Wong, Heather Shane A.

BSN 2F-D

NURSING CARE PLAN

INTERVENTION RATIONALE EVALUATION/EXPECTE
D OUTCOME
DX: STO
 Assess vital signs.  Increased temperature, pulse rate The goal was met.
& decreased BP are signs of - The patient was able
 Assess the patient for dehydration & hypovolemia. to demonstrate
edema, reports of feeling  Edema may mask a true failure to behaviors that
bloated, and benign, gain weight. Weight gain should decrease nausea and
dependent leg edema. reflect maternal and fetal growth, vomiting.
not retained excess fluid.
 Assess the patient's
abdomen every 2 hours  Accurate assessment can help LTO
including size, contour, diagnose various disorders that The goal was met.
and bowel sounds, and cause vomiting, including liver - The patient was able
note pain, tenderness, and disease, kidney infection. to resume a healthy
guarding. diet, yielding a
positive weight gain.
 Record intake and output.  To determine hydration fluids.

TX:
 Give the anti-emetic drugs  To prevent vomiting and maintain
as prescribed. fluid & electrolyte balance.

 Encourage nutrition in
small but frequent  For adequate intake of nutrients
portions. the body needs.

 Advise to avoid fatty,

 spicy foods.
 Maintain fluid therapy.
EDx:
 Teach the patient to use all
prescription and
over-the-counter drugs
with caution, not
exceeding the
practitioner's orders.
 Inform the patient of
medication effects and
adverse effects on her
fetus and herself.
 These foods can stimulate nausea
and vomiting.
 To correct hypovolemia &
electrolyte balance.
 For increased knowledge of the
patient.
 Thorough teaching is required so
the patient can make informed
decisions about recommended
drug therapy and know how to
safely use prescribed drugs.