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Nursing Care Plan - Readiness for Enhanced Knowledge

Assessment Nursing Diagnosis Scientific Explanation Objectives Interventions Rationale Expected Outcome

Subjective: Readiness for Behaviors being Short Term 1. Monitor vital 1. For baseline Short Term
enhanced demonstrated reflects After 1 hour of signs. data. The patient shall
Ano po yung knowledge related the motivation to nursing have verbalized
eclampsia? to patient learn at a certain interventions, 2. Verify patients 2. To provide an understanding of
expressing desire time. patient will be level of opportunity to the information
Ano yung bawal sa akin to learn about able to verbalize knowledge ensure gained.
niyan tsaka kailangan condition. understanding of about accuracy and
ko gawin? information condition. completeness Long Term
gained. of knowledge The patient shall
Objective: 3. Assist the base for have used the
Edema of the feet Long Term patient to learning. information gained
VS taken as After 2 days of identify to develop an
follows: nursing learning goals. 3. To help focus individual plan to
T: 36.5C interventions, on content to meet health needs
P: 98 patient will be 4. Encourage be learned. and goals.
R: 19 able to use the patient to
BP: information verbalize 4. To promote
120/70 gained to concerns ease in
develop an regarding handling
individual plan to knowledge and difficult
meet health skills needed situations.
needs and by the patient.
goals.

5. Assist the 5. Applying or


patient in using
identifying information
ways to use increases the
the desire to learn
information. and retain
information.
6. Repeat
instructions 6. Repetition
and reinforces
demonstrations learning.
of skills
needed by the 7. To ensure
patient. complete
knowledge
7. Encourage concerning
patient to ask condition to
questions and prevent risks.
clarify
information
concerning
condition.
Date Time Focus Nurses Progress Notes

7/20/17 8:00 AM Readiness for Data: Received patient on bed in sitting position, conscious and coherent. Patient had no contraptions
enhanced and no complaints of pain. Patient verbalized Ano po yung eclampsia? and Ano yung bawal sa akin
knowledge as niyan tsaka kailangan ko gawin? Presence of edema on feet.
evidenced by
Breasts- Breastfeeds effectively on both breasts. No tenderness or swelling.
patient
expressing desire Uterus- Contracted 1 finger breadth below umbilicus.
to learn about Bladder- Urinated 4 times, light yellow.
condition. Bowel- Defecated 1 time, semi-solid.
Lochia- Lochia serosa. Pink color. Started using napkins the day after delivery. Changed napkin twice.
Episiorrhaphy- Median, no swelling.
Skin- Warm to touch. Good skin turgor.
Homans Sign- Negative.
Emotion- Patient is in the taking hold phase as evidenced by breastfeeding her baby.
VS- T=36.5 C, P=98, R=19, BP=120/70 mmHg.
Actions: Established rapport, provided AM care, stretched bed linens, monitored VS. Asked patient about
previous VS and medications being taken. Assessed skin color and other extremities. Encouraged
patient to eat fruits and vegetables. Encouraged patient to elevate legs when possible. Encouraged
patient to drink water, buko juice, or pineapple juice to promote urination and defecation. Encouraged
walking and exercising to promote venous return. Recommended ankle and foot exercises to reduce
pooling. Discussed factors that affect circulation. Discouraged prolonged standing, tight clothing.
Emphasized at-home BP monitoring.
Response: After 1 hour of nursing interventions, patient will be able to verbalize understanding of
information gained.

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