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  • Scenario: Nursing Care Plan Assessment Diagnosis Planning Intervention Rationale Evaluation - Short Term Goal

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    Jeamine Talaver Palencia
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    6 views2 pages

    Scenario: Nursing Care Plan Assessment Diagnosis Planning Intervention Rationale Evaluation - Short Term Goal

    Uploaded by

    Jeamine Talaver Palencia

    Copyright:

    © All Rights Reserved
    Download as DOCX, PDF, TXT or read online from Scribd
    Flag for inappropriate content
    Download as docx, pdf, or txt
    of 2

    QUIZ # 1

    TRINILLA, DENIEL ALLIEZA C.

    BSN/ 2ND YR/ SECTION – B

    SCENARIO
    Mrs. Panganiban a 32-year-old woman is admitted at 37 weeks of gestation. The patient complains of having severe painful contraction, Mrs.
    Panganiban experiencing discomfort, Dra. Magat is requesting for ultrasound to check the baby, Dra. Magat see on the ultrasound the baby is in
    breech presentation. Mrs. Panganiban pelvis may not be large enough for the head to be delivered also so Dra. Magat is decided to deliver the
    baby via emergency cesarian section.

    NURSING CARE PLAN

    ASSESSMENT DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATION


    Subjective: Risk for maternal Short Term Goal: -Establish rapport. -To have a good Short Term Goal:
    The patient injury related to the After 3 hours of nurse client After 3 hours of
    verbalized that she delivery of the fetus nursing intervention relationship. nursing intervention
    had “severe painful via breech the patient’s will be the goal was met, the
    contraction”. presentation as able to demonstrate - Monitor vital signs. -To establish baseline patient was able to
    evidenced by severe relaxation techniques data. demonstrate
    painful contraction. to mitigate pain and relaxation techniques
    Objective: reports a minimized - Monitor time, - Monitor the labor to mitigate pain and
    -Ultrasound result discomfort by a pain frequency, intensity progress and provide reports a minimized
    fetus is in a breech scale of rating 3/10. and duration of information for the discomfort by a pain
    presentation. uterine contractile client. scale of rating 3/10.
    - Discomfort pattern.

    Long Term Goal: - Provide back rubs to -Promotes relaxation Long Term Goal:
    P/S: 8/10 After 6 hours of the patient as a and enhances feeling After 6 hours of
    nursing intervention comfort measure. of well-being. nursing intervention
    the patient will be the goal was met, the
    V/S: able to deliver the -Offer -Provides emotional patient delivered the
    BP – 90/60 baby via cesarian encouragement to support which baby via cesarian
    RR – 20 section. the patient by reduces fear and section.
    PR – 112 updating her anxiety levels and
    SPO2 – 98% regarding her labor help minimize pain.
    progress and provide
    positive
    reinforcement.

    -Provide comfort by -To avoid injuries or


    helping a patient to accidents when
    sit, stand lay on bed patients ambulate.
    and go to toilet or
    walk around.

    -Instruct to put pillow -To check for diastasis


    on the abdomen recti and protect the
    when coughing or area of incision to
    moving. improve comfort.

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