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CUES NURSING GOALS AND NURSING RATIONALE EVALUATION

DIAGNOSIS OBJECTIVES INTERVENTION


SUBJECTIVE: Situational low self- General objectives: INDEPENDENT:
esteem related to After 2 days of
“ Wala pa yung perceived failure at a nursing Determine clients/ couple Both members of the
dalaw ko.. life event AEB interventions, the emotional response to couple may have a
naghahanap pa kasi verbalization of client will be able caesarean birth. emotional reaction to
siya ng pambili ng negative feelings to verbalize the surgical
gamut ko..” about self in situation understanding of intervention. An
(e.g helplessness, individual factors unplanned cesarean
“andami na naming shame/guilt), that precipitated birth may have a
gastos.. tapos evaluates self as current situation. negative effect
nagcesarean pa unable to handle on the client’s self-
ako.. mas lalaong situation, difficulty Specific objectives: esteem, leaving her
dumagdag sa making decisions. After 1 day of feeling that she
gastusin..” nursing is inadequate and has
interventions the failed as a woman.
“biglaan lang kasi client will be able
itong CS ko dapat to:
normal talaga Determine client’s level of Cesarean birth may be
ako..kaya di ko Discuss concerns anxiety and source of viewed by the client/
talaga related to his role concern. Encourage couple as a failure at a
napaghandaan ang in and perception client/couple to verbalize life
ganitong gastos ee” of the birth unmet needs and event, and this may
experience. expectations. Provide have a negative impact
information regarding the on the
normalcy of such feelings bonding/parenting
“pang 6 ko na kasi Express positive process.
itong anak kaya self-appraisal
medyo nahihirapan Provides emotional
na kami ng asawa Encourage support; may encourage
ko..” presence/participation of verbalization of
partner in all that is going concerns
on.
OBJECTIVES:

• Emotionally
stressed. Client may alter her
• Facial grimace Emphasize similarities perception of cesarean
• Narrowed focus between vaginal and birth
cesarean birth. Convey experience as well as
• V/S taken as
positive attitude, and her perception of her
follows:
manage postpartal care as own wellness or illness
BP: 120/80
close as possible to care based on the
RR:21
provided to clients professional’s
PR:76
following vaginal birth. attitudes. Similar care
TEMP.:36.8
conveys the message
that
cesarean birth is a
necessary alternative to
vaginal
delivery, focusing on
the optimal outcome
rather
than on the birth
process.
Assist client/couple in Helps facilitate positive
identifying usual coping adaptation to new role;
mechanisms and developing reduces feelings of
new coping strategies if inadequacy.
needed.

Fantasies caused by
Provide accurate lack of information or
information about client/ misunderstanding may
infant status. increase sense of
helplessness/loss of
control.

COLLABORATIVE:
Client who is unable to
Refer client/couple for resolve grief or
professional counselling if negative
reactions are maladaptive. feelings may need
further professional
help.
Nursing Care Plan

Pinca, Angelica L.
BSN 128
GROUP 111-A

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