CUES AND EVIDENCES

NURSING DIAGNOSIS

SCIENTIFIC BASIS

GOALS AND OUTCOME CRITERIA

NURSING ACTION/NURSING ORDERS

RATIONALE

EVALUATION

S- “Wa pa gyud ko naka ihi sukad pagpanganak nako ganina”, as verbalized by the patient. O- looks weak -afebrile -coherent -4 hours postpartum

Altered urinary elimination related to perineal edema and decreased bladder tone from fetal head pressure during birth.

During vaginal After 8 hours of Nursing Action: birth, the fetal nursing Render nursing head exerts a interventions, the measures helpful in great deal of patient will be initiating voiding of pressure on able to attempt the patient. the bladder common and urethra as measures to it passes on initiate voiding. Nursing Orders: the bladder’s underside. 1. Assess amount This pressure The patient will of urine voided may leave the be able to: during labor, and bladder with a reassess fundal transient loss a. Verbalize height and of tone that, understanding position. together with s of the edema condition. surrounding urethra, b. Identify decreases a negative woman’s factors 2. Assess what ability to affecting measures patient sense when urinary thinks would help she has to elimination. her to void. void. (Pillitteri;2007: c. Participate in 630) different

Appropriate measures will be implemented to initiate voiding.

Goal met as evidenced by: Patient was able to void more than 100 ml within 2 hours’ time. Fundal height returns to 1 fingerbreadth below umbilicus after voiding.

Assessing fundal height and position provides evidence about the degree of bladder filling. (Pillitteri;2007: 642) Respecting client’s preferences helps her to maintain feeling of control.

Patient ambulates to the bathroom to void with assistance

nursing interventions. 3. Discuss the importance of continuing to drink.

(Pillitteri;2007: 643) Helps to initiate bladder reflex. (Pillitteri;2007: 642) Retention of urine predisposes to infection. (Pillitteri;2007: 642) Women should drink ample fluid during the postpartum period, to counteract normal dieresis and ensure good urine output. (Pillitteri;2007: 643) Patient confirms she has been drinking 1 glass of fluid an hour. Knows to drink 6 to 8 glasses of fluid daily.

4. Discuss importance of emptying bladder.

5. Stress importance of drinking extra water during postpartum period.

6. Teach normal physiologic changes that occur after birth and the importance of preventing complications such as urinary retention or thrombophlebitis. 7. Instruct patient to do Kegel exercises once voiding pattern is reestablished.

The more informed patients are, the more they can participate in self-care. (Pillitteri;2007: 643)

Kegel exercises help strengthen perineal muscle. (Pillitteri;2007: 643)

S- “Unsa diay ang dapat kan-on kay nidaot man ko”, as verbalized by the patient.

Imbalanced nutrition, less than body requirement s, related to lack of knowledge about

The postpartal period is a time of rebuilding and readjusting, for which a woman needs both ample nourishment

After 8 hours of nursing interventions, the patient will be able to acquire basic knowledge regarding her body’s nutritional requirements.

Nursing Action: Render nursing measures helpful in promoting a balanced nutrition of the patient.

Appropriate measures will be implemented to provide knowledge regarding proper nutrition.

Goal met as evidenced by: Patient was able to show understandings about importance of

O-sleepy - looks tired -weighs 90 lbs -5’0” in height -conscious -BMI is 18.2

postpartal needs.

and adequate fluid intake. Most mothers are hungry during the immediate postpartal period and consume an adequate diet without urging. . (Pillitteri;2007:
641)

The patient will be able to:

Nursing Orders: Patients may be unaware of their actual weight and height or weight loss. (Gulanick;2007
:135)

1. Document actual a. Verbalize height and understandings weight. about the importance of proper nutrition. b. Identify interventions to promote a 2. Obtain nutritional balanced history; include nutrition. family, significant others, or c. Demonstrate caregiver in techniques assessment. and lifestyle changes to 3. Monitor or promote explore attitudes proper toward eating nutrition. and food.

proper and balanced nutrition.

The patient’s perception of actual intake may differ. (Gulanick;2007
:135)

Many psychological, psychosocial, and cultural factors: determine the type, amount, and appropriateness of food consumed. (Gulanick;2007
:135)

4. Encourage to take foods, which is high in protein, vitamins and minerals.

These nutrients are needed for good tissue repair. (Pillitteri;2007:
641)

5. Encourage to have an adequate supply of roughage.

It is important to help restore the peristaltic action of the bowel. (Pillitteri;2007:
641)

6. Suggest liquid drinks for supplemental nutrition.

Such supplemental can be used to increase calories and protein without interfering with voluntary food intake. (Gulanick;2007
:136)

These may 7. Discourage decrease beverages that are caffeinated or appetite and

carbonated.

lead to early satiety. (Gulanick;2007
:136)

8. Encourage exercise.

Metabolism and utilization of nutrients are enhanced by activity. (Gulanick;2007
:137)

9. Discuss the importance of maintaining adequate caloric intake and the four basic food groups, as well as the need for specific minerals and vitamins.

Patients may not understand what is involved in a balanced diet. They are better able to ask questions and seek assistance when they know basic information. (Gulanick;2007
:137)

S- “Malipong ko inig lakaw nako”, as verbalized by the patient. O-sleepy - looks tired -generalized weakness noted -with the following vital signs: T-36.5 0C P-75bpm R-20cpm BP-110/70 mmHg

Activity intolerance related to stress during labor and birth.

By the time the date of birth approaches, a woman is generally tired from the burden of carrying so much extra weight with her. In addition, most women do not sleep well during the last month of pregnancy. Near the pregnancy, she probably was unable to find comfortable position in bed because of the fetus’ activity or the presence of back or leg

After 8 hours of nursing interventions, the patient will be able to tolerate activities within level of own ability. The patient will be able to: a. Identify negative factors affecting performance. b. Adapt lifestyle to increase energy level. c. Verbalize understanding of potential loss of ability in relation to existing condition.

Nursing Action: Render nursing measures helpful in increasing energy level of the patient to tolerate activities within level of own ability. Nursing Orders: 1. Assess sleep patterns and note changes in thought process.

Appropriate measures will be implemented to increase energy level.

Goal met. Patient was able to tolerate activities within level of own ability as evidenced by:

Multiple factors can aggravate fatigue, including sleep deprivation, emotional distress, side effects of medication, and progression of disease process. (Doenges;2002
:

Patient answered to the question asked and identified factors aggravating fatigue.

87)

2. Assess the patient’s level of

This aids in defining what

pain. All d. Develop an during labor, activity and she has eaten rest pattern very little, if that promotes anything, and optimal has worked independence very hard with and minimizes little or no fatigue. sleep. (Pillitteri;2007:
510)

mobility.

the patient is capable of, which is necessary before settling realistic goal. (Gulanick;2007
:8)

3. Monitor patient’s sleep pattern and amount of sleep achieved over the past few days.

Difficulties sleeping need to be addressed before activity progression can be achieved. (Gulanick;2007
:8)

4. Encourage patient to do whatever possible like self-care and sit in chair.

Provides for sense of control and feeling of accomplishment. (Doenges;2002
:

Patient can sit and can do tooth brushing by herself.

83)

5. Suggest that the client perform

Shorter activity Patient periods moves slowly

activities more slowly and for shorter times, resting more often, and using more assistance as required.

performed and rest more more slowly often. and more frequent rest periods promote optimal performance and achievement levels. (Doenges;2002
:

87)

6. Encourage proper nutritional intake.

Necessary to meet energy needs for activity. (Doenges;2002
:

Patient eats the right kind and nutritious foods.

83)

7. Plan time to be with the patient, and listen actively to the client’s concern.

Appropriate assistance ensures safety. (Kozier;2002: 908)

Patient verbalizes what are her concerns on her condition to the nurse.

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