Nursing Care Plan: NCM 109 Rle Clinical Wednesday 7:00 AM - 12:00 PM
Nursing Care Plan: NCM 109 Rle Clinical Wednesday 7:00 AM - 12:00 PM
Submitted by:
REGALA, BIANCA YSABELLE M.
BSN II – B
Group 3
Name: Mrs. Y Sex: Female
Subjective: Acute pain After 8 hours of Independent: The goal was partially met.
related to nursing intervention
- Evaluate pain - Provides information about After 8 hours of nursing
increased the patient’s pain wil
regularly (every 2 need for or effectiveness of intervention the reported
“Masakit po ang tahi ko,” as muscle decreased from the
hrs noting interventions. that her pain decreased
verbalized by the patient. contraction. scale of 9/10 to 3/10.
characteristics, from 9/10 to 4/10.
location, and
Objective: intensity (0–10
scale). Emphasize
patient’s
Vital signs taken as responsibility for
follows: reporting pain/
BP= 130/80 mmHg relief of pain
PR= 70 bpm completely.
RR= 20 cpm
Temperature= 37⁰
- Assess vital signs, - Changes in these vital signs
Pain= 9/10
noting tachycardia, often indicate acute pain and
hypertension, and discomfort. Note: Some
increased patients may have a slightly
respiration, even if lowered BP, which returns to
patient denies pain. normal range after pain relief
is achieved.
Collaborative:
- Administer - Analgesics given IV reach
analgesics as the pain centers
immediately, providing more
indicated.
effective relief with small
doses of medication.
Health Teaching:
- Educate proper - May help in decreasing
relaxation anxiety and tension, promote
techniques; position comfort and enhance sense
for comfort as of well-being.
possible. Use
Therapeutic Touch,
as appropriate.
Name: Mrs. Q Sex: Female
- Administer
- These medications
vasodilatiors as
increase venous
ordered. dilation and
decrease pulmonary
congestion that will
enhance gas
exchange.
Subjective: Risk for After 8 hours of Independent: The goal was met.
decreased effective nursing - Cold, clammy, and
“Nahihilo at nanghihina ako,” - Note skin color, After 8 hours of effective
cardiac intervention the pale skin is
as verbalized by the patient. temperature, and nursing intervention the
output patient will remains secondary to
moisture. patient remains
related to normotensive, with compensatory normotensive, with blood
Objective: dcreased blood loss less than increase in loss less than 800 ml.
venous 800 ml. sympathetic nervous
return. system stimulation
Vital signs taken as and low cardiac
follows: output and oxygen
BP= 90/60 mmHg desaturation.
PR= 112 bpm
RR= 23 cpm
Temperature= 36⁰ - Record intake and - Reduced cardiac
output. If patient is output results in
Uterus is soft and not acutely ill, measure reduced perfusion of
contracted. hourly urine output the kidneys, with a
Fresh blood discharge on and note decreases resulting decrease in
diaper. urine output.
in output.
Restlessness
- Monitor and record - To know the actual
blood loss. blood loss and to
determine the
appropriate
treatment needed
by the patient.
Collaborative:
- Administer oxygen - The failing heart may
therapy as not be able to
prescribed. respond to increased
oxygen demands.
Oxygen saturation
need to be greater
than 90%.
Health Teaching:
- Educate family and - Early recognition of
patient about the symptoms facilitates
disease process, early problem
complications of solving and prompt
disease process, treatment.
information on
medications, need
for weighing daily,
and when it is
appropriate to call
doctor.