NURSING CARE PLAN 1 CASE STUDY # 3

DEFINING SCIENTIFIC NURSING

NURSING DIAGNOSIS PLAN OF CARE RATIONALE
CHARACTERISTICS ANALYSIS INTERVENTIONS

SUBJECTIVE: Risk for infection related Prophylactic measure, to SHORT TERM: INDEPENDENT:
to surgical incision. alleviate problems of
Mild pain of abdomen as birth such as After performing 1. educate patient and 1. the more the patient
verbalized the patient cephalopelvic interventions, the support regarding cesarean will understand what is
disproportion or failure patient is less to have delivery happening, the more
to progress in labor. risk of infection. she can accept and
2. institute additional comfort cooperate with
OBJECTIVE: measures, such as changing procedures.
Vital signs: BP: 100/70, T: position, splinting incision,
36.4, HR: 95, RR: 18, using pillows and blankets for 2. reduce stress and
O2sat: 98% support. anxiety, elevate mood
and raise the pain
3. contact the support person threshold.
of the client
3. for the client and
4. provide reinforcement for support person feel
LONG TERM: positive coping mechanisms confidence in the health
that client demonstrates. care personnel who will
After performing
interventions, the COLLABORATIVE: care for them.
patient properly shows 4. enhances self-esteem
positive interventions 1. informed physician for any
unusualities occurring. and control.
outcomes
measure. 1.immediately take
2. Obtain client consent for action and prevents risk
ultrasound. Arrange for of infection.
ultrasound to establish fetal 2. Ultrasound can
health document fetal heart
and cervical dilation.

Reference: Pillitteri, A. Reference: Pillitteri, A.

(2007). Maternal and child (2007). Maternal and
health nursing: care of the child health nursing:
childbearing and childbearing care of the childbearing
family. and childbearing family.

NURSING CARE PLAN 2 CASE STUDY # 3

DEFINING NURSING NURSING
SCIENTIFIC ANALYSIS PLAN OF CARE RATIONALE
CHARACTERISTICS DIAGNOSIS INTERVENTIONS

SUBJECTIVE: Pain related to tissue Prophylactic measure, to SHORT TERM: INDEPENDENT:

trauma from alleviate problems of birth such
Mild pain of abdomen as abdominal incision of as cephalopelvic disproportion After performing 1. stress the importance of 1. early ambulation helps
verbalized the patient cesarean birth. or failure to progress in labor. interventions, the out of bed and caring for prevent thrombophlebitis
patient reports a infant.
decrease in pain. 2. reduce stress and
2. institute additional anxiety, elevate mood and
OBJECTIVE: comfort measures, such as raise the pain threshold.
Vital signs: BP: 100/70, changing position, splinting
incision, using pillows and 3. client cannot drink full
T: 36.4, HR: 95, RR: liquids until bowel sounds
18, O2sat: 98% blankets for support.
return.
3. offer ice cubes for dry
mouth as soon as bowel 4. enhances self-esteem
sound are presents. and control.

LONG TERM: 4. provide reinforcement for 5. encourages bonding

positive coping mechanisms while minimizing the risk
Client holds infant that client demonstrates. for additional fatigue.
warmly, maintains
eye contact with 5. praise client for positive 1. Client states she is
infant; makes behaviors and interactions afraid to use PCEA for pain
positive statements with the child in light of pain relief
about the newborn and fatigue level. 2. client cannot have
prior to discharge realistic expectations
COLLABORATIVE:
unless she understands
1. ask pain management technique.
team to consult on more
appropriate pain relief Reference: Pillitteri, A.
measure. (2007). Maternal and child
health nursing: care of the
2. review PCEA pump and childbearing and
technique with client. childbearing family.

NURSING CARE PLAN 3 CASE STUDY # 3

DEFINING NURSING SCIENTIFIC ANALYSIS PLAN OF CARE NURSING RATIONALE
CHARACTERISTICS DIAGNOSIS INTERVENTIONS

SUBJECTIVE: Acute pain related to Unpleasant sensory and SHORT TERM: INDEPENDENT 1.To help determine the
biological agents’ emotional experience arising possibility of underlying
Hypogastric pain mild- injury, obstruction / from actual or potential tissue After 5 hours of nurse 1. Assess for referred pain condition or organ
mod by 60 mins. duct spasm, damage or described in terms of health teaching, as appropriate. dysfunction requiring
inflammation, ischemic such damage (International patient will be able treatment.
to: 2. Note client’s locus of
tissue / necrosis Association for the Study of control.
Pain); sudden or slow onset of 2. Individuals with
-verbalize external locus of control
any intensity from mild to understanding of 3. Note and investigate
severe with an anticipated or changes from previous may take little or no
disease process, risk responsibility for pain
predictable end and a duration factors, and reports of pain.
of less than 6 months. management.
treatment plan. 4. Acknowledge the client’s
Pain is a highly subjective state description of pain and 3. To rule out worsening of
in which a variety of unpleasant convey acceptance of underlying condition or
sensations and a wide range of client’s response to pain. development of
distressing factors may be 4. Pain is a subjective
experienced by the patient. 5. Monitor skin color and
OBJECTIVE: temperature and vital signs. experience and cannot be
Acute pain serves as a LONG TERM: felt by others.
Abd: FH: 34 cm protective function to make COLLABORATIVE
patient aware of an injury or After 1 week of 5. These are usually
EFW: 3, 565 grams. nursing intervention: 1. Administer analgesics as altered in acute pain.
illness. The sudden onset of
acute pain prompts the patient indicated.
to seek relief. The physiological Patient will exhibit
IE: 1 cm, 80 Eff, St -5, manifestations that occur with increased comforts 2. Review lab data
such as baseline 1. To maintain an
IBOW, Cephalic acute pain result from the 3. Provide information on acceptable level of pain.
body’s response to pain as levels of pulse, BP,
No watery or bloody respirations, and test procedures
stressor. 2. For comparison with
vaginal discharge relaxed muscle tone current normal values
Reference: or body posture.
Reference: 3. To gain patient’s
https://www.sciencedirect.co participation
m/science/article/pii https://nurseslabs.com/3-
/S1028455919300105 placenta-previa-nursing-
care-plans/

NURSING CARE PLAN 4 CASE STUDY # 3

DEFINING SCIENTIFIC NURSING
NURSING DIAGNOSIS PLAN OF CARE RATIONALE
CHARACTERISTICS ANALYSIS INTERVENTIONS

SUBJECTIVE: Risk for infection related At increased risk for SHORT TERM: INDEPENDENT
to tissue trauma and / or being invaded by
Hypogastric pain mild-mod damage to the skin, pathogenic organisms. After 8 hours of nursing 1. Assess for the presence, 1. Each of these
by 60 mins. decreased hemoglobin, People at risk for intervention, patient will existence of and history of examples represents a
invasive procedures infection are those be able to: risk factors such as open break in the body’s
and / or an increase in whose natural defense wounds and abrasions; normal first line of
- Be remain free of indwelling catheters (Foley, defense.
environmental mechanisms are infection, as
improvement, rupture of inadequate to protect peritoneal); wound drainage
evidenced by tubes; endotracheal or 2. an increasing WBC
membranes in a long them from the inevitable normal vital count indicates the
time, malnutrition. injuries and exposures tracheostomy tubes; venous
signs and or arterial access devices and body’s efforts to combat
that occur throughout absence of pathogens.
the course of living. orthopedic fixator pins.
purulent
Infections occur when an drainage from 2. Monitor White Blood Cell 3. Patients with poor
organism (e.g., wounds, incisions (WBC) count. nutritional status may
bacterium, virus, fungus, and tubes. be anergic or unable to
or other parasite) 3. Assess nutritional status muster a cellular
OBJECTIVE: invades a susceptible including weight, history of immune response to
host. Breaks in the weight loss and serum pathogens and therefore
Abd: FH: 34 cm LONG TERM: albumin. more susceptible to
integument, the body’s
EFW: 3, 565 grams. first line of defense, After 1 week of infection.
and/or mucous 4. Assess the intactness of
health teaching and amniotic membranes. 4. prolonged rupture of
membranes allow nursing intervention:
invasion by pathogens. amniotic membranes
IE: 1 cm, 80 Eff, St -5, 5. Assess for exposure to before delivery places
If the patient’s immune - Patient was free individuals with active
IBOW, Cephalic from any signs the mother and infant at
system cannot combat infections.
the invading organism and symptoms of risk for infections.
No watery or bloody vaginal
discharge adequately, an infection infections as COLLABORATIVE 5. This information
occurs. manifested by provides warning with
absence of pain 1. Wash hands and teach
other caregivers to wash potential infections.
hands before contact with
patients and between
procedures with patient 1. friction and running
water effectively
2. Maintain or teach asepsis removes
for dressing changes and microorganisms from
wound care, catheter care, hands. Washing
and handling, and peripheral between procedures
Reference: Nursing Care IV and central venous access
Plan Book, Page 485 reduces the risk for
management. transmitting pathogens
Meg Gulanick/Judith L.
Myers from one area of the
body to another.

3. Demonstrate and allow

return demonstration of all
high-risk procedures that the 2. Use of aseptic
patient or caregiver will do technique decreases the
after discharge, such as chances of transmitting
dressing changes, peripheral pathogens to one
or IV site care, peritoneal another.
dialysis and self-
catheterization.
3. Patient and
caregivers need
Reference: Nursing Care Plan opportunities to master
Book, Page 485 Meg new skills to reduce risk
Gulanick/Judith L. Myers for infection.

Reference: Nursing Care

Plan Book, Page 485
Meg Gulanick/Judith L.
Myers

NURSING CARE PLAN 5 CASE STUDY # 3

DEFINING SCIENTIFIC NURSING

NURSING DIAGNOSIS PLAN OF CARE RATIONALE
CHARACTERISTICS ANALYSIS INTERVENTIONS
Subjective: Impaired ability to SHORT TERM: INDEPENDENT
perform or complete
Hypogastric pain mild-mod Self-care Deficit related activities of daily living After 20 minutes of 1. Assess the patient’s ability 1. The pt may only
by 60 mins. to the weakness of the for oneself, such as health teaching the to perform ADLs effectively require assistance with
body. feeding, dressing, patient will be able to: and safely on a daily basis some self-care
bathing, toileting. The using an appropriate measures. A variety of
- Understand the assessment tool, such as the tools are available,
Objectives: nurse may encounter the self-care deficit
patient with a self-care Functional Independent depending on the
Abd: FH: 34 cm topic being Measures (FIM) clinical settings.
deficit in the hospital or discussed and
EFW: 3, 565 grams. in the community. The why its relevant 2. Different etiological
deficit may be the result 2. Assess the specific cause
to her condition. of each deficit (e.g., factors may require
of transient limitations, more specific
such as those one might weakness, visual problems,
IE: 1 cm, 80 Eff, St -5, cognitive impairments) interventions to enable
experience while self-care.
IBOW, Cephalic recuperating from
surgery, or the result of 3.Assess the patient’s need 3. Assistive devices
No watery or bloody vaginal LONG TERM: for assistive devices. Assess
discharge progressive deterioration increase independence
that erodes the After 2 days of nursing the need for home health in performance of ADLs.
individual’s ability or intervention, the patient care after discharge.
willingness to perform will be able to: 4. The pt is more likely
the activities required to 4. Identify preferences for to participate in self-
care for himself or food, personal care items and care that supports
herself. Patients who are other things. his/her individual and
-perform (to maximum personal preference.
depressed or those with ability) self-care
low levels of motivation 5. Assist the patient in
activities. accepting the necessary 5. If disease, injury, or
may not have the illness resulting in self-
interest to engage in -patient identifies amount of dependence.
care deficit is recent,
self-care activities. resources that are the pt may need to
useful in optimizing grieve before accepting
autonomy and COLLABORATIVE that dependence is
independence. necessary.
1. Evaluate gag reflex or the
need for swallowing
assessment by a speech
therapist prior to initial oral 1. Absence of gag reflex
feeding. or inability to chew or
swallow properly may
Reference: lead to choking or
2.Absence of gag reflex or aspiration.
Nursing care plan book inability to chew or swallow
page 619, Meg properly may lead to choking
Gulanick / Judith L. or aspiration. 2. Absence of gag reflex
Myers or inability to chew or
swallow properly may
3.Monitor impulsive behavior lead to choking or
or actions indicative of aspiration.
altered judgment.

3.This may imply the

demand for
supplementary
interventions and
management to
guarantee safety or
security.

Reference: Reference:
Nursing care plan book page Nursing care plan book
619, Meg Gulanick / Judith L. page 619, Meg
Myers Gulanick / Judith L.
Myers

NURSING CARE PLAN 1 CASE STUDY # 4

DEFINING NURSING NURSING

SCIENTIFIC ANALYSIS PLAN OF CARE RATIONALE
CHARACTERISTICS DIAGNOSIS INTERVENTIONS
SUBJECTIVE: Risk for Bacterial vaginosis is a form of SHORT TERM: INDEPENDENT 1.In Africa, the male-to-
maternal/fetal vaginal inflammation caused by female HIV ratio is 1:1
“I came here in the infection related to the naturally occurring Within 8 hrs. of nursing 1.Obtain information on the due to traditional sexual
hospital because I had bacterial vaginosis overgrowth of bacteria in the intervention the patient client's cultural background activities, poor sanitation
some water discharges as evidence by vagina that upsets the normal will be able to: for risk factors and insufficient health
from my vagina” stated whitish discharges. balance. Women in their care, while new arrivals
by the patient - Reviewing 2. acquire information about past
reproductive years are more strategies and from Asia, South America
and present sexual partners of
OBJECTIVE: likely to have bacterial vaginosis, dietary and the Caribbean have
but it may affect women of any
the client and even the exposure raised the risk of
improvements to to any STDs
V/S taken as follows: generation. reduce the risk of exposure to the Hepatitis
infection B virus.
- BP: 90/60 mmHg Maternal infection is an infection 3.Educate patient to use gentle,
- HR: 96 bpm that is contracted by the mother, - Verbalize non-deodorant soaps and 2.Many sexual partners
- RR: 19 cpm who then transmits the infection knowledge of tampons or pads. or intercourse with
- Temp: 36.5 to the fetus. This transmission individual bisexual men raise the
- O2 Sat: 98% may occur through the placenta risk/cause 4.Address patient about avoiding risk of exposure to STDs
- Weight: 63 kg prior to childbirth or through the factors. douche and HIV/AIDS.
birth canal during labor and
delivery when the infant is COLLABORATIVE 3.To reduce vaginal
exposed to maternal blood. LONG TERM: irritation
Find out status of maternal
After 72 hours of membranes. If they are ruptured, 4.Vagina does not need
nursing intervention the monitor blood cell count and washing other than
Reference: patient will be able to: regular baths. Frequent
fetal heart rate; or vaginal
- Have a regular douching disrupts your
https://www.birthinjuryguideorg/birt discharge having an odor)
discharge and vaginal equilibrium and
h-injury/causes/the can raise your risk of
smell. Determine if the viral infection is
-facts-and-dangers-of-maternal- - Initiate habits either primary or recurrent. vaginal infection.
infection that restrict the Douching is not going to
transmission of Reference: clean up a vaginal
infection, as https://nurseslabs.om/3- wound.
necessary, and prenatal-infectionnursing-
reduce the risk of careplans/#riskformaternal/fetali
complications. nfection

NURSING CARE PLAN 2 CASE STUDY # 4

DEFINING SCIENTIFIC NURSING

NURSING DIAGNOSIS PLAN OF CARE RATIONALE
CHARACTERISTICS ANALYSIS INTERVENTIONS
SUBJECTIVE: Risk of injury related to Risk for injury as a result SHORT TERM: INDEPENDENT
low potassium of environmental
Patient noted sudden onset conditions interacting After 4 hours of nursing 1.Monitor vital signs, 1.To obtain baseline
of watery vaginal discharge, with the individual’s intervention the patient data
clear associated with adaptive and defensive report of less possibility
intermittent hypogastric resources. of fall. 2.Perform thorough
pain every 5-10 minutes. assessments regarding safety 2.Verblize
issues when planning for understanding of
client care. individual factors that
contribute the possibility
3.Note socioeconomic of injury.
status/vailability and use or
resources.

3.Demonstrate
behaviors, lifestyle
changes to reduce risk
factors and protect self
OBJECTIVE: from injury.
COLLABORATIVE
V/S taken as follows: 1.To provide
LONG TERM: After two 1.Develop plan of care with informations to the
T:36.5 weeks of nursing family to meet client’s clients’ needs.
intervention, the patient individual needs,
P:96 will be able to modify 2.Modify environment
R:19 environment as indicated to enhance
Reference::Nurses indicated to enhance safety.
BP:90/60 safety. 2.Refer to other resources,
Pocket Guide, Marilyn E. as indicated Reference::Nurses
Doenges, Mary Frances Pocket Guide, Marilyn E.
Moorhouse, and Alice C Doenges, Mary Frances
Murr, pgs. 414-417, 11th Moorhouse, and Alice C
edition. Reference: Nurses Pocket
Guide, Marilyn E. Doenges, Murr, pgs. 414-417, 11th
Mary Frances Moorhouse, edition.
and Alice C Murr, pgs. 414-
417, 11th edition.

NURSING CARE PLAN 3 CASE STUDY # 4

DEFINING SCIENTIFIC NURSING

NURSING DIAGNOSIS PLAN OF CARE RATIONALE
CHARACTERISTICS ANALYSIS INTERVENTIONS
SUBJECTIVE: Risk for disturbed Premature rupture of SHORT TERM: INDEPENDENT:
maternal-fetal dyad membranes (PROM) is a
Patient noted sudden onset related to PROM as rupture (breaking open) Within 8 hrs. of nursing 1. obtain history about 1. lack of prenatal care
of watery vaginal discharges evidenced by watery of the membranes intervention the patient prenatal screening and can place both mother
discharges (amniotic sac) before will be able to: amount and timing of care. and fetus at risk.
labor begins. If PROM - Verbalize 2. facilitate positive 2. Helps in successful
OBJECTIVE: occurs before 37 weeks understanding of adaptation to situation accomplishment of the
of pregnancy, it is called individual risk through active listening, psychological tasks of
V/S taken as follows: preterm premature factors that may acceptance, and problem pregnancy.
- BP: 90/60 mmHg rupture of membranes impact solving.
- HR: 96 bpm (PPROM) pregnancy. 3. Pregnancy may have
- RR: 19 cpm - Participate in 3. Discuss implications of no effect or may reduce
- Temp: 36.5 screening preexisting condition and severity of symptom of
- O2 Sat: 98% procedures as possible impact on chronic conditions
- Weight: 63 kg indicated pregnancy.
4. enhances self-esteem
4. provide reinforcement for and control.
AOG: 37 ²/₇ weeks positive coping mechanisms
that client demonstrates.
- PROM (premature LONG TERM:
ruptured of COLLABORATIVE:
membrane) After performing 1.immediately take
interventions, the 1. informed physician for any
unusualities occurring. action and prevents risk
patient properly shows of infection.
positive interventions measure.
outcomes 2. Obtain client consent for 2. Ultrasound can
ultrasound. Arrange for document fetal heart
ultrasound to establish fetal and cervical dilation.
health

Reference:
Reference: Nurse’s pocket guide
Nurse’s pocket guide 15th 15th edition
edition

NURSING CARE PLAN 4 CASE STUDY # 4

DEFINING SCIENTIFIC NURSING

NURSING DIAGNOSIS PLAN OF CARE RATIONALE
CHARACTERISTICS ANALYSIS INTERVENTIONS
SUBJECTIVE: Risk for infection as There are many SHORT TERM: INDEPENDENT: 1.Thick white discharge
evidenced related to potentially serious may suggest Candida
After 6hrs. of nursing 1 Note any change in
vaginal discharges. health problems that intervention the patient albicans infection;
Patient noted sudden onset pregnant women can color, consistency, and thin or purulent
will be able to:
of watery vaginal discharges transfer to their amount of vaginal drainage may reflect
unborn babies, one of -Patient will verbalize discharge. Chlamydia; Gray-green
which is a prenatal understanding of discharge may indicate
OBJECTIVE: individual causative/risk
infection which refers trichomoniasis;
factors.
V/S taken as follows:
to an infection that is 2.provide thin, watery, yellow-
transmitted to the LONG TERM: reinforcement for gray foul-smelling
- BP: 90/60 mmHg fetus through the (“fishy”) discharge may
After 2 weeks of nursing positive coping
- HR: 96 bpm placenta. indicate Gardnerella.
- RR: 19 cpm intervention mechanisms that
- Temp: 36.5 client demonstrates.
- Patient will initiate 2. enhances self-esteem
- O2 Sat: 98% behaviors to limit the and control.
- Weight: 63 kg spread of infection, as
appropriate, and reduce
AOG: 37 ²/₇ weeks the risk of
complications. COLLABORATIVE:
- PROM (premature
ruptured of - Patient will achieve 1. informed physician
membrane) timely healing, free of
complications
for any unusualities 1.immediately take
occurring. measure. action and prevents risk
of infection.
Reference: Nurse’s
Reference: pocket guide 15th
edition
Nurse’s pocket guide
15th edition

NURSING CARE PLAN 5 CASE STUDY # 4

DEFINING SCIENTIFIC NURSING

NURSING DIAGNOSIS PLAN OF CARE RATIONALE
CHARACTERISTICS ANALYSIS INTERVENTIONS
SUBJECTIVE: Risk for imbalanced Potassium is one of SHORT TERM: INDEPENDENT:
Nutrition as Evidenced the most important
by Hypokalemia minerals in the body. It After 3days. of nursing  Encourage patient to  Water helps in
helps regulate fluid intervention, the patient drink enough water the elimination
Patient noted sudden onset will be able to: daily
of watery vaginal discharges balance, muscle of byproducts of
contractions and nerve - Patient will design fat breakdown
signals. dietary modifications to and helps
meet individual long- prevent ketosis.
OBJECTIVE: In hypokalemia, the
level of potassium in term goal of weight COLLABORATIVE:
V/S taken as follows: blood is too low. A low control, using principles
potassium level has of variety, balance, and  Suggest patient to  Self-monitoring
- BP: 90/60 mmHg moderation. keep a diary of food
- HR: 96 bpm many causes but usually helps the
results from vomiting, intake and patient assess
- RR: 19 cpm - Patient will use sound circumstances
- Temp: 36.5 diarrhea, adrenal gland scientific sources to adherence to
disorders, or use of surrounding its self-determined
- O2 Sat: 98% evaluate need for consumption
- Weight: 63 kg diuretics. A low nutritional supplements. performance
potassium level can (methods of criteria and
make muscles feel weak, LONG TERM: preparation, duration progress toward
AOG: 37 ²/₇ weeks cramp, twitch, or even of meal, social desired goals.
become paralyzed, and After 1 month of nursing situation, overall Self-monitoring
- PROM (premature abnormal heart rhythms intervention mood, activities serves an
ruptured of may develop. accompanying important role
membrane) - Patient will initiate consumption).
good nutritional intake in the
maintenance of
internal
standards of
behavior.