Ateneo de Zamboanga University

College of Nursing
Case Study (HOSPITAL)

NURSING CARE PLAN (NCP)

CUES NURSING DIAGNOSIS GOALS AND DESIRED NURSING INTERVENTION IMPLEMENTATION EVALUATION

OUTCOME

Subjective: Pain related to Labor At the end of 2 hours of the 1. Encourage Comfortable 1. Assisted the woman in a After 2 hours of the Nursing
Contractions Nursing Interventions, the positioning. satisfying and comfortable Interventions, the Client
The client verbalized she Client will be able to state positioning. states pain is reduced to 7/10
experiences: pain reduced to 7/10 using Rationale: Position changes using the pain scale; was able
 Leg cramps and pelvic the pain scale; demonstrates are also essential in the early to also demonstrate ability to
pain. ability to listen and respond and second stage of labor. listen and respond to
 Lower abdominal pain of to questions and instructions. Depending on medical questions and instructions.
10/10 on a 0-10 pain protocols and barring any
scale. medical contraindications, a
 Contractions every 2-3 woman might prefer to sit,
minutes with duration of stand, kneel on hands and
estimated 70 seconds. knees, lie in dorsal
recumbent or lateral
Objective: recumbent positions, or
squat.
2. Supported the Woman with
 Skin: Paleness observed.
Prepared Childbirth Method
Absence of edema, 2. Assist the Woman With
such is the breathing pattern
lesions, abrasions, or Prepared Childbirth Method.
to alleviate discomfort.
redness. Sweats are
observed. Rationale: Depending on the
 Face: Facial grimace, type of childbirth preparation
eyes squinting, nose a woman and her support
scrunching, and person have had, the method
clenching of jaws are used may include breathing
noted. exercises, distraction by
 Mouth: lips color is pale, focusing on an external
and clenched teeth are object, acupressure,
 Ateneo de Zamboanga University
College of Nursing
Case Study (HOSPITAL)

observed.
 Neck and shoulders: therapeutic touch, music
Muscle tensions on therapy, guided imagery,
the neck and self-hypnosis, or a
shoulders are combination of these
observed methods. 3. Given Pharmacologic Pain
 Hands: shaky hands Relief and information about
and clenching of the 3. Provide Pharmacologic Pain the use of drugs and their
fist are noted. Relief. ultimate effects.
 Chest: Symmetrical
contour. Heavy chest Rationale: Helping a woman
breathing. decide if and when
medication for pain relief
Maternal Vital Signs: should be given requires an
 Temperature: 36.8 ᵒC in-depth understanding of the
 Pulse Rate: 95bpm available drugs, their effects
 Respiratory Rate: on the mother and the fetus,
24bpm and their mechanism and
 Blood Pressure: duration of action. It also
122/82mmHg requires sympathetic listening
and counseling skills.

References: Perry, S. E.,

Hockenberry, M. J.,
Lowdermilk, D. L., Wilson, D.,
Alden, K. R., & Cashion, M. C.
(2017). MATERNAL & CHILD
HEALTH NURSING Care of
the Childbearing &
Childrearing Family (6th ed.).
Mosby, 410-411.
 Ateneo de Zamboanga University
College of Nursing
Case Study (HOSPITAL)

CUES NURSING DIAGNOSIS GOALS AND DESIRED NURSING INTERVENTION IMPLEMENTATION EVALUATION

OUTCOME

Subjective: Anxiety related to Fear of At the end of 2 hours of the 1. Reduce Anxiety With 1. Decreased Anxiety With After 2 hours of the Nursing
Pain from Labor Contractions Nursing Interventions, the Explanations of the Labor Explanations of the Labor Interventions, the Client was
The client verbally stated: Client will be able to identify Process. Process and gave able to identify beginning and
beginning and ending of encouragement to the mother ending of contractions;
 The contractions had contractions; express Rationale: Offer careful that her labor would be expressed confidence rather
made her weak causing confidence rather than explanations of what is successful. than confusion about ongoing
her anxiety attack. confusion about ongoing happening or what will process; stated that she feels
process; state that she feels happen during labor, because less anxious.
 She stated that it was less anxious. this can help alleviate anxiety
overwhelming as her and thereby reduce some
first-time experiencing discomfort.
pregnancy. 2. Guided the Woman in
2. Help the Woman Identify Identifying Coping Strategies.
 Lack of energy and Coping Strategies.
constant nausea as well
lack of sleep. Rationale: Because pain is
not a new phenomenon for a
Objective: woman of childbearing age, a
nurse can help her recall
 Vomiting methods she usually uses to
combat pain or anxiety. This
 Restlessness can go a long way toward
helping the woman collect
 Musculoskeletal System:
her resources and decide on
 Ateneo de Zamboanga University
College of Nursing
Case Study (HOSPITAL)

Muscle tensions and a pain relief strategy.

stiffness on the lower
extremities are noted.

 Neurological System: 3. Provide Comfort Measures 3. Offered Comfort Measures

The patient responds to such as reassurance or a
pain by moaning and Rationale: Assist a woman’s change in position.
facial movement. support person to provide the
usual comfort measures that
are helpful for anyone with
pain, such as reassurance or
a change in position. For dry
lips, ice chips to suck on,
moistening the lips with a
wet cloth, or using a
moisturizing jelly may be
helpful. A cool cloth to wipe
perspiration from her
forehead can avoid her
feeling overheated.

References: Perry, S. E.,

Hockenberry, M. J.,
Lowdermilk, D. L., Wilson, D.,
Alden, K. R., & Cashion, M. C.
(2017). MATERNAL & CHILD
HEALTH NURSING Care of
the Childbearing &
Childrearing Family (6th ed.).
Mosby, 409-410.
 Ateneo de Zamboanga University
College of Nursing
Case Study (HOSPITAL)

CUES NURSING DIAGNOSIS GOALS AND NURSING INTERVENTION IMPLEMENTATION EVALUATION

DESIRED OUTCOME

Subjective: Impaired Skin Integrity Within 2 days of nursing 1. Monitor episiotomy site using REEDA: 1. Checked episiotomy site At the end of 2 days of
related to Surgical care the patient will be Redness, Edema, Ecchymosis, Discharge, and using REEDA: Redness, nursing care:
 The fetal head Incision (Episiotomy) able to: Approximation. Edema, Ecchymosis,
descends through the Discharge, and The patient stayed
vaginal canal or the Remain free of infection Rationale: In Davidson's (1947) REEDA Approximation. Noted the infection-free throughout
internal side of the throughout shift, without Assessment Tool, a score of 0 indicates healed redness, edema, the shift, with no signs or
perineum; episiotomy any signs and symptoms wound; 1-5, moderately healed; 6-10, mildly ecchymosis, discharge, and symptoms of infection,
was done, as of infections, and exhibit healed, and; 11-15, not healed. The white blood approximation of the client and give signs of
verbalized by the evidence of progressive cells, growth factors, nutrients, and enzymes and has detected the signs progressive healing as
client. healing as demonstrated create the swelling, heat, pain, and redness and symptoms of possible evidenced by clean, dry
by clean, dry, absent commonly seen during the first stage of wound infection. skin, no edema, and an
Objective: edema, and intact healing, which could last 1-3 days. Inflammation intact episiotomy site
episiotomy site with vital is a natural part of the wound healing process with vital signs in normal
Incised wound with signs in normal range. and only problematic if prolonged or excessive— range.
sutures at the perineum the presence of purulent discharge and
(Midline). ecchymosis extending beyond 1cm bilaterally or
2cm unilaterally from the wound
 Temperature: 36.8 ᵒC

 Pulse Rate: 95bpm

2. Instruct patient on use of sitz bath to promote 2. Taught patient on use of
 Respiratory Rate: healing, hygiene and comfort. sitz bath to promote
24bpm healing, hygiene and
Rationale: It serves to open up blood vessels, comfort and the provided
 Ateneo de Zamboanga University
College of Nursing
Case Study (HOSPITAL)

 Blood Pressure: increasing blood flow that brings in oxygen and water for the hot sitz bath
122/82mmHg other nutrients to the area promoting wound was warm.
healing. The water should be warm, but hot
enough to cause burns or discomfort

3. Provide routine incisional care, being careful to 3. Rendered routine

keep dressing dry and sterile. Assess and incisional care, being
maintain patency of drains. careful to keep dressing
dry and sterile. Assessed
Rationale: Promotes healing. Accumulation of and maintained patency of
serosanguineous drainage in subcutaneous layers drains.
increases tension on suture line, may delay
wound healing, and serves as a medium for
bacterial growth.

4. Advised early ambulation

4. Encourage early ambulation as tolerated by as tolerated by the client to
the client to promote healing. promote healing.

Rationale: Early ambulation after surgery is

demonstrated to reduce complications and
decreases patient length of stay (LOS) as part of
an enhanced recovery after surgery (ERAS)
program

5. Support and instruct client in incisional support 5. Assisted and helped

when turning, coughing, deep breathing, and client in incisional support
ambulating. when turning, coughing,
deep breathing, and
Rationale: Reduces possibility of dehiscence and ambulating.
incisional hernia.
Ateneo de Zamboanga University
College of Nursing
Case Study (HOSPITAL)

Reference/s: Ganis, M. (March 21,2012).

Impaired Skin Integrity Related To Surgical
Incision and Drains. Retrieved from
https://www.scribd.com/doc/86174934/Impaired-
Skin-Integrity-Related-to-Surgical-Incision-and-
Drains