Cues Nursing Scientific Planning Nursing Rationale Evaluation

Diagnosis Explanation Intervention

Deficient fluid HYPEREMESIS LONG TERM >Assess V/S, >To have baseline
Subjective: volume related to GRAVIDARUM GOAL: noting low blood comparison of
vomiting as After 2 days of pressure, rapid data.
Objective: manifested by dry nursing care, the heartbeat.
>dry mucous mucous client will be able
membrane membrane High level of HCG to: >Note complaints
>dry skin secondary to >Correct the fluid and physical signs
>weakness Hyperemesis deficiency as associated with
>decreased urine Gravidarum manifested by: dehydration.
output Prolonged nausea (+) Moist lips and
>elevated Hct and vomiting mouth >Compare usual
(+) Hydration and current
weight.
SHORT TERM
Severe GOAL: >Review
dehydration, After 8 hours of laboratory data.
ketonuria, and nursing >Prevents
significant weight intervention the >Keep fluids within dehydration.
loss client will be able clients reach and
to: encourage
>Maintain fluid frequent intake.
volume at a
Deficient Fluid functional level as >Administer IVF.
volume related to evidenced by
vomiting as urinary output with >Maintain accurate
manifested by dry normal specific I/O and weigh
mucous gravity, stable vital daily. Monitor urine
membrane signs, moist specific gravity.
secondary to mucous
Hyperemesis membrane, good >Monitor V/S
Gravidarum skin turgor and >Provides comfort.
prompt capillary >Provide oral care.
refill. >Pharmacological
>Administer approach.
medications.
Cues Nursing Scientific Planning Nursing Rationale Evaluation
Diagnosis Explanation Intervention
Risk for falls Predisposing LONG TERM INDEPENDENT:
related to cluttered factors: GOAL: 1. Evaluate source >To help the client
environment Cluttered After 1 day of of risk. understand what
environment community duty, she needs to
(+) Throw rocks in the client will be avoid.
the area able to: 2. Assist client in
(+) Slippery roads >Decrease the risk reducing/correctin
when raining for falls and injury g the risk by:
(+) Steep as manifested by >cleaning the >To help minimize
pathways clearer room the risk for falls.
environment and >home
safe for people management
living in their 3. Promote
Low home house. awareness of
maintenance family members on
SHORT TERM home
GOAL: management.
After 30 minutes of
nursing
intervention the
RISK FOR client will be able
FALLS to:
>Verbalize
understanding of
individual risk
factors that can
contribute to
possibility of falls.
>Demonstrate
behaviors, lifestyle
changes to reduce
the risk factors and
protect self from
injury.
>Modify
environment as
indicated to
enhance safety.
>Be free of injury.