EMILIO AGUINALDO COLLEGE

School of Nursing

NURSING CARE PLAN

NAME: Angelo James Fernandez PATIENT INITIAL: M.S AGE: 34 DATE: March 9, 2024
STUDENT #:23-1-01126 DIAGNOSIS: AUB due to prolapsed GENDER: F ROOM NO. 703 B2
submucous myoma via Hysteroscopic
Myomectomy

ASSESSMENT NURSING DIAGNOSIS PLANNING NURSING INTERVENTION RATIONALE EVALUATION

Subjective: Risk for maladaptive After 2 hours of nursing INDEPENDENT INDEPENDENT After 2 hours of nursing
grieving as evidenced by intervention, the patient will intervention, the patient
“Sobrang bigat ng legs ko,
the predisposition for be able to cope with improved will be able to cope with
hindi ko maramdaman anxiety and feelings of psychological and physical ● Establish rapport ● To have a good improved psychological
kinakabahan ako” inadequacy and fear. comfort. ● Measure vital signs and nurse-client relationship. and physical comfort.
physiological responses ● Fear and acute anxiety
to the situation. can involve sympathetic GOAL MET
Objective:
● Stay with the very arousal such as
Vital Signs: nervous client increased heart rate,
Temp: 36.3 C ● Discuss the client’s respiration, and blood
PR: 74 bpm perception and fearful pressure.
RR: 15 cpm feelings. Actively listen to ● The presence of a calm
BP: 120/90 mmHg the client’s concerns. caring person can
● Provide therapeutic provide reassurance that
(+) Facial grimace touch, massage, and an individual is safe.
- Skin warm to touch
other adjunctive Also, a sense of
- Feelings of nervousness
therapies as indicated. abandonment can
exacerbate fear.
● Promotes an
DEPENDENT atmosphere of caring
● Administer anti-anxiety and permits explanation
medication as if or correction of
indicated misperceptions.
● Aids in meeting basic
human needs,
decreasing the sense of
COLLABORATIVE isolation, and assisting
the client to feel less
● Refer to pastoral anxious.
spiritual care, psychiatric
nurse, clinical specialist,
and psychiatric DEPENDENT
counseling if indicated. ● To reduce nervousness
● Provide a support and provide comfort.
system to the patient by
discussing to the patient
by discussing the COLLABORATIVE
available treatment ● May be desired or
regimen with family and required for the patient
significant loved ones. to deal with fear,
especially concerning
life-threatening
conditions, and serious
and/or high-risk
procedures.
● To promote feelings of
care and concern. This
also encourages the
patient’s integrity and
motivation. Discussing
psychotherapy options
with a licensed therapist
will help the patient and
other/s understand the
effective management of
the symptoms of the
condition.