NCP For Pregnant
NCP For Pregnant
NCP For Pregnant
Dolores Wellbeing, a 16 y/o student, comes in for consultation with her mother and is 4. Compute for the AOG (Date of consultation is today).
having an unintended pregnancy. The mother stated that lately, her daughter is
experiencing severe nausea and vomited 3-4 times almost every day accompanied by March 1, 2019 – April 24, 2019
lightheadedness, cramping of legs and a feeling of irregular heartbeat. The mother also = 54 days or 7 weeks 5 days
informed the nurse that her daughter is having dysuria for a week, flank pain, spotting and
loss of appetite. During interview, the mother additionally stated that her daughter has 5. Compute for EDC.
been emotionally upset since the boy who got her pregnant disclaims that baby but still has
March 1, 2019 + 280 days
the conviction to take care of herself and her present condition. On assessment of the client,
she is coherent, states her pain is 7 on a scale of 1-10, and minimal blood on her vaginal pad. = December 7, 2018
Her temperature is 380C, Pulse 115 bpm, respiration 20 cpm, BP 140/ 100. LMP is March 1,
2019, height 4’11 and weighs 40 kgs. Laboratory results are as follows: March 1, 2019
Hgb- 9 gm/ dl +9 +7
1.Formulate 3 NCP (ADPIRE) based on priority need. AOG - 54 days or 7 weeks 5 days
BMI -17.8
3. Identify independent, dependent and collaborative nursing interventions
Collaborative:
Refer patient to home Continuity of care is facilitated by
health nurse or private community resources.
nurse in order to assist
patient, as appropriate.
Priority #2 Acute Pain
Assessment Diagnosis Planning Intervention Rationale Evaluation
Subjective: Acute pain related to Short-term: Dependent: Short-term:
The mother informed the nurse infection as evidenced by Patient exhibit signs of Administration of unusual Giving the right kind and dosage of a After 4 hours of nursing
that her daughter is having dysuria complains of pain, changes improvement with a methods of handling pain painkiller to the patient is the key for a intervention, the
(painful urination) for a week, flank in autonomic responses. satisfactory pain control requires a doctor’s order. faster way of getting rid of the pain patient exhibited signs of
pain, spotting and loss of appetite. at a level less than 3 to 4 which is usually prescribed by the improvement and is normal
on a rating scale of 0 to 10 doctor. with less to no pain.
Objective: Patient will have normal Independent:
Weak vital signs. Foresee the need for pain Preventing the pain is one thing that a Long-term: After 2 days of
Pale relief. patient experiencing it can consider. Nursing intervention, the
Flank pain scaling at 7 Long-term: Early intervention may decrease the Patient demonstrates lifestyle
Minimal spotting in pad Assess lifestyle changes total amount of analgesic required. changes and knowledge about
AOG - 54 days or 7 weeks 5 days that will help prevent or Acute Pain by:
EDC - December 8, 2019 reduce acute pain. Acknowledge reports of Pain can be aggravated with anxiety and verbalized awareness of
BMI -17.8 Talk about causative pain immediately. fear especially when pain is delayed. An causative factors and
factors and behaviors immediate response to reports of pain behaviors essential to cope
V/S taken as follows: essential to cope with may decrease anxiety in the patient. with acute pain
T- 38.0 acute pain. Demonstrated concern for the patient’s knew the measures that can
P - 115 bpm Educate about the welfare and comfort fosters the be taken to treat or prevent
RR - 20 cpm measures that can be development of trusting relationship. acute pain.
BP - 140/ 100 taken to treat or prevent
acute pain. Get rid of additional Patients may experience an
Lab results as follows: stressors or sources of exaggeration in pain or a decreased
Hgb- 9 gm/ dl discomfort whenever ability to tolerate painful stimuli if
Hct- 51.4 % possible. environmental, intrapersonal, or
WBC in U/A- 12,000 mcL intrapsychic factors are further stressing
Na- 114 mmol/L them.
K-2.5 mmol/ L
Collaborative:
Caregivers can promote adequate
Educate the caregiver
hydration and nutritional status by
about appropriate fluid and
acknowledging dietary points to
dietary options for nausea,
consider when nauseated, following the
importance of Changing
prescribed schedule for medications
positions slowly and proper
reduces episodes of nausea and that
administration of
Abrupt or gross movements may
medications.
aggravate the condition.
Priority #4 Situational Low Self-Esteem
Assessment Diagnosis Planning Intervention Rationale Evaluation
Subjective: Situational Low Self-Esteem Short-term: Independent: Short-term:
The mother stated that her related to teenage The patient reports Act as a role model for the Assume responsibility for own thoughts After 1 session of nursing
daughter has been emotionally pregnancy and rejection as progress in current patient or significant others and actions by using “I think” language in intervention, the
upset since the boy who got her evidenced by loss of situation. in healthy expression of conversations. Patients may want an patient reported progress in
pregnant disclaims that baby. appetite and feeling feelings or concerns. example of positive measures to display handling her emotions on the
depressed. Long-term: feelings. situation.
Objective: Assess lifestyle changes
Weak that will help with self- Spend time with the patient; Having enough time for the patient Long-term: After 3 sessions in a
Pale esteem. set aside enough time so conveys the nurse’s interest in and week of nursing intervention,
Worried Verbalizes positive that the encounter is calm acceptance of the patient’s feelings. A the
AOG - 54 days or 7 weeks 5 days acceptance of self and and deliberate. trusting relationship is an important Patient demonstrates lifestyle
EDC - December 8, 2019 situation. factor in building self-esteem. changes and acceptance of
BMI -17.8 the situation.
Provide privacy. Private discussions need to take place in
V/S taken as follows: a setting where the patient is free to
T- 38.0 express feelings without being
P - 115 bpm overheard.
RR - 20 cpm
BP - 140/ 100 Apply active listening and These communication methods permit
Lab results as follows: open-ended questions. the patient to verbalize interests,
Hgb- 9 gm/ dl concerns, worries, and thoughts without
Hct- 51.4 % interruption. This will convey a sense of
WBC in U/A- 12,000 mcL respect for the patient’s abilities and
Na- 114 mmol/L strengths in addition to recognizing
K-2.5 mmol/ L problems and concerns.