POLYTECHNIC COLLEGE OF DAVAO DEL

SUR
McArthur Highway, Brgy. Kiagot, 8002, Digos City, Davao del Sur, Philippines Telefax:
(63) (82) 237-4827 Email: [email protected]

NURSING CARE PLAN

Name of Patient: Attending Physician:
Age: Sex: Civil Status: Diagnosis:
Occupation:
Religion:
Address: Chief Complaint:
Ward: Room No. Bed No: Date of Admission:

GOALS
DATE/TIME CUES NEEDS NURSING SCIENTIFIC OBJECTIVE NURSING RATIONALE EVALUATION
DIAGNOSIS BASIS DATA INTERVENTIONS

Subjective: P Deficient Fluid Volume Immune response After 8 hours of nursing Independent: After the 8 hours of nursing
“Grabe dugay S related to excessive interventions, the patient * Recommend the client * To prevent orthostatic interventions, the patient has a
kayo nako Y blood loss after birth will demonstrate be seated when holding hypotension because it good fluid balance as
siya nautong C Innate improvement in the fluid the infant and change puts the client at risk of evidenced by a good capillary
maam, first H balance as evidenced by position slowly when falls. Advise the client to refill, adequate urine output,
baby mn gd O a good capillary refill, lying down or seated. dangle their legs first on and skin turgor.
L Adaptive adequate urine output, the side of their bed after
nako” ( It O and skin turgor. sitting up before
took me a G attempting to ambulate.
while before I
he came out, C MHC I AND II Dependent: * The cold application can
ma'am, A * Apply an ice pack on limit small hematoma and
because it's L the hematomas if reduce blood flow to the
my first baby) indicated. area. Cold also numbs the
as verbalized N Inflammatory area and makes the client
by patient. E Cytokines more comfortable. Apply
E an ice pack covered with a
Objective: D towel to prevent thermal
* Needs S injury to the skin to
assistance prevent further bleeding.
* Stay at the Larger ones may require
bed of most incision and drainage of
the time the clots.
Interdependent: * In case of a need to
 * Facial * Maintain a nothing- repair the laceration using
grimace by-mouth (NPO) status a general anesthetic, the
* Conscious while assessing the client should be kept on
and coherent client’s status. NPO until further orders
are received. This will
prevent aspiration of
gastric contents if the
mental status is impaired
and if surgical
management is required

Student Name: Year & Sec: Group No: Rating:

Reference: Clinical Instructor: