ASSESSMENT DIAGNOSIS PLAN INTERVENTION RATIONALE EVALUATION

Subjective: Deficient Goal: Dependent: Dependent: After 2 hours of

“Madalang nalang knowledge After 2 hours of - Attend anti- - May give nursing
naman po akong regarding nursing smoking additional interventions, the
naninigarilyo exposure to interventions, the seminars and knowledge on patient was able to
ngayon..” teratogens patient is able to programs as ways to quit identify and refrain
during identify and refrain advised by the smoking from the possible
Objective: pregnancy from the possible doctor risk and
 The risk and consequences of
patient’s consequences of teratogens to her
lips and teratogens to her Independent: Independent: pregnancy as
gums are pregnancy. - Assess the - To assess the evidenced by:
significantly patient’s patient’s
darker than Outcome Criteria: method of readiness to  Patient has
its original  Patient comprehending learn and identified
color identifies information. identify her learning
 RR: 23 bpm learning possible phase needs
 BP: 130/100 needs for the process.  Patient was
 Patient is - Provide health - To make the able to
able to teaching patient recognize
recognize regarding understand the and
and smoking and consequences familiarize
familiarize different of smoking and self with
self with teratogens, as encourage her different
different well as its to stop teratogens
teratogens effects and  Patient was
 Patient is consequences able to
able to to the mother understand
understand and the baby and
and acknowledge
acknowledge the possible
 the possible - Suggest - To avoid effects of
effects of hobbies that temptation these
these the patient that may cause teratogens
teratogens could redirect the patient to to her and
to her and her attention relapse and to her baby’s
her baby’s to. replace the health
health pleasure given  Patient was
 Patient is by tobacco able to
able to demonstrate
demonstrate Collaborative: Collaborative how to
how to - Collaborate - Provides incorporate
incorporate with the encouragement new
new patient’s and care from knowledge
knowledge relatives in the relatives, into her
into her monitoring her which could current
current habits at home. encourage the lifestyle
lifestyle. - Refer to the patient to stop.
patient’s - To identify any
previous cues or
physician information
regarding the that the patient
patient’s health was not able to
and medical state or
history observe
Cayabyab, Trisha M.
G2C

Nursing Care Plan

ASSESSMENT DIAGNOSIS PLAN INTERVENTION RATIONALE EVALUATION

Subjective: Health seeking Goal: Dependent: Dependent: Goal:
“Mahina po behavior After 1 hour of - the use of - May give After 1 hour of
akong kumain. related to nursing supplemental additional nursing
Makakapekto po guidelines for interventions, the nutrition as knowledge interventions, the
bai to sa bata?” nutrition and patient is able to prescribed by the on ways to patient was able to
activity during acquire sufficient doctor quit acquire sufficient
Objective: pregnancy knowledge regarding smoking knowledge regarding
 Weight: 43 the proper nutrition the proper nutrition
 Height: 5’6 and activities to be Independent: Independent: and activities to be
 Age: 25 done during - Identify probable - To assess done during
 Client pregnancy. underlying issues the patient pregnancy as
shows as to why the further and evidenced by:
evident Outcome Criteria: patient lacks the to identify
weakness  Patient is able will to eat certain  Patient was
to problems able to
acknowledge that may acknowledge
the also need the
consequences concern consequences
of unhealthy - Provide health - To increase of unhealthy
eating habits teaching the eating habits
to her regarding proper patient’s to her
pregnancy nutrition and awareness pregnancy
 Patient is able activities to be which could  Patient is able
familiarize contribute familiarize
 self with the done during to her self with the
proper food pregnancy willingness proper food
and activities - Use therapeutic to change and activities
during skills when talking - To provide during
pregnancy. with the patient support and pregnancy.
 Patient is able comfort for  Patient was
to express - Advise the client the patient able to
desire to to weigh herself - To motivate express
change daily in order to the patient desire to
specific habit monitor her further, or change
or lifestyle progress to improve specific habit
patterns to plan of or lifestyle
achieve action If patterns to
optimum needed achieve
health. Collaborative: optimum
 Patient is able - Consult dietitian Collaborative health.
to participate for further - To provide  Patient was
in plan for assessment and more able to
change. recommendations information participate in
regarding food and tips to plan for
preferences and the patient change.
nutritional
support.
- Refer to family
members or - May
relatives and facilitate
provide health long-term
promotion or attention to
monitoring skills. health.