Prepare a comprehensive nursing care plan that will address the priority problems of this client (no less

than 2 actual problems and 2 potential problems).

SUBJECTIVE / NURSING DIAGNOSIS RATIONALE GOALS / OBJECTIVES NURSING SCIENTIFIC EVALUATION

OBJECTIVE DATA INTERVENTIONS RATIONALE CRITERIA

Objective Data: Imbalanced nutrition: Patient is not receiving Short-Term Take nutritional history Knowing the foods At the end of the nurse-
• Height: 5’1 less than body adequate nutrition. After an hour or two of consumed by the patient patient interaction:
• Present weight: 165 requirements related to Although she was nurse-patient interaction: could provide more • the patient expressed
lbs (obese) inability to procure showing signs of weight • The patient will be information that caused that she should
Subjective Data: adequate amounts of gain which is normal able to show her current health consume nutritious
• Patient noticed that food during pregnancy during pregnancy, it understanding on the problems foods so that her body
her eating habits became unstable importance of can maintain
become irregular because her night shift adequate nutrition Look for physical signs of Assess risk factors that appropriate functions
• Patient noticed that schedule at work during pregnancy poor nutritional intake can cause further and to supply the
she is not resulted her to have • The patient will be complications so that needs of her baby
maintaining a stable irregular eating habits, able to determine immediate intervention • the patient verbalized
weight gain thus, a nutrition less than foods that are can be provided nutrient-dense foods
• Irregular sleep-wake her body requirements. nutritious and that she can buy and
time due to evening available for her Evaluate the type of Categorizing foods and consume around her
work shift starting a Long-Term consumed foods and the their frequency of area
month ago At the next prenatal visit frequency of each consumption by the • At the next visit:
after a month-long consumption patient could narrow o Patient showed a
interval: down the cause of her healthy state in her
• The patient will be problems and if it's overall functions.
able to show no contributing to her o A stable weight gain
signs of malnutrition diabetes that is preferable for
• The patient will be the course of 1
able to achieve a Individualize a mealtime Because the patient month was
stable and preferred schedule while works on night shift, achieved.
weight gain considering the activity specify the time when
time of the patient. she should take her
meals and to make it
regular for adequacy of
intake.

If possible, encourage It is still ideal and optimal

the patient to inquire with for a pregnant woman to
her manager about the have regular activities,
change of work shift. particularly eating, on
day than at night
 because of the circadian
rhythm of the body.

Recommend nutrient- Nutrient-rich foods are

dense foods with an beneficial for both the
additional 300 calories mother and the fetus. An
that are easily accessible additional 300 calories
and affordable to the will provide the nutrition
patient. needed by the fetus.
Adequate consumption is
necessary so it has to be
easily accessible.

Encourage mid-range A sedentary work such

exercises like walking as being a cashier
from time to time results in decreased
body metabolism. As a
counteractive measure,
such an exercise is
necessary.

Refer to a dietician for For a complete

complete nutrition assessment of the
assessment specificities such as the
daily calorie intake of the
patient, a dietician’s role
is essential.

Since the patient is

Administer insulin, as diagnosed with diabetes,
ordered insulin therapy is
provided so that she can
metabolize enough
glucose.
SUBJECTIVE / NURSING DIAGNOSIS RATIONALE GOALS / OBJECTIVES NURSING SCIENTIFIC EVALUATION
OBJECTIVE DATA INTERVENTIONS RATIONALE CRITERIA

Objective: Deficient knowledge Knowledge deficit may Short Term 1. Explain to the mother 1. Explaining to the At the end of the nurse-
• Glucose challenge related to a therapeutic be present as the mother After 12 hours of nurse- how insulin therapy mother the importance of patient interaction:
test and OGTT regimen necessary is to perform a procedure patient interaction: works on her blood the therapeutic regimen • The patient has
results revealed during pregnancy that she has no • The patient is able to glucose and its that needs to be done verbalized the
elevated plasma experience with. restate to the nurse importance: contributes to the importance of
glucose levels the importance of Insulin is necessary for adherence of the patient performing insulin
• Patient diagnosed to performing the the cells to take glucose to the treatment therapy and regularly
have gestational insulin therapy and from the bloodstream. monitoring her blood
diabetes mellitus blood glucose Insulin therapy is needed glucose levels
• Patient was started monitoring to control the blood • The patient has return
on insulin treatment • The patient is able to glucose levels of the demonstrated to the
return demonstrate mother nurse the process of
to the nurse the insulin therapy and
process of insulin blood glucose
therapy and blood 2. Demonstrate, or assist 2. As it is necessary for monitoring that she is
glucose monitoring the doctor in the the patient to have to perform at home
demonstration of insulin insulin therapy at home,
Long Term therapy to the mother. she should be able to As the patient returns for
The blood glucose levels Ask the mother to return perform how the check-up:
of the mother would be demonstrate the procedure is done • The record of the
kept controlled procedure afterwards. blood glucose levels
throughout the Short-acting insulin may of the patient shows
pregnancy and be used alone or with an that the blood glucose
postpartum. intermediate type levels of the patient
Two thirds of daily insulin has been kept
needs are given before controlled
breakfast and one third
before dinner
Insulin should be given
subcutaneously and at a
90-degree angle to the
skin. The injection site
should generally be the
same each injection
(arms or legs or
abdomen)
3. Demonstrate, or assist 3. This is to ensure that
the doctor in the the patient is able to
demonstration of glucose perform the blood
monitoring to the patient. glucose monitoring that
Ask the mother to return she needs to do at
demonstrate the home.
procedure afterwards.
The patient should obtain
fasting and 1-hour
postprandial values.
Completed 4 times a day
by the patient
The patient pricks her
finger and uses a
glucometer to determine
her blood glucose
She should track these
numbers with a chart and
bring it to her OB visits.
The OB will determine if
any adjustments in her
insulin or oral diabetic
regimen are needed.

4. Educate the mother on 4. This is so that as the

the normal levels of mother monitors her
glucose during blood glucose levels at
pregnancy home, she would be able
to determine if the results
are within the normal
range

5. Encourage the patient 5. The record can be of

to keep a record or
journal of home
assessment of glucose
levels. Diet, general well-
being, exercise and
symptoms experienced
help to the healthcare
providers in assessing
how the blood glucose
levels of the patient are
controlled through the
insulin therapy.
may also be written in Additionally, this may
this record or journal also help in assessing
the overall well-being of
the patient throughout
her pregnancy.

6. Encourage the mother 6. Breastfeeding reduces

to breastfeed her baby the risk of diabetes in
and discuss its benefits both the mother and the
and importance baby

7. Instruct the patient to 7. A woman who has had

undergo glucose testing gestational diabetes is at
during health risk for developing type 2
maintenance visits diabetes later in life.
throughout life Having the blood glucose
regularly checked gives
way for early detection of
Type 2 Diabetes.
SUBJECTIVE / NURSING RATIONALE GOALS / OBJECTIVES NURSING SCIENTIFIC EVALUATION
OBJECTIVE DATA DIAGNOSIS INTERVENTIONS RATIONALE CRITERIA

Subjective: Fluid volume deficit Edema during pregnancy Short Term: Advise the patient to Elevating the lower At the end of the nurse-
• Patient was related to nature of occurs due to the After 30 minutes of elevate the lower extremities will enhance patient interaction, the
previously a work as manifested by increase of aldosterone in nurse-patient interaction, extremities by placing a venous return and reduce patient was able to:
waitress who was presence of edema on order for sodium retention the patient will be able to: pillow underneath the legs. edema formation. • Note the different
transferred to the lower extremities to occur which also leads • Reiterate the health techniques she can
cashier. to water retention. This teachings provided by Instruct the patient to move Moving and using the do to minimize edema
occurs so that the body the nurse around and avoid long muscles of the legs can • Understand the need
Objective: may be able to • Show understanding periods of quiet standing. help promote circulation to follow the nursing
• Patient is 27-28 compensate with the as to why the and allow excess fluid to interventions provided
weeks pregnant increased blood volume following nursing be pumped back to the • Demonstrate the
• (+) edema on lower requirement interventions are heart. interventions given
extremities Edema is also a result done
• (+) GDM from the growing uterus • Demonstrate the Teach the patient how to Upward strokes reduce
which compresses the interventions provided properly massage the legs edema by stimulating As the patient returns for
vena cava. This major with upward strokes. blood flow and fluid her next check-up:
blood vessel allows the Long Term: movement. • The edema found in
return of blood to the • The patient will be the legs of the patient
heart from the legs. able to apply the Advise the patient to wear Wearing comfortable has been minimized
Prolonged periods of nursing interventions comfortable shoes. shoes reduces the • The patient continued
standing can interfere until the end of her pressure placed on the to perform the nursing
with venous blood flow as pregnancy. legs. interventions given to
this adds more pressure her
to the blood vessels. Recommend the use of Compression socks are
compression socks or used to help control the
stockings. swelling of the legs and
feet by preventing the
buildup of fluid in the lower
extremities.

Refer to a nutritionist for The patient may need to

recommendations on the change the food she
patient’s diet intakes to prevent edema
from worsening
SUBJECTIVE / NURSING DIAGNOSIS RATIONALE GOALS / OBJECTIVES NURSING SCIENTIFIC EVALUATION
OBJECTIVE DATA INTERVENTIONS RATIONALE CRITERIA

Objective Data: Risk for fetal injury Excess blood glucose Short term: Monitor fetal heart rate The normal range for At the end of nurse-
• Glucose challenge secondary to elevated passes through the After 30 minutes of fetal movement, and FHR is between 120-160 patient interaction:
test and OGTT maternal blood glucose placenta into the fetal nursing intervention evaluate periodic bpm and accelerates in • Mother was able to
revealed elevated levels circulation. This excess patient will be able to: changes response to maternal show compliance on
plasma glucose in glucose is stored as • Know what is activity, fetal movement the proper diet
levels body fat of the fetus happening to her and and uterine contractions. prescribed to her such
• Patient was thereby leading to understand her Deviance to the normal as avoiding sugary
diagnosed with macrosomia (LGA). current condition range may indicate foods and eating
GDM and currently Large for gestational age • Mother will be able to uteroplacental more vegetables and
on insulin treatment fetuses are vulnerable reiterate possible insufficiency thereby fruits
• Diagnostic tests: for neonatal morbidities effects of GDM on imposing danger • Mother noted the that
o Nonstress test. such as respiratory her newborn presence of fruity
o BPP distress syndrome, Monitor for signs of GDM may be a prelude breath odor, altered
asphyxia, shoulder Long term: pregnancy induced to hypertension due to level of
dystocia, brachial plexus After 24 hours of nurse- hypertension such as the cardiovascular consciousness and
injury, congenital patient interaction: edema, elevated blood changes associated with labored breath
anomalies and • The fetus will be able pressure and proteinuria diabetes. These sounds should be
premature birth. to display reactive diseases may negatively referred immediately
NST impact placental to the doctor
• The mother will have perfusion and fetal status immediately because
a stabilized blood it may put the fetus at
glucose level. Monitor for signs and Ketones in urine and risk
• The fetus will remain symptoms of diabetic presence of fruity breath • The fetus was able to
free from injury and ketoacidosis such as odor may lead to diabetic display reactive NST
in a healthy state ketonuria, fruity breath ketoacidosis which may • The mother showed
odor, altered level of cause permanent CNS normal blood glucose
consciousness and fetal damage or even levels
labored breath sounds fetal death • The fetus remained
free from injury
Educate patient about It is essential to control
the importance of blood glucose levels
adhering to prescribed during pregnancy to
diabetic treatment. prevent complications for
both the mother and the
baby
Provide information on Informing about the
the possible effects of possible effects may help
gestational diabetes the mother make sound
mellitus on fetal growth decisions about the case
and may even increase
their cooperation

Provide information Letting the mother know

about the rationale and that NST and BPP will be
procedures of NST and done to know the fetal
BPP status may increase her
cooperation

Assist in BPP, NST and Assessing the

ultrasonography as biophysical profile and
necessary non-stress test provides
the status of fetal well-
being

Review the patient’s Having a proper and

current diet and well-balanced diet and
nutritional needs and providing nutritional
collaborate with needs of the mother
nutritionist for change of ensures stable blood
diet glucose levels thereby
providing the needs of
the fetus