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NURSING CARE PLAN

laboratory Course Task 1

Case Scenario

Case Scenario

Diana, 25 Y/O female patient who is present to the clinic today for her routine OB-GYNE Check up

NURSING CARE PLAN STEPS

NURSING CARE PLAN STEPS

1. Assessment

2. Diagnosis

3. Planning

4. Implementation

5. Evaluation

SUBJECTIVE DATA:

"I am feeling really tired and unproductive lately, I am always sleepy the entire day and can’t do anything productive. I do think that I am useless because of this pregnancy."

ASSESSMENT

OBJECTIVE DATA:

OB-GYNE History: G5P4 34 weeks AOG

Vital Signs

Vital Signs

  • BP =148/100
  • T=36.8
  • P= 84
  • RR=21
  • RESTLESS
  • SIGNS OF FATIGUE

DIAGNOSIS

(Problem-Focused Nursing Diagnosis)

Nursing Care Plan Steps

Fatigue related to physiological condition as evidenced by blood pressure of 148/100, showing signs of fatigue and feeling useless and restless

FATIGUE

Fatigue

Definition: An overwhelming sustained sense of exhaustion and decreased capacity for physical and mental work at the usual level. (NANDA-I, 2019)

Planning

PLANNING

Short Term Goals

Short Term Goals:

After 3-4 hours of nursing intervention, the patient will have a lesser blood pressure state from 148/100 to 130/90

After 8 hours of nursing intervention, the patient will show less signs of fatigue and decrease the feeling of restlessness

Long Term Goals

Long Term Goals:

Within 2-4 days of nursing intervention, the patient will report continuous sense of energy, normal count of blood pressure and regain herself from doing daily activities

Implementation

IMPLEMENTATION

Independent

Independent

Aid the patient with developing a schedule for daily activity and rest, emphasizing the importance of frequent rest periods.

Educate the patient as well as her family about task organization methods and time organization methods

Encourage the patient to increase fluid intake

Assist the patient in setting priorities for preferred activities and role responsibilities

Collaborative

Collaborative

Collaborative with occupational therapist as needed

RATIONALE

Rationale

Independent

Independent

A plan that balance periods of activity with periods of rest can aid the patient complete preferred activities without contributing to levels of fatigue.

Task organization and time management can assist the patient in saving energy and avoiding the signs of fatigue.

Balance intake of fats, minerals, carbohydrates, vitamins, and proteins for energy and nourishment consumption between herself and her baby.

For continuous hydration of the patient to recover from restlessness and fatigue

Attaining desired goals can develop the patient's sense of emotional health and be able to utilize available energy to complete important activities.

Collaborative

Collaborative

Offers the patient with assistive devices and educate the patient towards energy conservation methods

EVALUATION

Evaluation

After 3-4 hours, the patient was able to report reduction of high blood pressure count from 148/100 to 130/90.

After 8 whole hours of nursing intervention, the patient was able to show less signs of fatigue and decreased feeling of restlessness.

Within 2-4 days of nursing interventions, the patient was able to report a continuous sense of energy, and normal count of blood pressure and do usual daily activities.

Goals met.

Table

Group 2

BSN 1-Y1-11

Group 2

Credo Jr., Louis Fernando

Cruz, Miara Angeline Gayle

Dacanay, Desiree

Dela Cruz, Charm Carol Sem

Fajardo, Felicity Jeanne

Franial, Carla Jane

Fulgado, Sasha Michelle

Fulla, Darlene Joy

Gantala, Janssen Ghon

Guevarra, Jonathan

Gusi, Sheera Daniela

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