VISION

Republic of the Philippines MISSION

A premier university in CAVITE STATE UNIVERSITY Cavite State University shall provide
historic Cavite Don Severino Delas Alas excellent, equitable and relevant
recognized for excellence educational opportunities in the arts,
Campus science and technology through quality
in the development of
morally upright and Indang, Cavite College instruction and relevant research and
globally competitive development activities. It shall produce
individuals. professional, skilled and morally upright
Of Nursing NURSING individuals for global competitiveness.

CARE PLAN

Name of Patient (initials): J.D.C Date: July 17, 2021

Age/Sex: 34 years old Diagnosis:

NURSING
ASSESSMENT NURSING DIAGNOSIS PLANNING RATIONALE EVALUATION
INTERVENTION
Subjective Data:
 Establish a nurse-  Rapport helps gain The goals were met
 "I have not had  Ineffective Short term goal: patient/ trusting patient’s partially because the
childbearing  Identify individual risk relationship cooperation to client was able to:
prenatal
process related to factors  Explain and have therapeutic
checkups yet insufficient prenatal  State understanding emphasize the communication Short term:
since the care as evidenced of needed care for self importance of  Reinforce the  The client
beginning of this by inadequate and infant health ongoing screening relationship identified the
pregnancy" as prenatal check-ups and close monitoring between health individual risk
stated by the client and lifestyle such Long term goal:  Teach client about assessment and factors.
 Inadequate as sleep, exercise  Participate in activities the health positive outcome  The client stated
and nutrition for childbirth and habits/lifestyle of pregnancy. understanding of
prenatal care and
newborn care concerns:  Develop comfort in needed care for
lifestyle [e.g. self and infant
preparation  Review physical managing
nutrition,  Demonstrate healthy changes to be pregnancy health.
elimination, sleep pregnancy without expected during  Develops own
cycle, exercise, complications through each trimester roles and Long term:
personal hygiene] prevention  Educate patient to responsibilities in  The client
 The client is on her  Have complication- be flexible in order to assist participated in
free labor and adjusting own roles client throughout activities for childbirth
2nd trimester of
childbirth and responsibilities her pregnancy. and newborn care
pregnancy preparation.
in order to assist the  Helps client make
 No history of client to meet her informed  The client
prenatal visit in needs. decisions/choices demonstrated healthy
health centers  Provide information to promote healthy pregnancy without
  The client about teratogens offspring. complications through
verbalized not  Provide information  Foundation for prevention.
taking up about the essential decision making  The client had
of laboratory, process complication-free
supplemental
diagnostic tests, or  To nurture labor and childbirth.
vitamins such as procedures maternal growth,
ferrous sulfate.  Nurturing maternal maturation, and
 Preferred delivery growth, maturation, competence at
of the client in and competence at Postpartum
home. Postpartum  To contribute in
 The pregnancy is  Contribute to positive positive adaptation
adaptation physical of client’s physical
unplanned as
and emotional and emotional
stated by the changes changes
client.  Awareness of  Client awareness
 The client has contraceptive information about
history of receiving methods and chance contraception
shots of Tetanus of pregnancy methods and
Toxiod, given year  To promote optimal chance of
maternal well-beings pregnancy.
2015-2016.
 Emphasize the  To support the
 Mother claims of
importance of maternal and fetal
no consultation maternal well-being needs by acquiring
visit in Brgy Pag- and fetal well-being the optimal
asa Health Center. related to maternal requirement for
health during the first nutrition to obtain
Objective Data: trimester, which is ideal weight gain
 bp = 110/80 most vulnerable for to decrease the
mmHg the developing risk of obtaining
 weight = 53 kgs. organs (IUGR)
 GTPAL = 43003  Recommend a Intrauterine
 Inadequate consistent sleep and Growth
preparation rest schedule. Retardation and
newborn care (LBW) Low Birth
items or home Weight infant.
environment  To provide a good
rest to meet the
optimal metabolic
needs related to
growth of maternal
and fetal tissues.
Submitted by: Submitted to:
Year/Section/Group: Date: