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Assessment

Subjective
Patient
complaining
of not feeling
of urge to
eat.

Objective
Patient
looks very
weak.

Nursing
diagnosis

Altered
nutritional
status less than
body
requirements
related to
pregnancy as
evidenced by
refusal to eat
food.

Goal

Patient
demonstrates
progressive
weight gain
towards goal.

Nursing intervention

Rationale

Nursing care planned


To ascertain the understanding
of individual nutritional needs
for pregnancy.

Nursing care given


Ascertained the
understanding of individual
nutritional needs of
pregnancy.

To determine
what
information to
provide to
client.

To discuss eating habits,


including food preferences to
appeal clients likes and
dislikes.

Discussed eating habits


including food preferences to
appeal clients likes and
dislikes.

To identify the
interest of
client.

To assess weight and


activity/rest level.

Assessed weight and


activity/rest level. Wt-45 Kg.

To assess the total daily food


intake and maintain diary of
calories intake.

Assessed the total daily food


intake and maintain diary of
calorie intake.

To provide diet modifications


with increase protein,
carbohydrate and calories.

Provided diet modifications


with adequate amount of
protein, carbohydrate and
calories.

Encouraging client to take


small and frequent diet in
small -2 intervals of time.

Client is ready to take small2 diet in frequent interval of


time.

To encourage client to choose


foods that are appealing to
stimulate appetite.

Encouraged client to choose


foods that are appealing to
stimulate appetite.

Provide us the
baseline data.
Helps in further
care of the
client.
Helps to
maintain the
adequate
nourishment
required.
To increase the
intake of diet to
improve
nutritional
status.
Helps the client
to develop
interest in
having food.

Evaluation
The client
demonstrated
interest in
having food.

Reassessment

Reassessment done.
To see the
effectiveness of
intervention.

Assessment
Subjective
Objectiv
e
The client
Patient
complaints
looks
of weakness. pale.

Nursing diagnosis
Activity
intolerance
related to
imbalance to
between oxygen
supply and
demand
secondary to
pregnancy as
evidenced by
exhibition by
client.

Goal
The client will
report measurable
increase in
activity
intolerance.

Nursing intervention
Nursing care planned
Nursing care given

Rationale

To evaluate the current


limitations of deficit in light of
usual status.

Evaluated the current


limitations of deficit in light
of usual status.

To monitor the vital signs.

Monitor the vitals signs.


T- 98.40F
P-80/min
R-22/min
BP-130/90 mmHg

To adjust activates and plan


care with rest periods between
activities.

Adjust activities with rest


periods in between.

To reduce over
exertion and
fatigue.

To increase exercise level


gradually

Exercise level gradually


increased.

Helps to
conserve energy

To provide atmosphere while


acknowledging difficulty of
the situations for the client.

Provide atmosphere while


acknowledging difficulty of
the situations for the client.

To assist with activities of the


client.

Assisted with activities of the


client.

This helps to
minimize
frustration and
rechannel
energy.
This protects the
clients from
injury.

This provides a
comparative
baseline data
about the
activity level of
the client.

Evaluation
The client
reported
measurable
increase in
activity
tolerance.

Assessment
Subjective
Patient
verbalized
that she
easily wakes
up whenever
she hears
noise.
Furthermore,
she reported
frequent
awakenings
during the
night to go
bathroom
due to
increase urge
to urinate
which
happened
around 5
times. She

Objective
Patient is
not
sleeping
during
night and
day.

Nursing
diagnosis
Disturbed
sleep pattern
related to
shortness of
breath and
frequent
urination
secondary to
pregnancy.

Goal

The client
verbalizes
understanding on
the cause of sleep
disturbance and
reports increased
sense of
wellbeing and
feeling of rested.

To provide information about


the effect of lifestyle and
overall health factors on
activity intolerance.

Provide information about


the effect of lifestyle and
overall health factors on
activity intolerance.

This helps in
effective
planning.

To encourage client to
maintain positive attitude.

Encouraged client to
maintain a positive attitude.

This enhances
the well-being
of the client.

Nursing intervention

Rationale

Nursing care planned


Assess vitals signs of the
client.

Nursing care given


Assessed the vitals signs of
the mother.
T-980F
P-88/min
R-28/min
BP-140/90mmHg

Encourage client to void


before sleeping.

Encouraged client to void


before sleeping.

Voiding before
bedtime limits
the sleep
disturbance.

Provided a quiet environment


conducive for sleeping.

Provided a quiet environment


conducive for sleeping.

A quiet
environment
promotes
continuation of
sleep without
disturbance.

Elevated blood
pressure is
usually
observed in
sleep disturbed
clients.

Evaluation
The client
reported of
being rested
and more
relaxed.

felt slight
pain on the
area near her
buttocks due
to the
pressure she
feels on her
chest which
affects her
breathing.

Assessment
Subjective
The mother
verbalized
that she feels
sad about her
physique and
body image.

Objective
Contour of
the
abdomen
changes
and
presence of
linea nigra
on the
abdomen.

Nursing
diagnosis
Disturbed
body image
related to
change of
appearance
associated
with
pregnancy.

Goal

The client will


express positive
feeling towards
self and
significant others.

The client will


verbalize
acceptance of
body image.

Encouraging client to drink a


glass of milk or to take bath
before sleeping.

Encouraged client to drink a


glass of milk or to take care
before sleeping.

This promotes
relaxation and
readiness for
sleep.

Reassessment

Reassessment done.

To check change
in condition.

Nursing intervention

Rationale

Nursing care planned


To assess the readiness of the
client to accept changes in
body image.

Nursing care given


Assessed the readiness of the
mother to accept the changes
in the body image.

This gives a
mother a sense
of control over
the situation.

To employ a care calm,


confident and non judgemental
approach towards the mother.

Employed a caring calm


confident and non
judgmental approach towards
the mother.

This improves
the nurse patient
relationship
with the client.

To discuss with client the


physiological changes during
pregnancy.

Discussed with the client the


physiological changes during
the pregnancy.

This creates a
sense of trust
and at the same
time educate the
client about the
changes during
the pregnancy.

Evaluation
The client
perceived the
pregnancy in a
positive
manner and
claimed that
she is excited
to see her
baby.

Assessment
Subjective
The client
verbalized
concern
about the
upcoming
delivery and
express
worries
about
childbirth.

Objective
The client
exhibits
poor eye
contacts

Nursing
diagnosis
Anxiety
related to
hospitalization
and child birth

Goal
The client will
acknowledge and
discuss fears
Recognizing
healthy and
unhealthy fears
verbalizes control
over the situation.

To allow client to express her


feeling towards her pregnancy.

Allowed the client to express


her feeling towards her
pregnancy.

To teach client coping


strategies.

Taught the client coping


strategies.

To monitor the vitals signs of


the client.

Monitored the vital signs of


the mother.
T-980F
p-82/min
r -28/min
BP- 130/90 mmHg.

This provides a
base line data.

Reassessment.

Reassessment done

To check change
in condition.

Nursing intervention

This creates a
positive outlet
for expression
of feelings.
This helps to
overcome
maladaptive
behaviour.

Rationale

Evaluation
The client
verbalized a
decrease in the
anxiety level.

Nursing care planned


To assess the level of anxiety
through verbal and non-verbal
cues.

Nursing care given


Assessed the level of anxiety
through verbal and nonverbal cutes.

This helps to
identify the
areas of concern
that might
interfere with
interfere with
the normal
progress labour.

To employ a caring a calm and


non judgemental approach.

Employed a caring, calm and


non-judgemental approach

This enhances
the nurse-client
relationship.

To allow the client to express


fears and feelings of anxiety
appropriately.

Allowed client to express her


fears and feelings of anxiety
appropriately.

To acknowledge normalcy of
fear and provide opportunity
of questions and answer
honestly within clients level of
understanding

Acknowledged normalcy of
fears and provided
opportunity for questions and
answered honestly within
mothers level of
understanding.

To offer support by staying


close to the mother.

Offered support by staying


close to the mother.

This promotes
healthy outlets
Of emotions and
relives anxiety.
Adequate
explanation
reduces anxiety
and soothes fear
and provides
assurance.
This provides a
sense of security
and trust
between the
nurse and the
client.