CHRISTINE JOY A.

ALA 2NUR1
RLE1
NURSING CARE PLAN
ASSESSMENT NURSING
DIAGNOSIS
SCIENTIFIC
ANALYSIS
GOALS/
OBJECTIVES
INTERVENTIONS RATIONALE EVALUATION
Subjective:
Maayos ang
pakiramdam ko
Walang sakit na
nararamdaman

Objective:
Pain scale: 0 rated
from 1-10
1- Least painful
10 most painful


Happy and laughing.

Relaxed and calm
Readiness of
enhanced
Comfort
The client will
verbalize sense of
comfort or
contentment

Demonstrate
behaviors of
optimal level of
ease

Participate in
desirable and
realistic health-
seeking behaviors


Assess the patient
of what type of
comfort is she is
experiencing:
1. Relief
2. Ease
3. Transcende
nce

Ascertain
motivation or
expectations for
improvement




Knowing what
type of comfort
will help the
nurse and the
patient to build
rapport and to
what the nurse
will provide.

To know what
will the patient
expect and what
the nurse will
focus on.



Within the stay of the
client:

The client verbalizes
sense of comfort and
contentment



The patient obtained a
positive outcome until
she was discharge




The client know her
Establish context/s
in which comfort is
realized:
1. Physical
2. Psychospiritu
al
3. Environmenta
l
4. Sociocultural


Giving health
teaching
especially to the
mothers in caring
of her baby such
as breastfeeding.

Help the mother
to know her
comfort and
contentment
through
physically,
psychospiritually,
environmentally
and
socioculturally

To resist
carelessness that
will be the way to
have negative
feeling of caring
the baby.

comfort thorugh
physically,
psychospiritually,
environmentally and
socioculturally






The patient learned new
health teachings and
different ways in
breastfeeding.




CHRISTINE JOY A. ALA 2NUR1 RLE1
NURSING CARE PLAN
ASSESSMENT DIAGNOSIS PLANNING INTERVENTION EVALUATION
SUBJECTIVE: Maayos
ang pakiramdam ko
Walang sakit na
nararamdaman

OBJECTIVE:
Pain scale: 0 rated from
1-10
1- Least painful
10 most painful


Relaxed, calm

Participating in comfort
measures




Readiness of
enhanced Comfort
















The client will verbalize sense
of comfort or contentment

Demonstrate behaviors of
optimal level of ease

Participate in desirable and
realistic health-seeking
behaviors










Assess the patient of what type
of comfort is she is
experiencing:
1. Relief
2. Ease
3. Transcendence

Ascertain motivation or
expectations for improvement

Establish context/s in which
comfort is realized:
1. Physical
2. Psychospiritual
3. Environmental
4. Sociocultural



Within the stay of the
client:

The client verbalizes
sense of comfort and
contentment


The client obtained a
positive outcome until
she was discharge

The client was able to
participate in knowing
the desirable and
realistic health-seeking
behaviors.



SUBJECTIVE:
Hindi ko masyadong
alam kung anong tama
at mali sa pagpapalaki
ng bata
Paano ba gawin yan?

OBJECTIVE:
Inaccurate follow-
through of instruction or
performance.

Development of
preventable
complications.

Deficient Knowledge
[Learning need]
(specify)

Participate in learning
process

Exhibit increased in interest
and assume responsibility for
own learning by beginning to
look for information and ask
questions

Identify relationship of
signs/symptoms to the
disease process and correlate
symptoms with causative
factors


Perform necessary
procedures correctly and
explain reasons for the action.

Assess the clients ability,
readiness and barriers of
learning

Assess for personal factors

Determine clients most urgent
need from both clients and
nurses viewpoint

Provide an environment that is
conducive for learning

Determine clients method of
accessing information and
include in the teaching plan.

Provide health teaching to the
client about procedures in taking
care of the baby.

The client was able to
participate in the
learning process


The client know all the
basic information and
able to ask questions.


The client was able to
understand
signs/symptoms of a
disease and know how
to deal and prevent it.



The client was able to
perform correctly all the
appropriate procedures.