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IV.

NURSING CARE PLAN

EVALUATION
CUES NURSING DIAGNOSIS OBJECTIVES OF CARE PLAN OF INTERVENTIONS RATIONALE
SCHEME
Objectives A1: Impaired skin P1: Within the shift, pt will To monitor and regulate IVF To supply balance of fluid E1: Reassessment
 Received pt asleep integrity r/t inflammation not demonstrate as ordered and electrolytes of pt’s skin integrity
in cradle position of dermal-epidermal scratching or rubbing through physical
with IVF # 5 D5IMB junctions secondary to action to skin To monitor and record vital For continuous pt examination
500 cc x 38-39 previous hyperthermia signs Q4 monitoring
µgtts/min, received P2: Within the shift, pt will E2: Reassessment
@ A2:
400 cc level, Effective continue giving effective To monitor and record I&O To observe abnormal of pt’s proficiency
hooked @ RMTV, breastfeeding r/t breastfeeding input and output of the and satisfaction with
infusing well adequate proficiency body the breastfeeding
and satisfaction with the process.
 The mother stated breastfeeding process To provide assistance To serve as a support
that her child has throughout the shift
rashes
To keep linens clean and To promote comfort
 The mother also wrinkle free
stated that her child
is still breastfeeding To maintain cleanliness at To promote sanitation in
bedside the area
 (+) some rashes;
redness; @ face, To wash reddened area gently To decrease affected area
arms and abdomen with a mild soap, rinse and prevent further
(+) itchiness thoroughly to remove soap, infection
and pat dry
 (+) good attachment
to breast To gently massage skin To stimulate circulation
(+) good positioning around affected area; do not and promote comfort
when breastfeeding massage if reddened
(+) satisfaction after
breastfeeding To provide opportunities to rest To promote comfort and
manifested by stable at day and periods of distraction from itchiness
reaction and the uninterrupted sleep
desire for more
(+) attentional To monitor for clinical signs of To implement progress in
smiling wound infection the healing process
(+) eye contact
To watch out for seizure To be aware and ready at
 with initial vital signs recurrence all times
of:
PR = 140 bpm, To provide health teachings To divert the attention of
regular, +2 about different distraction to the pt from itchiness
RR = 34 cpm, avoid scratching or rubbing
T= 36.8 OC such as playing with toys or
sleeping

To provide health teaching To further enhance the


about the importance of knowledge of the mother
breastfeeding e.g. it helps in
the healing process and
nutrition of the body

To provide health teachings To prevent the


about infection precautions transmission of
such as hand washing and microorganism that can
cleaning of nipples with water cause infection
when breastfeeding