NUR301 OBSTETRIC AND WOMEN'S HEALTH NURSING COURSE

NURSING CARE PLAN

Student name-surmane:HALIMAT ADELEYE Patient Name: MRS JANE DOE

Student number: 20213811 Date: DEC 18TH,2023.

Patients Information.

Name: Mrs. Jane Doe

Age: 40

Sex: Female

Height:168cm

Weight: 70kg

Body Mass Index: 24.80

Educational Level: Masters in International Law

Occupation: Lawyer

Language: Turkish, English

Marital Status: Married

Number of Children: 3

City/Country: Lefkosia, Cyprus

Admission date: 17th December, 2023

Clinic: Near East Hospital

Admission Route: Emergency

Patient’s Relative for Care: Husband

Blood group: O+. Genotype: AS

Presenting Complain: Lower Abdominal Pain, unusual vaginal discharge and vaginal bleeding

between regular periods.

History of Presenting Complain: Patient presented to the emergency department with lower

abdominal pain which has been going on for a week, she took Ibuprofen for the pain for 3 days

but it didn't help. She also stated that she has had an unusual vaginal discharge for a month and
vaginal bleeding between regular periods for about 3 months.

Past Medical History: The patient stated that she has been healthy and has only been admitted once

in the hospital for food poisoning. She doesn't have any chronic disease( diabetes, hypertension,

etc)

Family History: Patient’s parents are healthy but her Aunt( Mum’s sister) was diagnosed with

cervical cancer 10 years ago. No consanguinity.

Social History: Patient doesn't smoke or drink alcohol, she stated she started engaging in sexual

intercourse by the age of 14.

Allergies: No known allergies.

Medications: Patient is not on any medication apart from the Ibuprofen she's taking for pain.

Previous Surgeries or Transfusion: Nil

On Examination: Pelvic region is tender to palpate, anicteric, hydrated, no Edema, normal heart and breath sounds.

Review of Systems:

Neurologic System: Normal

Respiratory System: Normal

Cardiovascular System: Normal

Gastrointestinal System: Normal

Urinary System: Normal

Musculoskeletal system: Normal

Endocrine system: Normal

Hematological system: Not indicated.

Laboratory Tests and Other Diagnostic Tests:

CBC, BMP, CRP, Pap smear and Abdominal CT.

Diagnosis: Cervical Cancer( Adenocarcinoma)

Assessment Diagnosis Outcomes Interventions Rationales Eveluatio

n
1
Subjective By the end Assess the To address
Data: Deficient of the health patient’s the patient’s
“I want to Knowledge teaching readiness to cognition and
know session, the learn, mental
more about patient misconception status towards the
my should be s, new diagnosis and
diagnosis” as able to show and blocks to to help
verbalised by a good learning (e.g., the patient
the understandin denial of overcome
patient g of diagnosis or blocks to learning.
cervical poor
cancer and lifestyle
Objective how to habits)
Data: manage it
Increased effectively
curiosity

Imbalanced
Nutrition: Explore the
patient’s daily To create a
Less
2 The patient nutritional baseline of
than body
Subjective: will be able intake the patient’s
requirement
abdominal to achieve a and food habits nutritional
s (e.g., meal
cramping, weight status and
related to times,
stomach within her preferences.
the duration of
pain, normal BMI
adverse each
diarrhea or range,
effects of meal session,
constipation, demonstratin
chemotherap snacking, etc.
bloating, g
y
weight healthyeatin
loss, nausea g
and patterns and
vomiting, choices.
and
loss of
appetite

Objective:
Abdomen is To create a
tender to baseline of
palpate, Ask the patient activity
Fatigue
Malaise to levels,
related to
The patient rate fatigue degree of
consequence
will level fatigability,
of
establish (mild, and mental
chemotherap moderate,
3 adequate status
y or severe
Subjective: energy related to
for cervical fatigue).
Verbalisation cancer (e.g., levels and Assess the fatigue and
of immunosup will patient’s activity
tiredness, pr demonstrate activities intolerance.
generalised ession and active of daily living,
weakness and malnutrition participation as
well as actual
shortness of ) in necessary
and
breath upon and/or and desired perceived
exertion. emotional activities limitations to
distress due physical
Objective: to the activity.
Patient in diagnosis Ask for any Pain
distress, form management is
Patient of exercise that crucial in
expressing she used to do promotingmobility,
overwhelmin or as pain can
g wants to try. restrict movement
lack of Acute Pain The patient and cause muscle
energy. will report guarding. The
reduced pain nurse
levels within helps reduce pain
the levels by
4 tolerable administering
Subjective: range. The analgesics,
Complaint of patient will Administer enabling the
intense pain, demonstrate prescribed patient to engage in
restlessness, improved analgesics. mobility exercises
anxiety, ability to effectively.
decreased perform
concentration mobility
, related
difficulty in activities.
sleeping.

Objective:
Increased
pulse, Anticipatory To provide
increased Grieving an atmosphere
blood of acceptance
pressure, and to establish
pallor, The patient rapport with the
guarding the will be able patient.
area to identify It is important to
of pain. and express Using open use open ended
feelings in ended questions to allow
an questions, the
5 appropriate ask the patient patient enough
to
Subjective: manner express her fear time
Verbalisation without of life after to speak, rather
of inflicting surgery, and than
anger about harm to how asking questions
her oneself she feels about that are only
her disease and
disease, others. answerable
treatment
expression of by “Yes” or “No.
fear Maintaining
of life after integrity of
surgery, loss Oral
of Mucous
appetite and Membrane
inability to The patient This helps
sleep. will practice establishing
recommende baseline
Objective: d data of the
Educate the
Increased before,durin patient and
family and the
pulse g and after patient the it is ideal to
and blood care importance of have
pressure. plan for each regular periodic possible
treatment. assessments of prophylactic
The patient dental and oral treatments
6 and family health before any
Subjective: will promote therapy
Oral lumps, maintenance
inflammation of the oral
s, mucosa.
lesions that The patient
seem Disturbed and family
to never heal. Body Image will be able
due to to assess
Objective: imbalanced the patient's Adapting to
Increased nutrition oral health the patient’s
WBC. secondary to needs helps
Maybe the adverse in maintaining
accompanied effect of The patient Assess the open
with high chemotherap will have a overall communication and
body y more well-being of provides a rapport
the
temperature. realistic of
patient and set
view of questions that mutual trust.
one’s body are This also serves as
image than adaptable to an
an idealistic his/her needs. opportunity to
one. During the communicate on
assessment, the
allow the patient’s unrealistic
patient
7 Minimise to express image and
Subjective: Infection his/her perception.
Evidenced by Risk negative
decrease in emotions and
self feelings about
one’s self-
esteem and
image.
loss The patient
of self will be able The patient is
confidence. to now able to
implement implement strict
Objective: strict infection control
Patient is infection Temperature measures,
exhibiting control elevation including proper
signs of low measures, may occur (if hygiene and
self esteem including not isolation
proper hand masked by precautions
corticosteroids
hygiene, when necessary for
or anti
isolation inflammatory her safety.
precautions drugs)because
8 when of various
Subjective: necessary factors
Fever, (chemotherapy
Weakness side
Managing effects, disease
Objective: Sexuality process, or
Hyperthermi Concern infection).
a, Early
identification of
Tachycardia infectious
processes
enables
The patient appropriate Acknowledges the
will therapy to legitimacy of
verbalize be started the problem.
understandin promptly. Sexuality
g of the encompasses the
effects of way
cancer and men and women
therapeutic view
Discuss with
regimen on themselves as
the
sexuality patient and so individuals
and the nature of and how they relate
measures to sexuality and between and
correct/deal reactions when among
9 Anxiety with it themselves in
Subjective: problems. is altered or every area
"I am having The patient threatened. of life.
Provide
issues will information
engaging maintain about
in sexual sexual the normality of
activities activity at these problems
with my the desired and that many
people find it
partner” level
helpful to seek
as verbalised possible. assistance with
by the adaptation
the patient. process.
Therapeutic
Objective: communication
Decreased Patient will creates
libido be able to a safe and
reduce Establish a supportive
anxiety trusting and environment
levels and non judgmental allowing
relationship
increase the individual to
with
coping the individual. express their
skills Use active concerns
listening and
techniques and emotions,which
10 provide can
Subjective: empathy help reduce anxiety
Restlessness, and validation. and
excessive promote a sense of
worry, understanding and
difficulty validation.
concentrating
.

Objective:
Increased
pulse
rate and
blood
pressure