CUES HEALTH FAMILY GOAL OF OBJECTIVES OF NURSING METHOD RESOURCES CRITERIA STANDARD METHOD/

PROBLEM NURSING CARE CARE INTERVENTIO OF NURSE- REQUIRED TOOL

PROBLEMS N FAMILY
CONTACT

SUBJECTIVE: PRE- After 1 week of After 1 week of 1.Introduce self Home Visit, Material
ECLAMPSIA family nurse family nurse contact, and explain the and parent’s Resources:
AS A contact, the the family will: purpose of the class a. Visual aids,
Mrs. Light HEALTH family especially visit. and possibly,
verbalized “Pero DEFICIT Mrs. Light will: re-agents, test Verbal 1.Briefly explain the Interview
diri man ako I. Inability to 1.Recognize pre- 1.Briefly explain the 2.Establish rapport tubes, burner, Feedback disease process of
Ma’am nakakaabat recognize the eclampsia as a disease process of test tube holder, Preeclampsia.
hin maski ano labot presence of the health deficit Preeclampsia. 3.Prepare the bottles, if
la han pirme pag- condition due to: necessary urinalysis will a. Briefly explain,
ulol han ak ulo a. Briefly explain, materials needed be done by the Verbal in at least two Interview
ngan tangkugo. in at least two such as visual aids, nurse. Feedback sentences the signs
Waray la ako a. lack of sentences the signs handouts, PHN and symptoms of
mapakadto ha knowledge and symptoms of bag, etc. b. PHN Bag Pre-eclampsia.
sentro ka na-iilob Pre-eclampsia. with complete
ko man an sakit. 4.Give health contents for
Labot la ha amon teachings to Mrs. vital signs
pamilya puro man Light and the
gud normal it family c. Time and
paganak, salit effort of the
waray kabarak-an, a. Discuss the nurse and the
hereditary ngan disease process, family
kina-iya han amon and the signs and members
pamilya it panganak symptoms of pre-
hin normal.” eclampsia Financial
Resources:
b. Discuss the Transportation
importance of expenses of the
Complained of
early detection and nurse and the
persistent severe
management of family.
headache.
pre-eclampsia
She never had a Additional
prenatal check-up is finances for the
because of the 5. Introduce pre-natal
scarce financial methods on how to check-ups
resources and that screen or detect
she do not know manifestations of
where to go. She is pre-eclampsia
not even aware that
such service (pre-
natal) is being II. Inability to 2.Take the 2. Briefly explain the 5. Assess Mrs. Clinic visit Verbal 2. Briefly explain the Interview/
offered in the health provide necessary consequences/ Light’s condition: Feedback/ consequences/ Direct
center which is 5-7 adequate measures to complications that a. Take the client’s Compliance complications that Observation
km away from their nursing care to a prevent or may occur if vital signs with agreed may occur if
home. pregnant properly manage management is not (Temperature, BP, upon management is not
member due to: pre-eclampsia acted upon and PR and RR) intervention acted upon and
Objective: implement implement
appropriate nursing b. Prepare Head to appropriate nursing
BP is 140/90 care: Toe assessment care:
mmHg with slight
pedal edema a. Lack of a. Enumerate at least c. Take the EDC, Verbal a. Enumerate at least Interview
G7P5 (1-1-5-0); at knowledge on the (3) consequences/ AOG and perform Feedback (3) consequences/
present is on the nature and complications that Leopold’s complications that
31st weeks AOG. management of may occur if maneuver may occur if
All of her deliveries health condition management is not (including the management is not
were assisted by an acted upon. FHT and fundal acted upon.
untrained traditional height)
birth attendant b. Briefly explain, Verbal b. Briefly explain, Interview
b. lack of 6. Broaden the Feedback
(partera) in at least two in at least two
knowledge on the knowledge of the
sentences the disease sentences the disease
nature extent of family on
process of Pre- process of Pre-
nursing care complications of
eclampsia and its eclampsia and its
needed pregnancy,
corresponding corresponding
complications. specifically: complications.

3.Implement agreed- a. Discuss the Compliance 3.Implement agreed- Direct

upon health actions implications of with agreed upon health actions Observation
for Mrs. Light the signs and upon for Mrs. Light
especially in the symptoms intervention especially in the
areas of: presented by Mrs. areas of:
a. laboratory work- Light a. laboratory work-
up up
b. nutrition /diet b. Discuss the b. nutrition /diet
c. physical activity consequences of c. physical activity
d. rest and sleep failure to take d. rest and sleep
e. general hygiene appropriate action e. general hygiene
on the problem
7. Prepare pre-
natal care/health
education
a. Encourage
laboratory
examinations that
are provided from
community health
resources such as
urinalysis
b. For nutrition,
recommend and
discuss the
appropriate
nutrition for
pregnancy (e.g.
foods rich in iron
and folate)
c. Encourage
adequate sleep and
rest
e. Discuss the
proper self-care
hygiene, such as
dental care, breast
care, bathing,
perineal care,
clothing
f. Discuss and
encourage the
importance of
preparation for
child birth and
parenthood
g. Discuss the
importance of
 breastfeeding
including the
nutrition of the
lactating woman
and proper breast
feeding positions.

III. Inability to Utilize the 4. Identify facilities 8. Require Clinic visit Verbal 4. Identify facilities Interview
utilize resources needed health of care that gives admission to a Feedback of care that gives
for health care resource that are treatment and health care facility treatment and
due to: available in the services of care to for immediate services of care to
health care pregnancy e.g. attention to prevent pregnancy e.g.
a. Lack of facilities barangay health further barangay health
knowledge of complication
centers, RHU, centers, RHU,
community brought by Pre-
Birthing Clinics Birthing Clinics
resources for eclampsia
health care
9. Discuss with the 5.Ensure that Mrs.
5. Ensure that Mrs. Light will have
Light will have family the courses Compliance Record
of action open to with agreed regular prenatal Review
regular prenatal check-up at the
check-up at the them, and the upon
consequences of the intervention clinic.
clinic.
health actions on
the family.