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NURSING CARE PLAN

Name of Patient: _____Kadija_______________ Agency/ Area: _______________________

Diagnosis: ______________ Rating: ________________

ASSESSMENT
SUBJECTIVE OBJECTIVE

 Appears well nourished and is carefully groomed. English is


second language but she understands some. Daughter who is
 Her last menstrual period was May 28th of the year with present with her mom is well groomed and speaks English.
 Gravida 9 Para 7
 Skin: Dark tan in color, surface smooth, small scaring on left arm
an EDD of March 5th of next year making her 11 weeks and both legs. No lesions or tattoos
 Mouth: Poor dentition, oral mucosa pink, sore gum hypertrophy.
Thyroid gland small and smooth
 “She had a female circumcision as a child”
 Chest: Expansion equal, respiration effortless. Lung sounds clear
bilaterally with no adventitious sounds. No CVA tenderness
 “She is having nausea with occasional vomiting”  Heart: 84 bpm, regular rhythm, S1 and S2 are normal, not
accentuated or diminished, with soft, blowing systolic murmur
Gr iilvi at 2nd left interspace.
 “ Experienced pink vaginal spotting”  Breast: Tender, no masses, large everted nipples, no drainage
present. Breast self-exam reviewed.
 Abdomen: No masses, bowel sounds present in four quadrants.
No hepatomegaly or splenomegaly. Uterus non palpable. No
inginal lymphadenopathy noted. No healed incisions noted.
 Extremities: No loer extremity varicosities, edema or redness
notd. Negative Homan sign. 1+ DTRs. BP 124/76 mm Hg.
 Pelvic: Pubic arch wide: side walls straight, spines blunt
interspinous diameter >12 cm. biter bituberous diameter > 8cm.
Spacious, proven, gynecoid pelvis to 8 pounds

No

Nausea and vomiting related to symptoms in Pregnancy

SCIENTIFIC EXPLANATION

Possible causes include high levels of hormones, blood pressure fluctuations.

PLANNING
GOAL DESIRED OUTCOME

After 2-3 weeks of following nursing intervention After 2-3 weeks of following nursing intervention
the client will be able to lessen symptoms by 14 the client will be able to lessen symptoms by 14
week of pregnancy week of pregnancy

NURSING IMPLEMENTATION
INTERVENTIONS RATIONALE

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 The nurse will verbalized the client will be able  Following techniques reduces or lessen
to lessen symptoms by 14th week of pregnancy episodes of nausea and vomiting

 Teaching of oral Hygiene due to poor dentition  Oral Hygiene helps alleviate the condition and
facilitates comfort.

 Tell the patient to stay away from foods and  Strong and unpleasant odors can make you
smell that trigger nausea and vomiting feel sick

 Keep track of the patient's hydration, weights,  Nausea is often associated with dehydration,
blood pressure, intake and output, and skin which may cause a patient's hydration state to
turgor. change as a result of fluid depletion.

 Assist the patient in preparing for medical  To identify the contributing factor, a series of
tests. tests can be used.

EXPECTED OUTCOME/ EVALUATION

After 2-3 weeks of following nursing intervention the client will be able to lessen symptoms by 14 week of
pregnancy

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