NURSING CARE PLAN

CUES NURSING SCIENTIFIC PLANNING IMPLEMENTATION SCIENTIFIC EVALUATION

DIAGNOSIS EXPLANATION RATIONALE
Subjective Cues  Impaired physical After 1 -2 hrs of  Determine diagnosis  Identifying barriers After 1 -2 hrs of
 “Hindi ako mobility related to Difficult Delivery nursing intervention that contributes to to immobility nursing intervention the
makagalaw ng pain secondary to the patient will be able immobility. guides in design of patient was able to:
maayos kasi episiotomy. to: an optimal
masakit yung tahi  Evaluates patients treatment plan.  Verbalized
ko” verbalized by  Verbalize ability to perform understanding of
the patient. understanding of activities of daily  Determine situation and
Episiotomy situation and living and safely on strengths or individual treatment
 Discomfort individual daily basis. insufficiency and regimen and safety
treatment regimen may give measures.
Objective Cues and safety information
 Decreased in fine measures.  Execute passive or regarding recovery  Participate in
or gross motor Pain at the incision site active ROM exercises activities of daily
skills; movement-  Participate in to all extremities. living (ADL) and
induced tremor. activities of daily  Exercises enhances desired activities.
living (ADL) and increased venous
 Decrease in desired activities. return, maintains
reaction time; slow Impaired physical muscle strength  Identified measures
or spastic mobility and stamina. to increase
movement;  Identify measures mobility.
uncoordinated to increase
movement. mobility.
 NURSING CARE PLAN

CUES NURSING SCIENTIFIC PLANNING IMPLEMENTATION SCIENTIFIC EVALUATION

DIAGNOSIS EXPLANATION RATIONALE
Subjective Cues  Readiness for After 1 -2 hrs of  Assess the client’s  To provide After 1 -2 hrs of
 Mother express enhanced Feeding of infant from nursing intervention desire/plan for information for nursing intervention
desire to enhance breastfeeding mother’s breast the patient will be able feeding the infant. developing a plan the patient was able to:
ability to to: of care.
exclusively  Assess the client’s
breastfeed.  Verbalize knowledge about  To determine the  Verbalized
understanding of breastfeeding. level of awareness understanding of
 Mother expresses Breast milk produced in breastfeeding of the patient breastfeeding
desire to provide glandular tissue techniques; good  Identify cultural about techniques; good
breast milk for (alveoli) of the breast. latch and beliefs/practices breastfeeding latch and
child’s nutritional lactogenesis regarding lactation, lactogenesis
needs. let down techniques  To prevent
 Identify effective and maternal food  Identified effective
techniques for preferences  To calms the techniques for
Breastfeeding stimulate breastfeeding patient and the breastfeeding
milk production and  Encourage skin to baby.
keep the milk supply  Verbalize skin contact.  Verbalized
up. understanding of understanding of
the benefits of  Demonstrate how to  To provide a the benefits of
breastfeeding. support and position proper technique breastfeeding.
the infant. for breastfeeding.
 To promote a
Enhanced  Provide information timely feeding
Breastfeeding as needed about early experience for the
infant feeding cues. infant and mother.
 To provide
 Discuss the benefits knowledge about
of the breastfeeding the benefits of
to the newborn and breastfeeding to
baby. the mother and
infant.
 NURSING CARE PLAN

CUES NURSING SCIENTIFIC PLANNING IMPLEMENTATION SCIENTIFIC EVALUATION

DIAGNOSIS EXPLANATION RATIONALE
Subjective: Risk for infection After 30mins-1hr of Establish rapport To Gain trust After 30mins-1hr of
“masama ang related to surgical Delivery of the baby nursing intervention the nursing intervention,
pakiramdam ko” incision secondary to patient will be able Monitor vital signs For baseline data the patient was
episiotomy wound
Objectives: a. free from any Explain the manifestation To gain cooperation a. free form any
Facial grimace signs and of infection to the patient and understanding on signs and
T: 38.3 degree celsius symptoms of the causative factors symptoms of
a infection as of infection infection as
manifested by Emphasize the manifested by
Presence of surgical absence of fever importance of Prevent spread of absence of fever
incision at the b. understand the handwashing microorganisms b. understand the
perineum causative factors causative factors
of infections Maintain aseptic of infections
techniques in caring for Promotes fast healing
the laceration and drying of the
wounds
Keep the area of
perineum dry. Wet area can be a
Risk for infection lodging area of the
microorganisms
Emphasizes the necessity
on taking antibiotics as Discontinuation of the
ordered by the doctor treatment as
prescribed by the
doctor may result in
infection