Risk for Infection

Intervention
Assessment Diagnosis Planning Evaluation
Action Rationale
Objective Risk for infection NOC NIC After 8 hours of
 T=36.8 related to Infection Wound Care Nursing
 BP= 110/70 postsurgical Prevention Intervention the
 PR= 80 incision Health teaching patient is free
 RR= 19 After 8 hours of about: from infection.
 Weakness Nursing  What is  To know what  The goal is met
 Pain in the Intervention the infection is infection  The patient
incision site patient will be free verbalizes
from infection and  Causes of  To know what she’s feeling
fast wound infection causes of well
healing without infection
complications
 Assess signs  To know if
and symptoms there’s an
of infection. infection

 How to prevent
infection
a. Importance  To know how to
of hand prevent
washing infection
b. Keep clean  To know the
and dry the importance of
around area hand washing
of wound and it serves as
c. Do not a first line of
apply defense
anything on against
the wound infection
  Wet area can
be house of
bacteria

 Maintain  Regular wound

aseptic dressing
technique when promotes fast
changing healing and
dressing/ drying of
caring wound wounds

 Advice patient  Eating foods

to eat foods rich in Vitamins
rich in Vitamin C promotes
C fast healing

 Advice patient
to take her
medication in
right time and
right dose as
ordered and
explain the
importance of
it.
 Anxiety
Intervention
Assessment Diagnosis Planning Evaluation
Action Rationale
Objective cues: Anxiety related to NOC NIC After 8 hours of
 T=36.8 Perceived/Actual Relieve Anxiety Provision of Nursing
 BP= 120/80 threat of maternal Comfort Intervention the
 PR= 84 and fetal well- After 8 hours of patient is relax,
 RR= 20 being Nursing  Remain with  Helps to reduce less worried and
 The patient Intervention the the patient, interpersonal comfortable.
looks worried patient appears and stay calm. transmission She’s also ready
and nervous relaxed, less Speak in a anxiety, and for the procedure.
 Looks worried and slow manner. shows caring
uncomfortable comfortable Convey for the patient  The goal is met
empathy. or couple.
 The patient not
look nervous
 Ask the
 To let them and worried
patient/couple
express what
what they feel they feel and  The patient
and thought? what they verbalized she
And let them thought about is ready for
talk and just cesarean birth operation
listen
 She also
 Ask the  To know how verbalized
patient/couple can I help them she’s strong
for them what or what and can do it.
is cesarean teaching I need
birth to add

 Health
teaching about:
 a. What is  To know more
cesarean about cesarean
birth birth
b. Causes of  To why the
cesarean patient needs
birth to undergo
cesarean birth
and to lessen
 Explain to the the fear
patient and
relatives the  lessen their
reason why fear
she’s doing
cesarean birth

 Give support
to the patient
and motivate  to lessen the
her fear and make
the patient
brave
 Multiple Pregnancy
Intervention
Assessment Diagnosis Planning Evaluation
Action Rationale
Subjective Fatigue related to At the end of 8  Instruct the  To inform the After 30 minutes
 “I feel like my increased stress hours of client on what to mother about of nursing care,
body is over on body rendering nursing expect about the normal goal was met as
fatigue and it is functioning as care, the client multiple physiological evidenced by
manifested by will: pregnancy and and physical client’s statement
hard for me to
verbalization of the normal changes to a that she is not
sleep.” body fatigue and  Minimize physiological woman who is tired now as
facial grimace. Fatigue changes to a carrying two or before. She
 “Even if its woman’s body more than identified two
morning I’m tired  The client will carrying two or baby. steps she did to
already and my state that she is more baby in minimize fatigue.
back is aching tired but will their womb.
so bad.” identify steps to
minimize fatigue  Monitor vital  Immediate
 “My appetite is signs of the identification of
decreasing and  The client will client, fetal altered
my intake is report improved heartbeat, fetal changes that
falling”, as sense of energy. activity and requires
verbalized by growth. intervention.
the cient.
 Instruct the  To inform the
Objective client to bed rest mother that bed
 31 weeks AOG. and to sleep and rest prolong
rest while lying multiple
 facial grimace in her left side. pregnancy to
avoid preterm.
 Vital signs
a. FHR-144  Side lying
bpm/min position
increases
b. FHR-146 placental
bpm/min perfusion.
c. PR-90
bpm/min
d. RR-19 cpm  Discuss routines  To promote
e. BP-120-80 to promote rest.
f. T- 36.7 C restful sleep.

 Instruct methods  To conserve

to conserve energy for
energy: other tasks.
a. Sit instead
of stand
during daily
care.
b. Delegate
tasks
c. Ask for
assistance
d. Take
frequent
short rest
breaks
during
activities.
e. Combine
and simplify
activities
f. Plan steps
of activity
before
beginning
so that all
 needed
materials
are at hand.

 Encourage use  To conserve

of assistive energy for
devices. other tasks.

 Assist with self-  To minimize

care needs of fatigue.
the client.

 Encourage to  Extreme
avoid exposure humidity can
to extreme negatively
humidity. impact energy
level.
 Multiple Pregnancy
Intervention
Assessment Diagnosis Planning Evaluation
Action Rationale
Subjective Risk for uterine At the end of 8  Assess uterine  That is to note After 8 hours of
 “Nahihirapan atony related to hours of contraction and how much blood nursing care,
akong multiple rendering lochia flow every loss the client is goal was met as
maglakad, ang pregnancy as nursing care, the 2 hours after experiencing and evidenced by
manifested by client will be delivery. for immediate prevented
hirap pala
over distension prevented from intervention. hemorrhage, has
magbuntis pang of the uterus. post-partum effective tissue
una ko paman hemorrhage, will perfusion and
 Assess vital signs  Changes in BP
to” have effective stable vital signs.
and note for and pulse may be
tissue perfusion
peripheral pulses. used for basis of
 “Ang sakit din and stable vital
ng likod ko, signs. blood loss.
dahil sa bigat ng Postural
tiyan ko” as hypotension
verbalized by reflects a
the client. decrease in
circulating
 “33 years old”, volume.
as verbalized by
 Massage the
the client.  Massaging the
fundus
fundus stimulates
Objective contraction.
 37 weeks AOG.
 Encourage the  Breastfeeding
 Fundal height- mother to stimulates the
41cm breastfeed release of
immediately. oxytocin.
 Vital signs
a. FHR
b. 146  Administer  Oxytocin initiates
bpm/min oxytocin as uterine
prescribed by the contraction which
c. 144 physician. halts or prevents
bpm/min hemorrhage.

d. PR-90  Encourage to  Activity

bpm/min may predispose to
maintain bed
rest. further bleeding.
e. RR-21
cpm

f. BP-110-80

g. T- 36.4 C

h. Over
distension
of the
abdomen
 Hydramnios (Oligohydramnios)
Intervention
Assessment Diagnosis Planning Evaluation
Action Rationale
Subjective Maternal anxiety At the end of 8 After 30 minutes
 “I’m really related to fear of hours of  Monitor maternal  Immediate of nursing care,
worried for my threat to fetus rendering nursing and fetal status identification of goal was met as
baby,he is still a manifested by care, the client’s closely, including altered changes evidenced by
small fundal anxiety will be vital signs and that requires client’s smile and
baby and he
height for alleviated. fetal heart rate Intervention. verbalization that
doesn’t deserve gestational age. patterns. she knows that
to experience God will save her
difficulty living  Monitor maternal baby.
after birth.” weight gain
pattern, notifying
the health care
provider if weight
loss occurs.
Objective
 The uterus fails
to meet
 Provide  To reduce
expected growth
emotional anxiety.
rate.
support before,
 Amniotic fluid is
during, and after
only 450 cc
ultrasonography.
confirmed by
ultrasound.
 The mother
 Encourage the
looks anxious
mother to ask
with teary eyes.
about the
situation.
 Vital signs
 FHR-144  Inform the
bpm/min patient about
 PR-90 coping measures
bpm/min if fetal anomalies
 RR-19 cpm are suspected.
 BP-120-80
 T- 36.7 C

 Reinforce the  To monitor the

need for close growth and well-
supervision and being of the
follow up. fetuses.

 Continuously  Immediate
monitor maternal identification of
vital signs and altered changes
fetal heart rate that requires
during the Intervention.
amniotransfusion
procedure.

 Encourage the  Side lying

patient to lie on position
her left side. increases
placental
perfusion.
 Scheduled Cesarean Section
Intervention
Assessment Diagnosis Planning Evaluation
Action Rationale
Pre-operative Anxiety r/t Patient anxiety  Encourage  Allow Anxiety relieved
 Fear verbalized surgical alleviated and will patient to express verbalization and patient able
procedure as able to cope and fear and concern. of fear and to provide
 Restlessness manifested by utilize relaxation concern. relaxation
fear, technique. techniques.
 ↑ BP restlessness, and  Monitor vital sign.  To evaluate
BP of 140/90 response to
stressor.

 Instruct the use of

relaxation
technique  Reduce stress
a. Bathing and anxiety.
b. Deep
breathing
exercises.  Help
c. YOGA. relaxation.
d. Promote rest
and sleep.
e. Quiet and
core
environment.
 To identify
 Evaluate patient’s foreseeable
perception to problem;
threat to self. facilitate
intervention.

 To reduce
anxiety.
 Administration of
anti-anxiety drug
as ordered.  To relay
emergency plan
 Provide support for patient and
to family and to provide
assist them to answers to
deal with their questions.
own
fears/concerns.

 Explain the
procedure that
will be done.
 Scheduled Cesarean Section
Intervention
Assessment Diagnosis Planning Evaluation
Action Rationale
Post-operative Pain r/t surgical  Pain control.  Assess patient’s  To establish Patient able to
incision as pain level. plan care of utilized
Subjective manifested by  Patient will be patient. alternative
 The patient “Masakit ang relieved of measures to
verbalized hiwa sa’kin.” pain 30 mins  Use relaxation  To relieve relieve pain and
“Masaki and after technique such discomfort discomfort.
hiwa sa’kin.” administering as: and pain.
medication. a. Positioning.
b. Deep
 Patient will be breathing
able to utilize techniques.
alternative
method to
ease pain and  Proper  Help relieve
discomfort. ventilation of pain.
environment.

 Administer pain  To relieve

medication as pain.
ordered.

 Assess patient  Other patients

for non-verbal are reluctant
cues of pain and and shy in
discomfort. verbalizing
pain.

 Instruct family in  Allow family to

the use of touch participate in
and other patient’s care
support and provide
measures to time to express
help patients. concern.
 Scheduled Cesarean Section
Intervention
Assessment Diagnosis Planning Evaluation
Action Rationale
Risk for infection  The mother  Instruct mother Patient free of
r/t surgical will be free of about personal infection and
incision. infection and hygiene and complication.
other care of the
complication. incision.
 The mother
will participate  Keep dressing  Measures will
in prevention clean and dry. prevent
measures and infection
will maintain  Perform
physical well- bedside care.
being.
 Turn mother  Turning
from side to patient from
side. side to side
will prevent
hypostatic
pneumonia.

 Encourage  Helps to
early recover.
ambulation.

 Emphasize the  Helps to heal

importance of after surgery.
good nutrition.

 Instruct on the  To alleviate

importance of suffering.

 regular intake
of medication.

 Increase fluid  To prevent

intake 8 – 12 dehydration.
glasses/day.

 Instruct mother  To identify

on the unnecessary
importance of problems and
follow-up after take
discharge. immediate
action.
 Trauma and Pregnancy – Fear
Intervention
Assessment Diagnosis Planning Evaluation
Action Rationale
Subjective Fear related to NOC NIC
As verbalized by threat of injury to Psychological Coping
the client: the fetus as and physical enhancement, fear
 “Kumusta yung manifested by support reduction,
baby ko? Okay PR of above 125 presence,
lang ba siya? bpm; RR of Goal counseling,
May masama above 20 bpm; The client will relaxation therapy
bang mangyayari presence of relate an
samin ng baby flushed skin and increase in  Encourage  May help the  The client
ko?” dilated pupils psychological expression of client to feel shows
and physiological feelings calm decreased in
Objective comfort after visceral
 PR: above 125 nursing response
bpm immediate care
 Encourage  To provide  Was able to
 RR: above 20 response that positive outlook differentiate
bpm reflect reality. at the same real from
Discuss which time preventing imagined
 Avoids questions aspects can be false hopes situations
changed and
 Asks too many which cannot
questions about  The client was
her and her  Teach relaxation  Aids in letting also able to
baby’s well-being techniques: go of the discuss her
a. Slow, emotions and fears and
 Shows rhythmic calming the exhibits less
compulsive breathing mind behavioral acts
mannerism b. Progres- of panic and
sive fear
relaxation
 Presence of muscle
increase group
sweating c. Positioning
d. Thought
 BP above 120/80 stopping
e. Guided
 Presence of imagery
flushed skin f. Provide
therapeutic
 Pupils are dilated environ-
ment

 Allow personal  This will give  The client was

space the client a able to express
room to herself with the
breathe that provision of her
will later on own personal
help in space
expressing
herself

 Speak slowly  Helps a person  The client was

and calmly to understand able to
the trauma and desensitize
slowly herself from the
desensitize intensity of her
themselves to emotions
the emotional caused by the
intensity of it trauma
 Trauma and Pregnancy – Situational low self-esteem
Intervention
Assessment Diagnosis Planning Evaluation
Action Rationale
Objective Situational low NOC NIC
 The mother shows self-esteem Acceptance of Active listening,
expressions of guilt related to the accident coping
I in response to an occurrences of enhancement,
accident that could accident Goal increase self-
possibly harm her manifested by The client will esteem
baby expressions of express positive
guilt; difficulty in outlook for the  Assist the  This will the  This was able
 The mother had a making future and individual client to recognize and
hard time making decisions; resume level of identifying and recognize her convey her
decisions isolation of self functioning expressing feelings and feelings
from others feelings convey as an
 The mother isolate outlet to work it
herself from other out
people, does not
communicate with  Examine and  To divert the  He client was
them reinforce client’s mind able to divert
positive over positive her mind over
abilities and things that will positive things
traits (eg, alleviate the where it
hobbies, skills) acquisition of alleviates her
low-self esteem acquisition of
low-self esteem
 Trauma and Pregnancy – Abruptio Placentae
Intervention
Assessment Diagnosis Planning Evaluation
Action Rationale
Objective Ineffective NOC NIC
 Presence of tissue Promotion of Accurate assessment
excessive blood perfusion safety to the and prompt intervention
loss related to mother and
excessive newborn during  Physiological
 Altered BP  Assess patient’s vital
blood loss as delivery  For baseline statistic are
compared to manifested by signs, O2 saturation, within baseline
data
baseline loss of blood, Goal: and skin color
altered BP Provision of
 Altered PR compared to safety both for  Absence of
baseline, the mother and  Monitor for  These restlessness,
restlessness, anxiety, conditions may
 Severe altered PR, newborn will be
hunger and changes
anxiety and
indicate
abdominal pain severe successfully
in LOC
hunger.
abdominal pain provided decreased Presence of
and rigidity
and rigidity, cerebral positive
change LOC, perfusion
 Change LOC changes in
decreased LOC
 Decreased urine output,
urine output edema  Increased
 Monitor accurately  To obtain data urine output;
I&O about renal
 Edema perfusion and
decreased
blood loss
function and the
extent of blood
loss

 Monitor FHT  To provide  No fetal

continuously information distress; FHT
regarding fetal within 120-160
distress and/or bpm
 worsening of
condition

 Assess skin color,  To determine  Within normal

temperature, peripheral tissue range
moisture, turgor, perfusion
capillary refill like hypervolemia

 Helps promote  Presence of

 Elevate extremity
circulation good
above the level of
circulation; BP
the heart
and PR are
within normal
range

 Teach patient not to  Uterine pressure  Absence of

apply uterine can cause edema
pressure pooling of
venous blood in
lower extremities

 Instruct patient to  To immediately  Prompt

report immediately provide interventions
signs and symptoms additional have been
of thrombosis: (1) interventions provided; no
pain in leg, groin (2) secondary
unilateral leg complications
swelling (3) pale skin have been
noted
 A Woman Who is Substance Dependent
Intervention
Assessment Diagnosis Planning Evaluation
Action Rationale
Subjective Powerlessness After 2 hours of  Talk to the  To think or After 2 hours of
 “Hindi ko matigil related to nursing client in formulate a plan nursing
ang pag-inom ko substance intervention, the formulating plan that will help to intervention, the
at pag gamit ng addiction as client will able to to stop abusive solve the patient verbalized
mga evidenced by achieve and situation. problem. that she will
pinagbabawal na verbalization of maintain body participate with
gamot kahit na inability to stop function and  Listening  Having a the treatment and
alam ko naman na using substances. understand the attentively nonjudgemenal have a healthier
may epekto ito sa importance of about the manner can be pregnancy.
aking baby.” as stopping and the situation without more Therefore, the
verbalized by the toxic effects of reaction and therapeutic goal was met.
patient drugs to fetus. understand because the
clients problem patient may
Objective cues: and facilitate participate more
 Fear realistic coping with a positive
 Helplessness outlook.
 Insomnia
 Loss of appetite  Advice the  So that the
 Needle tracks on patient to have patient will
left and right a diversional forget about
forearms. activities such using
 Foul smelling as: substances that
breath. a. Exercise is harmful for
like low her baby and to
impact divert her
aerobics, attention to
brisked things that may
walking or help her to have
other a more health
exercises pregnancy.
 that is safe
for
pregnancy.
b. Listening
to music
c. Watching
TV
d. Reading
books, etc.

 Discuss how  Discussing

drugs, alcohol about these
and other things is
harmful important to
subtances destroy the
affects her life sense of
and the life of powerlessness
her baby and of the patient.
also her
interpersonal
relationships.

 Encourage the  Continuing

client to seek treatment helps
help to other to have a
agencies. positive
outcome.
 A Woman Who is Substance Dependent
Intervention
Assessment Diagnosis Planning Evaluation
Action Rationale
Subjective Risk related to After 2 hours of  Build rapport with  So that the After 2 hours of
 “Hindi ko na ata teratogenic nursing the patient and patient will be nursing
kayang tumigil effects of intervention the talk to her with a feel free in intervention, the
pa sa pag-inum drugs/alcohol to patient will non-judgmental talking about patient
ko at pag gamit the fetus. verbalized that approach. her problem. verbalized
ko ng she will start the willingness to
pinagbabawal treatment  Assure the patient  This will be a start the
na gamot program and that that there will be big help for the treatment
matagal tagal she will no longer someone that will patient to program and
na din mula use or at least support her overcome stop using
nung nagsimula reduce throughout the substance substances that
ako eh.” as substance pregnancy and will abuse because may harm the
verbalized by abuse. encourage and she will feel fetus.
the patient help her to stop more
substance abuse. determined.
Objective
 Irritated  Health teaching
 Fatigue about the
 Shaking teratogenic effects
 Sweating of drug and
 Nausea alcohol to the fetus
such as:
a. Her infant  Infants who are
may born to cocaine-
experience indepent
withdrawal woman may
symptoms suffer the
after birth. immediate
effects of
withdrawal
 syndrome of
tremoulousness,
irritability, and
muscle rigidity.

b. Breastfeeding  Because just as

is usually not all drugs cross
encouraged the placenta to
for women some extent,
with they are also all
substance excreted in the
abuse breastmilk.

c. Taking drugs  Studies show

during that using
pregnancy drugs, legal or
also illegal during
increases the pregnancy has
chance a direct impact
of birth on the fetus. If
defects, you smoke,
premature drink alcohol, or
babies, ingest caffeine,
underweight so does
babies, and the fetus.
stillborn
births.

 Encourage the  Continuing

client to seek help treatment helps
to other agencies. to have a
positive
outcome.
 Constipation
Intervention
Assessment Diagnosis Planning Evaluation
Action Rationale
Objective Risk for Short Term  Monitor vital  Changes in After 8 hours of
 Delayed hemorrhage After 8 hours of sign, compare blood pressure nursing
capillary refill related to nursing with patient’s may be used for intervention the
passage of intervention, the normal or rough estimate patient was able
 Restlessness conceptus client’s bleeding previous of blood loss. to demonstrate
will be minimized. readings. improved fluid
 Spontaneous balance
bleeding  stable vital  Monitor  Symptomatology evidenced by
signs cramping and may be useful in stable vital signs,
 Uterine bleeding. gauging severity good skin turgor,
cramping  good skin turgor or length of and prompt
 Save expelled bleeding capillary refill.
 Passage of clots  moist mucous clots. episode.
membranes

 prompt capillary  Note patient’s  Worsening of

refill individual symptoms may
physiological reflect continued
Long Term response to bleeding or
 The patient will bleeding such inadequate fluid
maintain fluid as changes in replacement.
volume. mentation,
weakness,
restlessness
and pallor.

 Count perineal  Provides

Deficient fluid pads. guidelines for
volume related to
excessive blood fluid
loss  Monitor intake replacement.
and output
(I&O) and
correlate with
weight
changes.

 Administer IV
fluid as
ordered

 Maintain bed
rest.  Activity
increases intra-
 Schedule abdominal
activities to pressure and
provide can predispose
undisturbed to further
rest period. bleeding.

 Monitor for
danger signs

 Prepare for
possible D&C  Bleeding will not
as prescribed stop if there is
for incomplete retain placental
abortion. fragments.
 Intraoperative Care Measures
Intervention
Assessment Diagnosis Planning Evaluation
Action Rationale
 Vital signs Risk for infection Short Term The client shows
monitoring related to tissue After the shift, the  Wash hands  Front line of no signs and
injury as client will: before entering defense against symptoms of
 Client is in manifested by the delivery infection infection
supine position invasive  Be free from room
with abdomen procedure complication
exposed  Disinfect the  To reduce the
Long Term patient’s skin number of
The client will using antiseptic microorganisms
recover after solutions in the skin
surgery without
the presence of  Sterile drapes  To reduce the
infection must be placed risk for infection
on the patient

 Maintain sterile
technique for
invasive
procedures

 Monitor vital  To have the

signs baseline data
 Postpartal Care Measures
Intervention
Assessment Diagnosis Planning Evaluation
Action Rationale
 Pain increases Pain related to Short Term  Monitor vital  To establish The client
when moving surgical incision After 1 hour of signs baseline data reported pain
vigorously as manifested by nursing relieved/controlled
pain, facial intervention, the  Promote  Bedrest in a low- and understood
 Facial grimace grimace and client will: bedrest fowler’s position the importance of
irritable restlessness reduces well-balanced diet
 Participate in intraabdominal
 Restlessness demonstrating pressure
and inability to techniques to
concentrate relive pain  Provide calm  Calm and
and comfortable comfortable
Long Term environment environment
The client will be helps to relieve
relieved of pain anxiety of the
client and will
promote relieve
of pain

 Instruct the  Wound healing

client and requires protein,
client’s family to and calories for
have a well - building new
balanced diet cells and for the
immune system
to produce
antibodies
 Complications with the Powers: Dysfunctional Labor (Prolonged Labor) - Fatigue
Intervention
Assessment Diagnosis Planning Evaluation
Action Rationale
Subjective Fatigue related to Short Term The nurse will do the After 1 hour of
 The pregnant prolonged labor After 1 hour of following: nursing
woman verbalized as evidenced by nursing intervention:
“I’m very tired, verbalization of intervention,  monitor vital signs  It is always a
anxious and the patient The patient’s and fetal heart necessity to  The patient’s
scared about this fatigue will be rate every 15 monitor the vital fatigue
delivery because minimized minutes signs of a lessened
it’s longer than patient in labor
usual “answered Long Term to know the  After 2 hours
the woman when After 2 hours condition of the of nursing
she was asked by of nursing woman and the intervention,
the nurse to intervention, fetus
the patient
express her the patient will
was able to
feelings and be able to  Explain  This will help to
concerns. actively actively
procedures being relieve fear and
participate in done to the anxiety of the participate in
Objective labor and woman and her patient and labor and
 Inadequate maintains support person, reassure the maintained
relaxation between effective allow them as support person effective
contractions breathing many choices as as well and give breathing
(contractions are pattern with possible and help them a sense of pattern with
less than 15mmHg contractions them express control. contractions
and ineffective) their concerns
 Prolonged latent and feelings  The goal was
phase (more than  This will give met
14 hours)  Encourage the energy to the
patient to drink patient
high-carbohydrate throughout the
fluid or to eat a whole delivery
light meal
 hence lessen
fatigue

 Those
 Provide comforting
nonpharmacologic measures will
comfort measures help to lessen
to the patient by: fatigue of the
a. Offering a patient
back tub
b. Changing
sheets
c. Using cool
wash cloths
or whatever
else seems
comforting  Lying on her
side will help the
 position the uterus to be
patient on her lifted off the
side and she vena cava thus
insists on lying preventing
supine, the nurse hypotension
will place a hip syndrome and
roll under one of placing a hip roll
her buttocks will tip the pelvis
and at least
move the uterus
to the side.
 Pregnancy Induced Hypertension – Risk for Injury and Seizures
Intervention
Assessment Diagnosis Planning Evaluation
Action Rationale
Objective Risk for injury Short Term The nurse will do After 3 days of
and seizures After 1 day of the following: nursing
 BP:180/90 related to nursing intervention, the
 Edema pregnancy intervention, the  Monitor B.P,  The increased patient was
 Proteinuria:4+ induced patient will be urinary output, B.P indicate protected from
hypertension protected from proteinuria, deep vasospasm, injury and free of
injury tendon reflexes decreased urine seizures
output and
Long Term protein in the
After 3 days of urine indicate
nursing renal perfusion
intervention, the while hyper
patient will be flexion indicate
free of seizures cerebral
irritability

 Monitor for  Headache and

headache, blurred vision
edema, visual indicate
blurring and cerebral
epigastric pain edema.
Epigastric pain
indicate hepatic
edema

 Avoid too much  Too much

stimulation by: excitement
a. Ventilating increase
the room cerebral
irritability and
 (dark and risk for
cold) convulsion
b. Restricting
visitors
c. Maintain
quiet
atmosphere
(closing the
door, avoid
unnecessary
noise)
d. Promote
rest
 Problems of the Passage and Anomalies of the Placenta and Cord – Forceps Delivery
Intervention
Assessment Diagnosis Planning Evaluation
Action Rationale
Subjective Acute pain At the end of the NIC: Pain relief  Patient
“sobrang sakit na related to nursing participated in
po,” as effects of labor interventions  Assess current  Allows the nurse to interventions,
verbalised. and delivery the: knowledge of develop an labor pattern
process obstetric pain individualised was improved
 Patient will be control measures. teaching plan for with and
able to cope the patient. reduce d
Objective with labor pain identified risk
 Facial grimace and  Assess if patient  Provides factors.
attended childbirth necessary
 Uncomfortable  also know classes; if yes, information so the  Patients feels
pain control determine he nurse can less pain
 Irritability options she childbirth reinforce
would like to techniques taught psychoprophylactic  Pain scale
 Restlessness use. methods of coping reduced
or initiate teaching
 Vital signs: BP=  Patient will of non-  Patient states
130/80 express relief pharmacologic that she feels
obtained from comfort measures relaxed and
 Pain scale: 9 labor pain by that can be used will be able to
the us of during stages of tolerate the
childbirth labor pain.
techniques
learned and  Provide positive  Positive
comfort reinforcement and reinforcement and
measures, encouragement to encouragement
analgesics patient and support provide the patient
and persons as they and support
anesthetics apply person a sense of
given. nonpharmacologic
 techniques learned control and self-
in childbirth confidence.
classes. Assist with
techniques as
necessary

 Assess anxiety  Allows for early

level ansd intervention to
implement measres decrease anxiety
to reduce anxiety levels. High levels
as needed. of anxiety can
increase the
perception of pain,
decrease ability to
tolerate pain, and
decrease
comprehension of
verbal instruction.

 Provide teaching  These

between uterine nonpharmacologic
contractions. comfort measures
work by providing
 Teach patient pain diversion during
control options uterine
available, giving contractions.
the pros and cons According to the
of each. gate control theory
of pain, only a
 Initiate limited number of
teaching/reinforcing sensations can
of non- travel along neural
pharmacologic
comfort measures pathways at any
that can be used one time,
during labor if
needed (e.g use of
focal point, visual
imagery, breathing
and relaxation
techniques). Assist
with
implementation of
these measures as
needed.
 Abnormalities of Placenta – Placenta Accreta
Intervention
Assessment Diagnosis Planning Evaluation
Action Rationale
Subjective Fluid volume Short Term  Continuous  Alteration in vital  Increased skin
woman stated deficit related to After 30-60 the evaluation of signs can call tugor
that “I feel thirsty, Active Blood Loss patient’s blood maternal and for prompt
dizzy and also Secondary to components that fetal physiologic actions  Blood pressure
weak”. Disrupted were lost will be status, back to normal
Placental replaced and the particularly:
Objective Implantation patient’s  Normal pulse
 Urine output= circulation of a. Vital signs rate
30cc/hour blood and oxygen b. Bleeding
delivery/transport c. Electronic  Increased urine
 Urine to the tissues will fetal and output
concentration be stabilized (to maternal
– dark orange replace fluid loss). monitoring  Woman states
tracings no more feeling
 Blood Long Term d. Signs of of dizziness and
pressure- After 4-8 hours of shock – weakness.
90/70 nursing rapid pulse,
intervention, the cold and
 Pulse rate: patient will be moist skin,
110 able to show decrease in
improvements blood
 Body such as moist pressure
temperature- skin, moist mucus e. Decreased
37.9 membrane, urine output
normal skin tugor. f. Never
 Decreased perform a
skin turgor, vaginal or
dry skin and rectal
mucous examination
membrane or take any
 action that
would
stimulate
uterine
activity.

 Administer  To replace
oxygen as oxygen lost to
prescribed the blood

 Administer
blood and other
blood
components as
prescribed

 Assess the need  If the client is in

for immediate active labor and
delivery. bleeding cannot
be stopped with
bed rest,
emergency
caesarean
delivery may be
indicated.

 On admission,  To prevent
place the pressure on the
woman on bed vena cava.
rest in a lateral
position
  For fluid
 Insert a large replacement.
gauge
intravenous
catheter into
large vein for
fluid
replacement
 To find out the
 Obtain a blood extent of
sample for hemorrage for
fibrinogen level prompt
as order intervention
 Postpartum Infection – Risk for Infection
Intervention
Assessment Diagnosis Planning Evaluation
Action Rationale
Subjective Risk for infection After 8 hours of  Assess vital  Increase body After 8 hours of
Client stated that related to nursing signs: odor of temperature, nursing
“recently I am prolonged labor intervention the lochia, tachycardia Intervention the
having chills and I and rupture of the client will be frequency, suggests Client is free of
am also sweating” membrane Infection free due urgency, pain in infection infection and able
to prevention as urinating. process to verbalize
Objective evidenced by:  Foul odor of measure to
 Fever- lochia indicates reduce infection.
temperature  The postpartum endometrial
37.9 client will be free infection
of infection  Painful,
 Chills and frequent
sweating  The client will be urination may
 Nasal able to verbalize suggest urinary
congestion and infection
demonstrate on
 tachycardia how to prevent  Instruct hygiene
 infection. practices
a. Hand  Hand washing
washing is important
before and against the
after spread of
perineal microorganism
care
b. Changing  Lochia is the
pads best culture for
frequently bacteria
c. Perineal  Prevent growth
cleaning of bacteria
 after  Prevent fecal
elimination contamination
d. Wiping from
front to back

 Instruct to eat  Protein, vitamin

well balanced C, promotes
diet. Provide tissue healing
vitamin C.

 Instruct proper  To prevent

breast feeding breast
and proper engorgement
attachment

 Instruct client  Adequate

for how to hydration and
prevent/reduce emptying of
urinary bladder will
infection. prevent stains
a. Increase of urine thus
fluid intake preventing
up urinary track
2000ml/2 infection.
litres per
day.
b. Monitor
bladder
retention
c. Emphasize
the
importance
 of bladder
emptying
d. Running
water in
the shower

 Ambulation.
 Ineffective Thermoregultion
Intervention
Assessment Diagnosis Planning Evaluation
Action Rationale
Objective Ineffective NOC NIC Goal met as
Axillary temp. 36 thermoregulation The preterm Maintain evidenced by the
to 37. 5 Degree related to infant will be able thermoregulation following:
Celsius immature to maintain body or neutral thermal
Cold skin temperature temperature from environment.  Infant
Mild shivering control center in 36. to 36.5 - 37 .  Assess the vital  To identify temperature
Show signs of the brain 5 Degree Celsius signs every 4 early signs of maintained
Hyperglycemia by helping the hours. ineffective between 36.5
infant thermo to 37.5 Degree
adopt/adjust to  Keep skin dry. regulation or Celsius.
normal Do not remove heat loss.
environment. vernix  Infant was able
 Heat loss in to adopt or
infant could be adjust to
through normal
 Wrap with evaporation, environment.
blanket or convection,
bonnet. conduction and
radiation. (For
 Avoid contact intervention no.
with cold 2-4)
surfaces.

 Establish /
maintain skin to
skin contact to
the mother.
  Skin to skin
contact and
Kangaroo
Mother Care
can contribute
much to the
care of the
premature
baby. It helps
in the baby’s
temperature to
be more stable
and reach
normal values.

 Regulate room  Maintaining a

temperature of thermoneutral
25-28 Degree environment,
Celsius helps prevent
stress due to
the cold.

 Place the infant  Newborns

in an incubator infants,
until they are especially
able to maintain when born
normal body prematurely,
temperature. are prone to
hypothermia
because they
have difficulty
regulating their
own body
 temperature,
and their
bodies do not
have a lot of
subcutaneous
fat to protect
them from the
cold
environment.

 Assist infant to
gradually adjust
to maintaining
their own
temperature
without added
heat.

 Lower the
temperature of
the incubator to
a degree at a
time. Take
temperature
every 30
minutes.

 Do not lower  Brown fat or

the temperature adipose tissue
further, until the is inadequate
infant's with pre
temperature mature infant if
reach and exposed in
maintain within cold
normal. environment,
the inadequate
surfactant will
be used
leading to
respiratory
distress
 Post Term Pregnancy – Fetal Compromise
Intervention
Assessment Diagnosis Planning Evaluation
Action Rationale
Objective Fetal compromise NOC NIC After 8 hours of
 FHR 170 bpm related to fetal Adequate fetal maintain fetal nursing
distress as oxygen oxygen intervention, the
evidenced by Goal was met.
FHR 170 bpm Short term After 8 hours of
After 8 hours of nursing  FHR reduced
nursing intervention, from170 bpm, to
intervention:  Close  Close 160 bpm which
monitoring for monitoring of is normal for
 Normal fetal fetal the client will fetus.
oxygenation will compromise enable obtaining
be promoted with client with of baseline data
diabetes for therapeutic
 FHR, uterine mellitus, intervention
activity will be pregnancy
monitored as induced
baseline data. hypertension
and labor
induced by
oxytocin

 Instruct the  Supine position

client to avoid will compress
supine position the aorta and
reduce cardiac
 Monitor labor output and will
every 15 reduce
minutes 0n the precentral
 first stage, every perfusion
5 minutes on leading to high
second stage. risk pregnancy

 Evaluate fetal  Fetal chords

response to regularly
labor: assessed for
a. Fetal heart immediate
rate, intervention of
b. Acceleration fetal
deceleration compromise
variable
c. Uterine  Tachycardia
activity could be
response to
hypoxia

 Acceleration are
meaning sign of
fetal wellbeing
 Late
deceleration are
signs of utero
placental
insufficiency
 Variable
umbilical cord
compression.

 Administer  Oxygen
oxygen as administered to
ordered lessen fetal
distress by
increasing the
available
oxygen from the
mother.
 Fetal Death – Powerlessness
Intervention
Assessment Diagnosis Planning Evaluation
Action Rationale
Subjective Powerlessness Short term H/T After 8 hours of
 Mrs. P related to fetal After 8 hours of After 8 hours of nursing
verbalized that “I demise as nursing nursing intervention, the
feel ashamed evidenced by, intervention: intervention: Goal was met.
yesterday I gave Client verbalizing
birth to a lifeless that she feels  The client and  Pat the client on  Patting the  Client verbalized
baby. I am so ashamed she her partner will the shoulders to client’s that she accepts
distressed and I gave to a lifeless be emotionally extend solace shoulders loss and felt
have been fetus, distressed, supported to and care extends stronger than
crying the whole acute insomnia, verbalize allowing her nurturing, care before.
night and did not and weeping feelings on the together with the and solace to
sleep well. I during the loss partner to the her. This  RR went down
really needed interview. verbalize enhances to 20 cpm
my baby to be  Couples will feelings while verbalization of
with me a live”  RR 24 understand 5 mourning their feelings and  PR lowered to
events baby as helps the client 100 which is the
Objective  Temp. 37.1ºc surrounding couples. to conserve normal range
 Client wept fetal death energy required
during the  Bp120/80 for grieving.  Client verbalized
interview mmHg  Counsel couples to follow
regarding  Monitor vital  Monitoring vital prescribed
 Client appeared  PR 110 bpm pregnancy, signs of the signs will medication
weak with red dying; death client after every enhance regimen
eyes 4 hours by monitoring of
checking on the client’s  Couple
 Client avoiding Long term Temp, PR, RR, condition and verbalized 5/5
eye contact The client to and BP therapeutic level causes of fetal
accept the loss. achievement death.
 RR 24 cpm
 Temp 37.1°C  Encourage deep  Deep breathing
breathing exercises will
 Bp 120/80 exercises and enable the client
mmHg complete bed relax and
relaxation reduce pulse
 PR 110 bpm rate and
respiration rate
to normal levels
of RR and PR
20 cpm and 100
bpm
respectively.

 Advise client to  Enhances

follow healing process
prescribed and prevents
medication chances of
toxicity.

 Discuss with the  Enables couple

couple’s to gain
chromosomal knowledge on
abnormalities, the cause of
Congenital fetal death.
malformation
and Hepatitis B
and other
infections that
cause of fetal
demise.
 Post Term Pregnancy - Fear
Intervention
Assessment Diagnosis Planning Evaluation
Action Rationale
Subjective Fear related to Short term After 8 hours of After 8 hours of
Mrs. M verbalized hospital After 8 hours of nursing nursing
that “IT has taken procedures and nursing intervention, intervention, goal
me more than 42 treatment as intervention: partially met
weeks before evidenced by the  Discuss faulty  The health Woman verbalized
delivery and I am client ‘s verbal  Patient together dates of last teaching about 3/3 causes of post
scared of the report that she with her partner menstrual causes of post term pregnancy
treatment and has taken more as a couple will period, Long term pregnancy
procedures the than 42 weeks be enlightened menstrual will ease  Client verbalized
doctor may order before delivery on the possible cycles, and tension of the to follow deep
for me like C/S. I and she is scared causes of post myometrium woman and her breathing
do not want to of the treatments term pregnancy. consequences partner and get exercises and
lose my baby” and procedures as the causes of her prepared return-
the MD  Client’s labor post term psychologically demonstrated
Objective prescribed and will be initiated pregnancy for late delivery proper deep
 Client appeared she said she did as ordered by by any ordered breathing
alert during the not want to lose MD means. technique
interview her baby
 Temp. 37.5⁰c  Client will be  Administer  Prostaglandin  Vital signs
 Client pulling educated on prostaglandin gel, misoprostol a. Temp.37.5⁰c
out eyebrows  RR 24 how to relax gel or and oxytocin b. RR24 cpm
during interview and rest by misoprostol to are given to c. PR100 bpm
 PR 110 cpm deep breathing initiate ripening, initiate labor d. Bp
 RR 28 cpm exercises. stripping off, 120/80mmHg
oxytocin
 Temp 37.5⁰c  BP 120/80  Client will exhibit
mmHg  Monitor vital  Vital signs will positive attitude
 Bp 128/80  Patient will be signs for every enhance to towards prenatal
mmHg scheduled for 4 hours by monitor the check-ups.
possible C/S checking
 PR 113 bpm temp.PR, RR client’s
and BP condition

 Monitor FHR  To closely

monitor FHR
will ensure no
placental
insufficiency is
 occurring from
aging of the
placenta.

 Demonstrate  Deep breathing

deep breathing exercise will
exercises enable the
woman to relax
and rest to
prevent panic
and save
energy.

 Instruct client  To avoid

on the potential risk of
importance of pregnancy
prenatal
Checked-ups,
and proper care
of newborns
 Nursing Care of a Pregnant Family with Special Needs Pregnant Adolescent
Deficient Knowledge in Pregnancy Process
Intervention
Assessment Diagnosis Planning Evaluation
Action Rationale
Subjective Deficient Short Term The student nurse Goal met. After a
The client knowledge After 1 hour of will discuss the series of prenatal
verbalized, regarding nursing following: visits and one-on-
“Di ko po alam pregnancy intervention, the  Establishes a one counselling,
kung ano ang process related to client will be able  Prenatal check- basis for future the client feels
mga dapat gawin lack of to: up and its learning. confident about
kapag information as importance her knowledge in
nagbubuntis, evidenced by  Adhere to pregnancy
kinakabahan po request of components of  Components of  Helps client process.
ako.” information prenatal diet. a prenatal diet learn
information
Objective  Express  Prenatal necessary to
 Behavior: willingness to vitamin the
Agitated have a regular development of
prenatal check-  Prenatal improved
up. immunizations knowledge.

Long Term
The client will:

 Identify the
components of
a prenatal diet
including the
prenatal
vitamins.

 Be encouraged
to have a
regular prenatal
check-up.
 Nursing Care of a Pregnant Family with Special Needs: Pregnant Woman who is Physically Challenged – Fear
Intervention
Assessment Diagnosis Planning Evaluation
Action Rationale
Subjective Fear of ineffective Short Term The student nurse Goal met. After a
 The client newborn care After 1 hour of will discuss the series of prenatal
verbalized, related to physical nursing following: visits and one-on-
“Baka ‘di ko impairment intervention, the one counselling,
maalagaan ng client will be able To family/ support the client feels
maayos ang to: system: confident about
anak ko dahil  Encourage  An her knowledge in
pilay ako.”  Express trust to family/ encouragement pregnancy
family/ support support from a support process.
Objective system through system to system will
 Client is crippled verbalization. provide further alleviate the
 Be prepared in care and client’s fear.
case of attention to
emergency the pregnant
(obtain woman.
emergency
hotline To client:
numbers.)  Discuss safety  An independent
measures care would be
Long Term when alone very helpful
The client will: with the since
 Alleviate newborn (eg. assistance is
worry and fear ensure not always
through wheelchair provided to the
expressing belt is locked) client.
trust to family/
support  Provide  Emergency
system. emergency numbers will
 Be hotline help the client
encouraged to numbers in
have case of any get urgent care
emergency serious when left alone.
hotline accident.
numbers to
help her in
times of need.
 Nursing Care of a Family Experiencing a Postpartum Complications – Postpartum Hemorrhage
Intervention
Assessment Diagnosis Planning Evaluation
Action Rationale
Objective Risk for NOC NIC  Hypovolemic
Signs and hypovolemic The nurse cannot Prevent postpartum shock
symptoms of shock independently hemorrhage prevented
shock: manage
 Cool, postpartum  Monitor BP,  Detect early
clammy hemorrhage: pulse, skin signs of
skin colour, uterine excessive
 Rapid Short Term tone q 15 bleeding so
pulse rate  Monitoring mins (every that it can be
 Pale or for signs 15 minutes) controlled and
ashen skin and signs of shock
 Weakness symptoms prevented
of
postpartum  Assess for  Bleeding is
hemorrhage uterine controlled by
 To minimize position and effective
the risk for lochia uterine
postpartum contraction
hemorrhage
 Massage
Long Term fundus to
 Preventing maintain
hypovolemic contraction
shock
 Administer
oxytocin as
ordered
 Monitor
bleeding by
saturation of
more than
one pad per
hour

 Assess for  Delivery and

signs of associated
trauma, with trauma
lacerations and laceration
(herniation,
rectal and
perineal pain)

 Administrating
IV fluids as
needed

 Immediate  Breastfeeding
breastfeeding facilitates
uterine
contraction

 Monitor intake
and output

 Administer  To minimize
oxygen as saturation of
ordered red blood cells
 Immediate  To prevent life
referral to the threatening
doctor if conditions
condition
worsened
 Nursing Care of a Family Experiencing a Postpartum Complications – Postpartum Hemorrhage
Intervention
Assessment Diagnosis Planning Evaluation
Action Rationale
Subjective Deficient fluid After 8 hours of NIC After 8 hours of
 The patient volume related to nursing Maintain fluid nursing
verbalized that excessive intervention, the volume intervention, the
she feels dizzy bleeding after patient will goal is met as
when she sits up birth as demonstrate an The student evidenced by:
or stands up. evidenced by improvement in nurse will do the
delayed capillary fluid balance as following:  The patient’s
Objective refill and evidenced by vital signs are
 There is delayed dizziness when good capillary  Monitor the  To watch out back to normal
capillary refill she sits up or refill and patient’s vital for signs of
stands up. decreased signs hypovolemia  The patient
 The patient dizziness when and impending does not have
looks pale standing up or shock excessive fluid
sitting up. loss
 The patient’s  To determine
uterus is still  Monitor the the amount of  The patient’s
bleeding patient’s input fluid lost uterus is
and output contracted
 Tachycardia is  Massaging the
present (>  Assess the uterus helps it  The patient is
100) location of the contract no longer pale,
uterus and feels dizzy and
check for the has good
contractility of capillary refill
the uterus and
give it a  The patient is
massage getting
 To increase adequate
 Encourage the venous return amount of
patient to and ensure the fluids replaced
 maintain bed availability of
rest with legs blood to the
elevated vital organs.

 To replace the
fluids that has
 Start IV been lost
infusion with
isotonic or
electrolyte
fluids
 Nursing Care of a Family Experiencing a Postpartum Complications – Mastitis
Intervention
Assessment Diagnosis Planning Evaluation
Action Rationale
Subjective Acute pain After 8 hours of The student After 8 hours of
 The patient related to swollen nursing nurse will do the nursing
stated that her breast as intervention, the following: intervention, the
left breast is manifested by patient will report goal was met as
painful tenderness when an apparent evidenced by:
whenever her she breastfeeds decrease of pain  Encourage the  Getting
baby tries to her baby. and swollenness patient to adequate rest  The patient is
breastfeed on on her left breast. promote rest helps the getting
the left side of patient to get adequate rest
her breast and well and
would hurt when prevent fatigue  The patient is
it gets touched. using a cold
 Advise the  A cold compress on
 The patient also patient to use a compress can her left breast
verbalized that cold compress help reduce every 2 hours
she thinks her on the left swelling and
left breast breast every 2 inflammation  The patient is
seems swollen hours taking the pain
medications
 The patient  Take pain  Taking pain that were
verbalized that medications as medications prescribed to
she has fever prescribed by helps alleviate her
the doctor the pain
Objective  The patient
 The patient’s  Advice the  Pressure verbalized that
breast is swollen patient to could worsen she is not
eliminate the swelling placing too
 Redness pressure on much pressure
present her left breast on her left
breast
 Warm to the  Health teach  So that the
touch the patient mother will be  The patient is
about signs aware about able to recite
 There is facial and symptoms the signs and the signs and
grimace when of mastitis and symptoms and symptom and
breast was also the also causes of also the causes
palpated. causes of mastitis, to of mastitis
(Tenderness) mastitis prevent
infection in the  The patient will
 Temperature: 39 near future continue breast
degrees celcius feeding

 Encourage the  Breastfeeding  The patient’s

mother to stimulates temperature
continue production of decreases
breastfeeding oxytocin which significantly
helps in
contraction  The patient is
taking enough
 Perform tepid  Tepid sponge fluids
sponge bath bath helps in
lowering the
body
temperature

 Increase fluid  Fever causes

intake sweating
which can lead
to fluid and
electrolyte
loss; so,
increased fluid
intake helps
replace the
fluid loss in the
body and to
prevent mild
dehydration
 Hematologic Disorders and Pregnancy – Anemia
Intervention
Assessment Diagnosis Planning Evaluation
Action Rationale
Objective Ineffective tissue Short Term  Monitor vital  Initiate Client monitor
 Decreased perfusion related Client will have signs q 2 (every identification of adequate
hemoglobin of to altered or adequate tissue 2 hours) or prn. altered changes perfusion to all
10g/dl decreased perfusion to all that may require body parts and
oxygen carrying body part with intervention monitor stable
 Pallor capability stable vital sign vital signs and
and  Auscultate lungs  Anemia can hemodynamics
 Dizziness hemodynamics for abnormal cause
breath sound palpitation,
 Fatigue Long Term and heart tone dyspnea and
Increased tachycardia
hemoglobin and
hematocrit with in  Decrease in
 Administer O2
normal range RBC decreases
(oxygen) as
prescribed oxygen carrying
capability as O2
(oxygen) is
bound to
hemoglobin for
transport
oxygen
supplementation
is needed to
maintain
oxygenation

 To asses
 Monitor impaired central
neurologic perfusion
status
  To assess
 Monitor for chest decreased
pain cardiac
perfusion

 May indicate
 Monitor FHR Fetal distress
and activity due to poor
oxygenation

 May facilitate
 Administer impaired O2
ferrous sulfate (oxygen)
and carrying ability
multivitamins as and increases
prescribed RBC

 Increase
 Take iron on absorption
empty stomach
with Juice and
vitamin C
 Increase RBC
 Administer blood will improve O2
or blood product (oxygen)
as prescribed carrying
capability and
correct volume
deficiency

 Food to correct
vitamin
deficiency and
 Nutritional Increase Iron in
instructions high the body
Folic acid and
iron diet such as
liver, kidney
beans, highly
contained  Vasoconstriction
vegetables reduces
peripheral
 Monitor perfusion
environment
within normal  Vasodilation due
range to excessive
heat reduces
organ perfusion
 Fear of Losing the Fetus
Intervention
Assessment Diagnosis Planning Evaluation
Action Rationale
Subjective Fear of losing the Short Term  Assess the  to determine the After the
 Contractions ( fetus related to  Client labour will status of the condition of the Intervention given
Client verbalized pre term ‘’labour be controlled or client and the fetus inside the the client is able
biglang sumakit halted fetus (fetal heart mother’s womb to:
ang tyan ko, na tone)
feeling ko Long Term  Take bed rest
parang  The client will be  Encourage bed  To relieve the
manganganak safe and free rest to the client pressure of the  Relieve the pain
na ako) from fear of with side lying fetus to the from abdomen
losing the Fetus. position cervix and lower back
 Lower back pain
 Relive in fear
 Pain scale of  Apply external  Uterine fetal due to thinking
8/10 uterine and fetal monitoring of losing a baby
monitoring provides
Objective evidence of
 Facial grimace maternal and
fetal well being
 BP of 140/100
 Monitor Client  Maternal pulse
 Cervix dilated vital signs over 120 beats
about 2 cm closely q15 per minute or
(every 15 persistent
minutes) tachycardia or
tachypnea,
chest pain,
dyspnea and
adventitious
breath sounds
  Early
 Instruct patient recognition of
to report any possible
feelings of adverse effects
difficulty of allows for
breathing or prompt
chest pain, intervention
dizziness,
nervousness
and irregular
heartbeats
 Monitor of
 Monitor uterine uterine
contractions, contractions
including provides
frequency and evidence of
domain effective therapy
 Fatigue
Intervention
Assessment Diagnosis Planning Evaluation
Action Rationale
Subjective Fatigue related to Short Term  Monitor the O2  Lack of HGB After the plan and
 Fatigue / decreased After 8 hours shift saturation reduces intervention, the
weakness oxygen supply to the client will be oxygenation and client is able to:
the body, and able to relieve leads to hypoxia
 Dizziness increased cardiac from pain and any which causes  Enumerate at
work load as discomfort due to damage to least five kinds
 Shortness of manifested by fatigue tissues and vital of food that rich
breath decreased organs in iron and folate
hemoglobin and Long Term
 Chest pain hematocrit level The Client comply  Monitor  Identify the
with the hemoglobin and importance of
medication and hematocrit level taking vitamins
 Headache
nutritional for Iron and
instruction  Provide  Food that rich in folate
Objective
nutritional Iron and folate supplement
 Pale or
Education will help the
yellowish skin
body to gain the  Maintain a BP of
 Bleeding /  Green leafy normal amount 120/80
vegetables are of Iron and
hemorrhage
rich in Iron and folate in the  Relieve the pain
folate blood from headache,
 Syncope
chest pain, and
 Foods that rich cramps
 Hypotension in vitamin C
(BP of 80/60)
 Daily intake of  To prevent
iron and folic anemia, neural
acid tube defect of
the fetus
 Meats, fish and  Food that high
selfish are in calcium will
contain heme prevent the
Iron absorption of
Iron in the body

 Avoids Food
that rich in
calcium

 Monitor  It will help to

hemoglobin and determine what
hematocrit level kind or anemia
q2 is the problem
and the possible
treatment for it.
 Ineffective Airway Clearance
Intervention
Assessment Diagnosis Planning Evaluation
Action Rationale
Subjective Ineffective NOC NIC The goal was
 Fatigue Airway Respiratory Airway Patency/ met
Clearance Patency and Measure
Objective related to Status Patient was able
 T: 36.4 C increased  Establish rapport  To develop to achieve the
production of Long Term: towards the client mutual trust return of ability to
 RR: 36 br/pm respiratory Patient will be and good maintain patent
secretions able to maintain interpersonal airways and
 PR: 89 bpm patent airway relationship respiratory status
with the client baselines as
 BP: 120/80 Short Term: evidenced by:
mmHg After 8 hours of  Promote Bed Rest  To avoid a. RR: 16
nursing exacerbation br/pm
 Difficulty in intervention the of the
Breathing patient secretions symptoms b. (-) Cough
will be mobilized,
 Productive and will show  Elevate head of  Positioning c. (-) Purulent
Cough uncompromised bed of the patient enhances Sputum
respiratory rate and change pulmonary
and the absence position frequently ventilation and d. Normal
 Crackles Breath
of being restless perfusion and Breath
Sounds
expectoration Sound
 Runny Nose of secretions
After 8 hours of
 Production of  Instruct patient to  Drinking plenty nursing
drink fluid 2-3 of fluid loosens intervention the
Purulent goal was partially
Sputum liters a day. Offer pulmonary
warm rather than secretions and met
cold fluids improves a. RR: 20
 Restlessness br/pm
ventilation
 Observe sputum  Change in
color and changes sputum b. Decreased
characteristics output of
may indicate nasal
infection secretions

 Administer  Mucolytic c. Crackles

mucolytic, liquefy breath
expectorants and respiratory sounds can
bronchodilator as secretions, still be
ordered expectorants heard at
increase right lower
productive lobe
cough to clear
the airways, d. Cough
bronchodilators continues to
facilitate be
respiration by productive
dilating the
airways

 Administer  To provide
humidified O2 as enough source
ordered of oxygenation

 Teach the patient  To prevent

and family about further
the cause, complications
management of by providing
signs and patient
symptoms of information
pneumonia and about the
about the factors disease
that may process,
contribute the prognosis and
disease treatment
 Hyperthermia
Intervention
Assessment Diagnosis Planning Evaluation
Action Rationale
Subjective Hyperthermia Long Term  Establish  To develop The goal was met
 Headache related to Patient will be rapport towards mutual trust and
increased free from the client good Patient is now
Objective metabolic rate hyperthermia interpersonal free from
 T: 38.2 C relationship with hyperthermia
Short Ter the client
 RR: 17 br/pm After 4 hours of After 4 hours of
nursing  Monitor Vital  To establish nursing
 PR: 89 bpm intervention the Signs baseline data of intervention the
patient’s body the patient goal was met
 BP: 120/80 temperature will a. T: 36.7 C
mmHg drop from 38.2 C  Provide Tepid  To lower body
to 37 C Sponge Bath temperature
 Rales

 Flushed skin  Instruct the  To release heat

family of the and provide
 Skin is warm to patient to comfort
touch provide loose
clothing for the
 Dehydration patient

 Irritability  Assess skin  Warm, dry,

temperature flushed skin
and color may indicate
fever

 Monitor WBC  Leucocytes

count indicate an
inflammatory
 and infectious
process
presence

 Instruct patient  To replace fluid

to increase fluid lost by
intake to 2-3 insensible loss
liters a day and perspiration

 Measure  To determine
patient’s fluid fluid balance
intake and and need to
output increase fluid
intake

 Give Antipyretic  To block the

medications as synthesis of
ordered prostaglandins
that act in the
hypothalamus
 Congenital Heart Failure and Pregnancy
Intervention
Assessment Diagnosis Planning Evaluation
Action Rationale
Subjective Activity At the end of  Monitor vital  This will help At the end of
 ”I have difficulty intolerance r/t to rendering nursing signs. establish a administering
in breathing increased cardiac care, the client baseline data nursing
when walking output as will be able to of the client’s intervention, the
even for a few manifested by gain enough rest normal vital client verbalized
steps, I feel my increased blood to tolerate activity signs. that she was able
heart aches pressure, such as walking. to tolerate small
and sometimes increased pulse  Monitor  This will activities such as
I feel like rate, increased changes in vital promote the walking.
fainting.” As respiratory rate signs as well as fetus’ safety.
verbalized by and weakness. fetal heart rate.
the client.
 Note skin pallor  Difference in
or cyanosis. skin color
signifies that
Objective the client is
 34 yo female undergoing
difficulty in
 G1P0 breathing.

 28 weeks AOG  Increase  This will help

activity levels the client no to
 Diagnosed gradually and exert too much
CHF teach methods effort that can
to conserve tax her heart.
 BP : 160/100 energy, such
mmHg as stopping to
rest for 3
 PR : 120 bpm minutes during
 RR : 29 bpm a 10 minutes’
walk.
 FHR : 152 bpm
 Plan care with  This will ensure
rest periods the client and
between will give her
activities to calm.
reduce fatigue.

 Provide a
positive
atmosphere,
while
acknowledging
the difficulty of
the situation. It
helps minimize
frustration by
rechanneling
energy.

 Monitor fluid  Compromised

intake and regulatory
weight gain. mechanisms
Weigh patient may result in
regularly prior fluid and
to breakfast. sodium
retention
because weight
is an indicator
of fluid balance.
 Thrombophlebitis
Intervention
Assessment Diagnosis Planning Evaluation
Action Rationale
Subjective Ineffective At the end of  Assess history of  Knowledge of At the end of
 ”I have difficulty peripheral tissue rendering nursing varicosities, high risk administering
in breathing, perfusion r/t care, the client immobility, leg situations helps nursing
pain on my venous stasis as will not trauma, in early intervention, the
lower legs.” As manifested by experience malignancy, detection. client did not
verbalized by changes in pulmonary obesity, oral experienced
the client. femoral, popliteal embolism as contraceptive pulmonary
or small calf evidenced by use and venous embolism as
Objective veins, increased normal breathing, stasis. evidenced by
 42 yo female leg warmth, normal heart rate normal breathing,
unilateral edema, and absence of  Measure the  Unilateral leg normal heart rate
 G4P3 pain during dyspnea and affected leg with and thigh and absence of
palpation of calf chest pain. a tape measure. swelling can be dyspnea and
 34 weeks muscle and assessed by chest pain.
AOG tenderness. measuring the
circumference
 BP : 140/90 of the affected
mmHg leg 10 cm
below tibial
 PR : 100 tuberosity and
bpm 10 to 15 cm
above the
 RR : 14 bpm upper edge of
the patella.
 FHR : 120 DVT is
bpm suspected if
there is a
difference of
>3cm between
the extremities.
 Monitor the  These tests are
results of the used to
diagnostic tests. document the
location of a
clot and the
status of the
affected vein.

 Maintain  Hydration
adequate prevents an
hydration. increase
viscosity of
blood, which
contributes to
venous stasis
and clotting.

 Apply below-  Compression

knee stockings
compression enhance
stockings as circulation by
prescribed. providing a
Ensure that the graduated
stockings are pressure on the
the correct size affected leg to
and are applied help return
correctly. venous blood to
the heart.

 Administer  Analgesics
analgesics as relieve pain and
prescribed.
 promote
comfort.

 Administer  Treatment of
anticoagulants anticoagulant is
such as used primarily
Heparin/Warfarin to prevent the
as prescribed. formation of
new clots by
decreasing the
normal activity
of clotting
mechanisms.