minutes comfort measure on
of going to or sleeping aids measure
bed such as s help
appropriate induce
positioning and sleep.
supports, soft (Kozier,
music and warm 2002:96
milk. 3)

e. Reports e. Provide a quite

feeling of peaceful
being rested environment
and during sleeping
refreshed periods.
after e. A quite

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waking. peaceful
environment
promotes
restful sleep.
(Kozier, 2002 :
963)

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 APPENDIX C
DISCHARGE PLAN

PATIENT’S OUTCOME CRITERIA NURSING ORDERS

As soon as the patient is discharge from OPC the patient will be

able to:

A. Assessment:

➢ Asses the characteristic of the wound. Asses ➢ Discuss the signs of infection such as:
for signs of infection  formation of pus
 swelling
 redness
 pain
B. Planning:  heat at the area

➢ Plan schedules visit as ordered ➢ Instruct patient to follow schedule for visits

➢ Plan for correct medication to be taken ➢ Instruct patient how to take her medication
properly, what time to time and what dose.

C. Implementation

Medication: ➢ Remind the patient and significant others of the

➢ Comply the medication regimen medication schedule.
➢ Encourage client to take several naps. Instruct

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Cefalexin (Cefalin) 500mg 1 cap TID client to ask the physician if they will visit the
clinic what is the appropriate time to resume
Celecoxib (Celebrex) 500mg 1 cap TID work.
➢ Teach patient on restriction on exercise or
Nefedipine (Adalat) 38mg 1 cap TID activity (she should not lift any object heavier
than 10 lbs for the first two weeks).
Hydalazine (Apresoline) 25mg Q4
➢ Encourage the patient and significant other to
help watch out for the schedule of the
medication

Exercise/Environment ➢ Discuss with the patient the importance of

➢ Develop routine rest and activity perineal care for her fast wound recovery.

➢ Encourage the patient and significant others to

Treatment follow the given schedule.
➢ Follow the schedule of medication administration

➢ Immediate postpartum diet is clear liquid

Health Teaching (ginger ale, bullion, juice, water) and gradually
➢ Do self - perineal care everyday returning to patient regular tolerated diet.

Out-Patient Referral
➢ Comply the schedule for check-up

Diet

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 ➢ Eat nutritious foods for faster recovery

➢ Food should be rich in Vitamin C to prevent

further infection and protein to promote wound
healing.
Spiritual
➢ Attend mass every Sunday with her family.

A. Evaluation ➢ Encourage the patient to attend mass every

➢ Evaluate the patient’s understanding of all the
treatment regimens and planned actions
Sunday with her family
➢ Let the patient repeat the instruction being said
➢ Let the patient demonstrate on the proper way
to do perineal care.
➢ Ask the patient a question to know if they
really understood the planned action

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