JAN MIKHAIL M.

ROSALES

BSN – 2C

NURSING CARE PLAN ON COMPROMISED FAMILY COPING

ASSESSMENT NURSING PLANNING NURSING RATIONALE EVALUATION

DIAGNOSIS INTERVENTION
SUBJECTIVE: Ineffective After 4 hours of  Assess specific  Accurate The patient was able
She said that her compromised coping nursing intervention, stressors. appraisal can to describe and
usual mood is calm related to difficulty the patient will be facilitate initiates alternative
but in times of adapting in stress development of coping strategies in
able to describe and
appropriate adapting stress.
difficulty her mood is initiates alternative
coping
mostly irritable. coping strategies in strategies.
adapting stress.
The client described  Assess level of  Appropriate
herself as understanding problem solving
"maraminganak at and readiness to requires accurate
learn needed information and
nahihirapan lalo at
lifestyle understanding of
may sakit ang baby changes.
ko". options.

 Patients may feel

"Nahihirapanako, yun  Assess decision- that the threat is
yung nafefeelko… making and greater thantheir
parang gusto ko nang problem-solving resources to
bumigay" abilities. handle it and feel
a loss ofcontrol
When asked if how over solving the
she handled big threat or
problem.
problems in her life
she answered “
 Determine  These
Inaaway ko nalang
asawa ko”. alcohol intake, mechanisms are
drug use, often used when
Objective: smoking habits, individual’s is
sleeping and not coping
- used negative forms
eating patterns. effectively with
of coping like arguing stressors.
- inability to meet
basic needs including
no time for self-  An ongoing
 Establish a
hygiene working relationship
- high illness rate as relationship with establishes trust,
evidenced by high patient through reduces the
blood pressure continuity of feeling of
care. isolation, and
OBJECTIVE: may facilitate
 Appears coping.
restless
 - Visible dark
 Provide
cirle  Verbalization of
opportunities to
 under eyes actual or
express
 - Appear concerns, fears, perceived stress
problematic feelings, and can help reduce
 - poor expectations. anxiety.
personal
 hygiene

 Encourage  During crises,

patient to may not be able
identify own to recognize
strengths and their strengths.
abilities. Fostering
awareness can
expedite use of
these strengths.
 Provide
information the  Patients who are
patient wants coping
and needs. Do ineffectively
not provide have reduced
more than ability to
patient can assimilate
handle. information.

 Encourage
patient to  Unexpressed
communicate feelings can
feelings with increase stress.
significant
others.

 Instruct in need
for adequate rest  These facilitate
and prescribed coping strengths.
diet. Inadequate diet
and fatigue can
themselves be
stressors.

 Teach use of  Methods to cope

relaxation, with stress.
exercise, and
diversionalactivi
ties.

 Determine
previous  To identify
methods of successful
dealing with life techniques that
problems. can be used in
 current situation.
 Converse at
client’s level,  Enhances
providing therapeutic
meaningful relationship.
conversation
while
performing care.

 Encourage and
support client in
evaluating  Promotes long
lifestyle, term
occupation, and development that
leisure activities. deals with
current situation.
 Provide for
gradual
implementation  Enhances
and continuation commitment to
of necessary plan
behavior/lifestyl
e
 NURSING CARE PLAN ON FLUID VOLUME DEFICIT

ASSESSMENT NURSING PLANNING NURSING RATIONALE EVALUATION

DIAGNOSIS INTERVENTION
SUBJECTIVE: Fluid volume deficit After 8 – 24 hours of  Monitoring of  Increased The patient was able
“Pag uubo siya nag related to some loss nursing intervention vital signs at least temperature to exhibit moist
susuka siya at of fluids and the patient will be every four hours and mucous membrane
nagtatae” as electrolytes as able to: respiratory and good skin turgor.
verbalized by the manifested by Exhibit moist mucous rate contribute
mother vomiting and membrane and good to fluid loss. A Was able to retain
diarrhea skin turgor weak, thread feeding without
OBJECTIVE: pulse and drop experiencing
 Dry skin and Retain feeding in blood vomiting and reduced
mucous without experiencing pressure diarrhea
membrane vomiting indicate
 Poor skin dehydration. Patient maintain
turgor Maintain fluid fluid volume at a
 Serum volume at a  Assess turgor,  Fluid loss functional level and
electrolytes: functional level and mucous occurs first in stable vital sign
sodium-133 have stable vital signs membrane every extracellular
mmol/L shift spaces,
(Low) resulting in
 VITAL poor skin
SIGNS turgor and dry
TAKEN AS mucous
FOLLOWS: membrane

T: 39.5⁰C  When vomiting  To replace

PR: 90 decreased, offer fluid loss
RR: 63 small amounts (5- without
10ml) clear fluids causing
further GI
irritation
  Monitor IV fluid  Fluid balance
infusion every is less stable
hour (0.45% in young ones,
NaCl with 5% infusing too
glucose+ 20 rapidly or too
mmol KCl/L) slowly can
lead to fluid
imbalance

 Secure the IV site  To protect the

by wrapping in it site and allow
a soft bandage the infant to
move his/her
hand and arm
freely

 Collaboration:  In presence of
Provide IV fluid reduced
infusion every intake/
hour (0.45% excessive loss,
NaCl with 5% use of
glucose+ 20 parenteral
mmol KCl/L) route may
correct,
prevent
deficiency

NURSING CARE PLAN ON INEFFECTIVE TISSUE PERFUSION

ASSESSMENT NURSING PLANNING NURSING RATIONALE EVALUATION

DIAGNOSIS INTERVENTION
SUBJECTIVE: Ineffective tissue After 8 hours of  Monitor  It is an The patient was able
 “Hirap siyang nursing intervention respiratory indication of to demonstrate an
 makahinga” as perfusion related the patient will rate respiratory increased perfusion,
verbalized by to impaired demonstrate distress and adequate urine output,
the mother accumulation no more edema and a
transport of increased
of secretions stable vital sign
oxygen across perfusion as
OBJECTIVE: alveolar and on evidenced by  Note quality  To asses
 Pale in capillary warm and dry skin, and pulse that
appearance membrane strong peripheral strength of may
 Skin or pulses, normal peripheral become
temperature vital signs, pulses weak or
changes adequate urine thready,
 Weak pulses output and because of
absence of edema sustained
 Edema functional level and  Assess hypoxemia
have stable vital signs
 Inadequate respiratory  To note for
urine output rate, depth, an
and quality increased
 RR= 32
respiration
 restlessness
that occurs
in response
to direct
effects of
endotoxins
on the
respiratory
center in the
brain, as
well as
developing
hypoxia,
 stress.
Respirations
can become
shallow as
respiratory
insufficiency
develops
creating risk
 Assess of acute
respiratory respiratory
rate, depth, failure.
and quality
 To assess
for
 Assess skin compensato
for changes ry
in color, mechanisms
temperature of
and vasodilation
moisture
 To promote
 Provide TSB circulation /
venous
 Elevate drainage
affected
extremities
with edema  To decrease
once in a temperature
while
  lowers O2
 Provide a demand
quiet, restful
atmosphere

 To maximize
O2availabilit
y for cellular
uptake

NURSING CARE PLAN ON INTERRUPTED BREASTFEEDING

ASSESSMENT NURSING PLANNING NURSING RATIONALE EVALUATION

DIAGNOSIS INTERVENTION
SUBJECTIVE: Interrupted After 4 hours of  Assess mother’s  To After 4 hours of
“ I don’t get to spend breastfeedin nursing understanding assess/evaluat nursing
a lot of time with my g related to interventions, the (perception and e the need for interventions, goal
baby,” as verbalized neonate’s mother will be knowledge) for further met. Patient was
by the mother present able to identify interrupting instruction able to identify,
illness as and demonstrate breastfeeding demonstrate and
evidenced by techniques to verbalize
OBJECTIVE: separation of sustain lactation  Emotional techniques that
 Assess mother’s
 Infant is mother to until feelings may would help
infant breastfeeding is emotional sustain lactation
diagnosed affect
initiated. reactions to until
with sepsis resumption
having to after breastfeeding is
 Newborn is
interrupt interruption initiated.
separated
breastfeeding.
from mother
Give emotional
 The mother
unable to support to
provide breast mother and
milk to accept decision
newborn regarding
continuously cessation/
continuation of
breast feeding.
 Mother must
have a plan in
 Review
order to carry
mother’s daily
on usual
routine routine and
still make sure
the baby is fed
on schedule

 To advise her
 Instruct mother how to
in methods for incorporate
expressing and breastfeeding
storing breast into her
milk. schedule
Demonstrate
the use of a
breast pump
(manual piston
type)
 To aid in
 Review feeding the
techniques for neonate with
storage/use of breast milk
expressed without the
breast milk mother
 breastfeeding
the infant.

 Determine if a  To provide
routine visiting optimal
schedule or nutrition and
promote
advance
continuation
warning can be
of
provided breastfeeding
process
 Provide
privacy, calm  So that infant
surroundings will be
when mother hungry/ ready
breast feeds. to feed

 To promote
 Recommend for successful
infant sucking infant feeding
on a regular
basis
 Reinforces
 Encourage that feeding
mother to time is
pleasurable
obtain adequate
and enhances
rest, maintain
digestion and
fluid and
to sustain
nutritional adequate milk
intake, and production
schedule breast and breast
pumping every feeding
3 hours while process
awake
 NURSING CARE PLAN ON RISK FOR IMPAIRED PARENT-INFANT ATTACHMENT

ASSESSMENT NURSING PLANNING NURSING RATIONALE EVALUATION

DIAGNOSIS INTERVENTION
SUBJECTIVE: Risk for impaired SHORT TERM  Encourage  Opens line of The patient was able
“Mga two days na attachment due to GOAL: px to talk communicatio to interact with
nga wala mi nag restriction from about her n so the px newborn and is able
uban.” “Dili siya staying at NICU. After 8 hours of feelings will feel to identify parental
puwede pa iroom in comprehensive NSG regarding comfortable strength
tungod kay basin interventions the px being a parent. and be honest
malipong ko.” “Dili will: Verbalize about her The patient was able
sad ko puwede  Be able to positive feelings/fears. to restore her health.
musulod sa NICU kay interact with And able to spend
aspects of px.
nalipong ko didto last newborn to more time with
time.” As verbalized the very least newborn
by the patient. way.  Encourage &  This motivates
provide health the px while
OBJECTIVE:  Be able to teaching about being
identify parenting and educated. It
 Mother cannot parental maintaining can lead to
hold the child strengths. good health by fast recovery
 No room getting
visits LONG TERM adequate rest,
 BP: 140/90 GOAL: nutrition, and
-170/110 After a week of exercise.
mmHg comprehensive NSG  Involve
interventions the px
parents in  Enhances
will: self-concept
 Be able to activities
 restore her with the
health. newborn
that they
 Be able to
spend more can
time with accomplish
newborn successfully