NURSING CARE PLAN

PROBLEM #1
Defining characteristics Nursing diagnosis Outcome Identification Nursing intervention Rationale Evaluation

Subjective Imbalanced nutrition, Long term: After a Independent- The goal has been
“Permi lang ko du masuka kag less than body couple of months of  Obtain weight and compare it to the  To determine the effects of nausea and met as the patient
galingin akon ulo” as verbalized requirements related nursing intervention the baseline. vomiting on nutritional intake. verbalize of
by the patient. to nausea and patient will verbalize  Review client’s typical dietary intake over  To determine nutritional intake and decrease in the
Missed menstrual period for 2 vomiting. statements indicating an 24 hours. patterns so that suggestion can be number of nausea
months increase food intake individualized. and vomiting and
RATIONALE: Note: with decrease in the  Encourage client to eat five or six small  Eating small frequent meals helps to the patient had
Objective Nursing number of episodes of frequent meals throughout the day. prevent her stomach become empty. ingested adequate
T=36.8C diagnosis should be nausea and vomiting.  Suggest eating of dry munch crackers, toast,  In order to minimize nausea. amounts of
PR= 83 bpm based on (NANDA- cereals, or drink a small amount of nutrients.
RR= 20 cpm American Nursing Short term: After 8 lemonade before arising.
BR= 110/70 mmHg Diagnosis) hours shift of nursing  To reduce stimulation of the vomiting
 Encourage client to arise slowly from bed in
Weight= 42kg intervention, the patient the morning and avoid sudden movements. center.
“Positive serum pregnancy test” will ingest adequate
amounts of nutrients for  Encourage the patient to increase intake of
maternal and fetal well- foods high in vitamin B6 such as meat,
being as evidenced by  In order to ensure adequate nutrient intake.
poultry, banana, fish, green leafy vegetables,
acceptable weight gain peanuts, walnuts, raisins, and whole grains.
pattern.
 Advise patient to avoid greasy, fried, or
 Foods that are greasy, spicy and has strong
highly spiced foods and to avoid strong odor,
odor can cause gastrointestinal upset.
foods.
Avoiding these foods could minimize it.
 NURSING CARE PLAN
PROBLEM #2
Defining characteristics Nursing diagnosis Outcome Nursing intervention Rationale Evaluation
Identification

Subjective Ineffective Coping Long term: After a Independent- The goal has been
related to sudden change couple of months met as the client
“Waay gid ako nag expect nga • Assess for the presence of defining • Behavioral and physiological responses to
in health status. pf nursing showed coping
mabusong ako kag di pako ready characteristics. stress can be varied and provide clues to the
intervention, the mechanisms, as
para mabusong.” As verbalized by level of coping difficulty.
patient will • Use therapeutic communication such evidence by a
the patient.
RATIONALE: Note: verbalize feeling of as active listening, maintaining eye • Showing understanding and empathy positive statement
Nursing acceptance of her contact, and encouraging the patient establishes trust between the patient and the that about accepting
diagnosis should be first pregnancy. to verbalize feelings without showing healthcare team. the unexpected
Objective based on (NANDA- pregnancy.
judgment.
American Nursing
T=36.8C
Diagnosis) • Assist patients with accurately
PR= 83 bpm Short term: After • It can be helpful for the patient to recognize
evaluating the situation and their own
RR= 20 cpm 8 hours shift of that he or she has the skills and reserves of
accomplishments.
BR= 110/70 mmHg nursing strength to effectively manage the situation.
Weight= 42kg intervention, the The patient may need help coming to a realistic
“Positive serum pregnancy test” patient will perspective of the situation.
verbalize ability to • Convey feelings of acceptance and
cope and asks for understanding. Avoid false • An honest relationship facilitates problem-
help when needed reassurances. solving and successful coping. False
by the end of the reassurances are never helpful to the patient and
shift. only may serve to relieve the discomfort of the
• Be supportive of coping behaviors; care provider.
give patient time to relax.
• A supportive presence creates a supportive
environment to enhance coping.