Scientific

Assessment Diagnosis Planning Intervention Rationale Evaluation

explanation
S=Ø Impaired Placenta previa After hours of Assess vital Provides baseline After hours of
O= fetal gas is the nursing signs q 15 data on the maternal nursing
Changes in exchange r/t development of interventions, minutes blood loss interventions,
fetal heart altered placenta in the the pt. will the patient was
rate or blood flow lower uterine verbalize Systemic rest is able to
activity and segment understanding Maintain bed mandatory and verbalize
decreased partially or of causative rest or chair rest important throughout understanding
Release of surface completely factors and when indicated. al phases of dse. to of causative
meconium area of gas covering the appropriate Provide frequent reduce fatigue, and factors and
exchange at internal interventions. rest periods and improve strength. appropriate
Slight the site of cervical os. uninterrupted interventions.
change in placental The cause is night time sleep. Provide objective
vital signs detachment. unknown but a evidence o bleeding.
except for possible theory Monitor amt.
the BP states that the and type of To promote placental
embryo will bleeding. perfusion.
implant in the
lower uterine Position the Prevents tearing of
segment if the mother on her placenta if placenta
deciduas in the left side. previa is the cause of
uterine fundus bleeding.
is not Restrict vaginal
favorable. examination.
Complications Assess whether labor
are immediate is present and fetal
hemorrhage, status and external
shock and system avoids
maternal Monitor fetal cervical trauma.
death; fetal contractions and
mortality and fetal heart rate Support mother and
post partum by external child bonding.
hemorrhage. monitor.

.
Provides adequate
Monitor positive fetal oxygenation
attitude about despite of lowered
fetal outcome. maternal circulating
volume.

Administer
oxygen as
indicated
 Scientific
Assessment Diagnosis Outcomes Nursing Intervention Rationale Evaluation
explanation
S- Ø Fluid Volume Fluid volume After hours of Assess color, odor, Provides Pt. has no further vaginal
Deficient r/t deficient is a state nursing consistency and information about bleeding; Blood pressure is
O- Active Blood in which an intervention amount of vaginal active bleeding maintained at at least 100/60
Bleeding Loss individual is and medical bleeding; weigh pads versus old blood, mm Hg; PR <100 bpm; fetal
Episodes Secondary to experiencing assistance, Pt. tissue loss and HR is maintained at 120-160
(amount, Disrupted decreased will exhibit degree of blood bpm; UO >30ml/hr.
duration) Placental intravascular, signs of Assess hourly intake loss
Facial Grimace Implantation interstitial and/or adequate fluid and output.
due of Pain or intracellular fluid. balance during
no complaint of Active Blood Loss pregnancy. Provides
pain or Hemorrhage information about
Abdomen due to disrupted Assess baseline data maternal and fetal
soft/hard when placental and note changes. physiologic
palpated implantation Monitor FHR. compensation to
Manifest Body during pregnancy blood loss
Weakness may manifest
Low BP signs and Assessment
Increased HR symptoms of fluid provides
Decreased RR vol. deficient that information about
Fetal HR >120- may later lead to Assess abdomen for possible infection,
160 bpm hypovolemic tenderness or rigidity- if placenta previa or
Decreased shock and cause present, measure abruption. Warm,
Urine Out maternal and fetal abdomen at umbilicus moist, bloody
Increased Urine death. (specify time interval) environment is
Concentration ideal for growth of
Pale, Cool Skin Assess SaO2, skin microorganisms.
Increased color, temp, moisture,
Capillary Refill turgor, capillary refill Detecting
(specify) (specify frequency) increased in
Lab. Results measurement of
Assess for changes in abdominal girth
LOC: note for suggests active
complaints of thirst or abruption
apprehension

Assessment
Provide supplemental provides
O2 as ordered via information about
facemask or nasal blood vol., O2
cannula @ 10-12 L/min. saturation and
peripheral
perfusion
Initiate IV fluids as
ordered (specify fluid To detect signs of
type and rate). cerebral perfusion

Position Pt. in supine Intervention

with hips elevated if increases
ordered or left lateral available O2 to
position. saturate
decreased
hemoglobin

Monitor lab. Work as

obtained: Hgb & Hct,
Rh and type, cross For replacement
match for 2 units RBCs, of fluid vol. loss
urinalysis, etc.
Scheduled for
ultrasound as ordered.

Determine if Pt. has any Position

objections to blood decreases
transfusions- inform pressure on
physician. placenta and
cervical os. Left
lateral position
improves
Administer blood placental
transfusion as ordered perfusion
with client consent.
Monitor closely for Lab. Work
transfusions reaction provides
information about
degree of blood
loss; prepares for
possible
Provide emotional transfusion. Ultra
support; keep Pt. and sound provides
family informed of info about the
findings and continuing cause of bleeding
plan of care.
Pt. may have
Administered prenatal religious beliefs
vitamins and iron as related to
ordered: provide a diet accepting blood
high in iron: lean meats, products
dark green leafy
vegetables, eggs, and
whole grains.

Prepare Pt. for To provides

cesarean birth if replacement of
ordered when severe blood components
hemorrhage, abruption, and volume
complete previa at term
is already experience. To prevent for
Potentially life-
threatening
allergic reaction
may result from
incompatible
blood

Support and
information
decrease anxiety
and help Pt. and
family to anticipate
what might
happen next.

Proper diet and

vitamins replace
nutrient losses
from active
bleeding to
prevent anemia-
iron is a
necessary
component of
hemoglobin

Cesarean Birth
may be necessary
to resolve the
hemorrhage or
prevent fetal or
maternal injury.
 Scientific
Assessment Diagnosis Planning Intervention rationale evaluation
explanation
S- Ø Anxiety Vague uneasy After hours of Establish rapport. To gain the trust and After hours of
O- feeling of discomfort nursing intervention Provide reassurance cooperation of the nursing intervention
Elevated BP, P, R or dread the pt. will and comfort. patient. the manifested
Insomnia accompanied by an Demonstrate a decreased anxiety
autonomic decrease in anxiety Monitor vital signs. Identify physical AEB reduced
Restlessnes response; a feeling A.E.B. reduction in responses presenting
of apprehension presenting associated with both manifestations of
Dry mouth caused by physiological, medical and anxiety and the pt.
anticipation of emotional, and/or emotional was able to
Dilated pupils danger. It is an cognitive conditions. verbalize a relief
altering signal that manifestations of from anxiety.
Frequent urination warns of impending anxiety; and
danger and enables verbalization of relief
Diarrhea the individual to of anxiety. This can point to the
take measures to Observe the clients clients level of
Patient complains of deal with threat. behavior. Note any anxiety.
apprehension, unusual activities.
nervousness,
tension This may point to
physiological source
Inability to of anxiety.
concentrate Review results of
diagnostic test.
Shaking
It may interfere with
ability to deal with
problem.
Be aware of defense
mechanisms that the To determine those
pt. manifests. that might be helpful
in the current
circumstance.
Review coping skills
that was used in the
past.
Helps client to
identify what is
reality based.

Provide accurate To provide ongoing

information about and timely support.
placenta previa.

List available
resources or persons,
including hotlines or Useful for being
crisis managers. prepared in dealing
with anxiety
provoking situation.
Review strategies,
such as role playing,
use of visualizations Helps to manage
to practice the pt. experiencing
anticipated events. anxiety.

Administer anti-
anxiety
drugs/sedatives, as Helps minimize side
ordered. effects of drugs that
may aggravate the
condition.
Review medications
regimen and possible
interactions,
especially with OTC
drugs/alcohol, and so
forth. Discuss
appropriate drug
substitutions,
changes in dosage or
time of dose.
 Nursing Scientific
Assessment Planning Intervention Rationale Evaluation
diagnosis explanation
S-Ø Activity Intolerance Insufficient After hours of Evaluate actual and Provides After hours of
O- r/t Enforced Bed physiological or nursing perceived limitations comparative nursing intervention
Weakness or fatigue Rest During psychological intervention the pt. of deficient in light of baseline and the Pt.’s vital signs
Pregnancy energy to endure or will demonstrate a unusual status. provides have returned to
Exertional discomfort or Secondary to complete required decrease in information about normal range and
dyspnea Potential for or desired daily physiological signs needed manifested
Hemorrhage activity. of intolerance AEB interventions decreased
Abnormal heart rate or normal range of regarding quality of physiological signs
blood pressure in pt.’s vital signs. Monitor vital or life. of activity
response to activity cognitive signs, intolerance.
watch for changes of Provides baseline
Electrocardiographic blood pressure, data to detect the
changes reflecting heart and respiratory changes due to
arrythmias or ischemia rate; note skin pallor intolerance.
and cyanosis and
the presence of
confusion.

Adjust activities.
Reduce intensity
level of activity or Prevents the pt.’s
discontinue activities overexertion.
that cause undesired
physiological
changes.

Increase exercise
levels gradually,
such as stopping to Preserves
rest for 3 mins. conservation of
during a 10-minute energy.
walk or sitting down
to brush hair instead
of standing.

Provide positive
atmosphere while
acknowledging Helps minimize
difficulty of the frustration and
situation of the client. rechannel energy.

Assist with activities

and provide clients’
use of assistive Protects the client
devices. from injury.

Promote comfort
measures and
provide relief of pain. Gives the chance
for the client to
enhance ability to
Provide to other participate in
disciplines, such as activities.
O/PT, exercise
physiologist or To develop
psychological individually
counseling. appropriate
therapeutic
Give client regimens.
information that
provides evidence of
daily progress. Sustains clients
motivation.
Provide/monitor
response to
supplemental
oxygen and Assess if the client
medications and is responding to
changes in treatment the tx.
regimen.
 Nursing Scientific
Assessment Planning Interventions Rationale Evaluation
diagnosis explanation
S-Ø Fear r/t Threat Response to After hours of Ascertain Fear is a
to Maternal perceived nursing clients’s defensive
O- and Fetal threat that is interventions the perception of mechanism in
Diminished Survival consciously pt. will display what is occurring protecting
productivity Secondary to recognized as appropriate and how it affects oneself but, if left
Excessive danger. range of feelings life. unchecked, can
Increased Blood Loss and lessened become
alertness fear. disabling to the
client’s life.
Increased
pulse; vomiting; Identify sensory Identify if this
diarrhea; deficits that may affects sensory
muscle be present, such reception and
tightness as vision/hearing interpretation of
impairment. the environment.
Increased RR;
dyspnea Stay with the
client or make Providing client
Increased BP; arrangements to with
pallor have someone usual/desired
else be there. support persons
Increased can diminish
perspiration and Acknowledge feelings of fear.
pupil dilation. normalcy of fear,
pain, despair, Promotes
and give attitude of caring,
“permission” to opens door for
express feelings discussion about
appropriately. feelings and/or
addressing
Modify reality of
procedures, if situation.
possible.
Limits degree of
stress, avoids
overwhelming
Promote client the fearful
control, where individual.
possible, and
help client Strengthens
identify and internal locus of
accept those control.
things over which
control is not
possible.

Explain
procedures
within the level of Prevents
client’s confusion or
understanding overload of
and handle. information.

Review use of
antianxiety
medications and To check for
reinforce as correct treatment
prescribed. and to assess
efficiency of tx.
 Post-operative NCP
ASSESSMENT DIAGNOSIS PLANNING INTERVENTION RATIONALE OUTCOME
Subjective: Acute pain r/t STG: Independent: Goal met. After
“Sobrang sakit,” as disruption of skin After 1-2hr of 2hrs of nursing
verbalized by the and tissue nursing - Established rapport. -To have a good intervention, the
patient. secondary to intervention, nurse-client patient verbalized
cesarean section. patient will relationship pain decreased
Objective: verbalize decrease - Monitored vital signs. from a scale of
-Pain scale= 8/10 intensity of pain -To establish a 8/10 – 3/20 as
-Teary eyed from 8/10 to 3/10. - Assessed quality, baseline data evidenced by
-(+) guarding characteristics, severity of (-) facial grimace
behavior pain. -To establish (-) guarding
-(+) facial grimace baseline data for behavior.
-Irritable comparison in Frequent small
-Pale palpebral making evaluation talks with
conjunctiva and to assess for significant others
-Skin warm to touch - Provided comfortable possible internal
-V/S taken as environment – bleeding.
follows: changed bed
BP= 110/80 linens and turned -Calm
PR= 80 on the fan. environment helps
RR= 22 to decrease the
T= 37.6 anxiety of the
- Instructed to put pillow on the patient and
abdomen when coughing promote
or moving. likelihood of
decreasing pain.

- To check for
diastasis recti and
protect the area of
the incision to
improve comfort.
And to initiate
nonstressful
- Instructed patient to do deep muscle-setting
breathing and coughing techniques and
exercise. progress as
tolerated, based
on the degree of
separation.
- Provided diversionary
activities. Initiate ankle - For pulmonary
pumping, active lower ventilation,
extremity ROM, and especially when
walking exercising, and to
relieve stress and
Collaborative: promote
- Administer analgesic as per relaxation.
doctor’s order.
- To promote
circulation,
prevent venous
stasis, prevent
pressure on the
operative site.

-Relieves pain felt

by the patient

ASSESSMENT DIAGNOSIS NURSING PLANNING INTERVENTION RATIONALE EVALUATION

ANALYSIS
Subjective: Risk for Due to an STG: Independent
- none infection elective After 4 hours -Monitor vital -To establish a Patient is
related cesarean of nursing signs baseline data expected to be
Objective: inadequate section, intervention, free of
- dressing dry primary patient’s skin patient will be -Inspect dressing infection, as
-Moist from
and intact defenses and tissue able to and perform evidenced by
drainage can be
-V/S taken as secondary to were understand wound care normal vital
a source of
follows: surgical mechanically causative signs and
infection
T: 37.3 incision interrupted. factors, - Monitor white absence of
P: 80 Thus, the identify signs blood count (WB purulent
- Rising WBC
R: 19 wound is at of infection drainage from
indicates body’s
BP: 120/80 risk of and report wounds,
efforts to combat
developing them to health incisions, and
pathogens;
 infection. care provider normal values: tubes.
accordingly. 4000 to 11,000
mm3
LTG: - Monitor Elevated
After 2-3 days temperature, -these are signs
of nursing Redness, of infection
intervention, swelling,
patient will increased pain, or
achieve timely purulent drainage
wound at incisions
healing, be -Friction and
free of - Wash hands and running water
purulent teach other effectively
drainage or caregivers to remove
erythema, be wash hands microorganisms
afebrile and before contact from hands.
be free of with patient and Washing between
infection. between procedures
procedures with reduces the risk
patient. of transmitting
pathogens from
one area of the
body to another

- Encourage fluid - Fluids promote

intake of 2000 ml diluted urine and
to 3000 ml of frequent
water per day emptying of
(unless bladder; reducing
contraindicated). stasis of urine, in
turn, reduces risk
of bladder
infection or
urinary tract
infection (UTI).
- Encourage
coughing and
- These
deep breathing;
measures reduce
consider use of
stasis of
incentive
secretions in the
spirometer.
lungs and
bronchial tree.
When stasis
occurs,
pathogens can
cause upper
respiratory
infections,
Independent:
including
- Administer
pneumonia.
antibiotics

-Antibiotics have
bactericidal effect
that combats
pathogens
NURSING
ASSESSMENT PLANNING INTERVENTIONS RATIONALE EVALUATION
DIAGNOSIS
Objective Cues:
 Patient Risk for Short Term Goal: INDEPENDENT After 8º of nursing
has not constipation r/t INTERVENTIONS: interventions, the
yet post pregnancy Within 8º of  Ascertain  This is patient was able
eliminated 2° cesarean nursing normal bowel to to identify
since section interventions, the functioning of determi measures to
delivery patient will be the patient, ne the prevent infection
 Absence able to about how normal as manifested by
of bruit demonstrate many times a bowel client’s
sounds behaviors or day does she pattern verbalization of:
 Normal lifestyle changes defecate “Iinom ako ng
pattern of to prevent  Encourage  To maraming tubig at
bowel has developing intake of foods increas kakain ng prutas
not yet problem rich in fiber e the para makadumi
returned such as fruits bulk of ako.”
the
stool
Long Term Goal: and
 Promote facilitat
Within 3 days of adequate fluid e the
nursing intake. passag
interventions, the Suggest e
patient will be drinking of through
able to maintain warm fluids, the
usual pattern of especially in colon
bowel functioning the morning to  To
stimulate promot
e moist
 peristalsis soft
 Encourage stool
ambulation
such as
walking within
individual limits
 To
 However, stimula
since she has te
had cesarean, contrac
also tions of
encourage the
adequate rest intestin
periods es and
prevent
COLLABORATIVE: post
operati
 Administer ve
bulk-forming complic
agents or stool ations
softeners such  To
as laxatives as avoid
indicated or stress
prescribed by on the
the physician cesare
an
incision
/
wound

 To
promot
e
defecat
ion