1.

CUES/ NURSING
Actual Diagnosis: Labor painSCIENTIFIC
related to on and off uterine contraction
OBJECTIVES INTERVENTION RATIONALE EVALUATION
NEEDS DIAGNOSIS BASIS

SUBJECTIVE: Labor pain Sensory and GENERAL: INDEPENDENT:

related to on emotional
“Sakit akong and off experience After 2 days of  Note for vital signs  To monitor if Goals are
tiyan” as uterine that varies effective nursing there are any partially met.
verbalized by contraction from pleasant intervention, the abnormalities Patient were
the patient. to unpleasant, patient will be during pain able to stay
 Encourage/provide  Promotes active and
associated able to verbalize
OBJECTIVE: use of comfort relaxation follows the
with labor and and identify
measures guidelines given.
childbirth. different
VS taken as  Assess client’s  May serve as
positioning to
follow: desire for physical a distraction
ref: NANDA ease the pain
touch with consent and reducing
T: 37.6ᵒC 15th Edition
SPECIFIC: during contraction pain
PR: 105bpm
RR: 24bpm After 12 hours of  Coach use of  Controls the
BP: 140/100 effective nursing appropriate level of
mmHg intervention, the breathing discomfort
SpO2: 99% patient will be technique
able to:  Recommend  Reduces Goals are
patient to void bladder partially met.
 Be able to distention to Patient were
focus on lessen the able to stay
breathing discomfort active and
technique DEPENDENT: follows the
independently guidelines given.
 during  Administer  To promote
effacement medication as pharmacologic
prescribed regimen.
 Exercise  For patient to
patients right to be aware of
medication the
medications
given

CUES/ NEEDS
1. Risk Diagnosis: Risk for fetalSCIENTIFIC
NURSING distress or serious disability related to preterm labor
OBJECTIVES INTERVENTION RATIONALE EVALUATION
DIAGNOSIS BASIS

SUBJECTIVE: Risk for fetal Regular uterine GENERAL: INDEPENDENT:

distress or contractions
“sakit akon serious occurring at After 2 days of  Note for vital  To monitor if
tiyan” as effective nursing there are any Goals are
disability least once signs
verbalized by intervention, the abnormalities partially met.
related to every 10 Patient were able
the patient. preterm labor minutes and patient will be during pain
able to participate  Assess fetal  his will help to stay active and
resulting in follows the
OBJECTIVE: in interventions heart rate and determine the
cervical guidelines given.
that can help any notable fetus’s
VS taken as dilatation or
prevent the changes in fetal condition
follow: effacement
progression of movement. inside the
before 37
weeks' preterm labor and uterus. An
T: 37.6ᵒC
gestation early delivery increase or
PR: 105bpm
decrease in
RR: 24bpm SPECIFIC:
ref: NANDA fetal heart rate
BP: 140/100 can indicate
mmHg After 12 hours of fetal distress
SpO2: 99% effective nursing and may
intervention, the require an
patient will be emergency
able to: cesarean
 Educate the delivery
 Be able to
manage blood patient about
 When the Goals are
pressure interventions that
patient knows partially met.
 The patient can help prevent
and Patient were able
will adhere to the progression
understands to stay active and
the treatment of preterm labor
what is follows the
regimen and and early
happening, guidelines given.
reach at least delivery.
she will be
37 weeks more likely to
gestation adhere to the
 The patient interventions
will deliver a  Encourage bed and treatment
preterm infant rest. regimen.
without any  To reduce
complications DEPENDENT: pressure on
the cervix and
 Administer slow preterm
medication as delivery.
Prescribed
 To promote
 Exercise pharmacologic
 patients right regimen.
to medication
 For patient to
be aware of
the
medications
given
CUES/ NEEDS
1. Psychological Diagnosis: Fear
NURSING related to unknown outcome situation
SCIENTIFIC
OBJECTIVES INTERVENTION RATIONALE EVALUATION
DIAGNOSIS BASIS

SUBJECTIVE: Fear related Response to GENERAL: INDEPENDENT:

to unknown perceived
“Mahadlok ko outcome threat that is After 2 days of  Note for vital  To monitor if Goals are
kay 1st time situation consciously effective nursing signs there are any partially met.
nako” as recognized as intervention, the abnormalities Patient were
verbalized by a danger patient will be able during pain able to stay
the patient to verbalize  Ascertain  Fear is active and
ref: NANDA accurate client’s/significant defensive follows the
OBJECTIVE: 15th Edition knowledge of and other’s perception mechanism in guidelines
sense of safety of what is protecting given.
VS taken as related to current occurring and oneself, but if left
follow: situation how this affects unchecked, it
life can become
T: 37.6ᵒC SPECIFIC: disabling to
PR: 105bpm
client’s life.
RR: 24bpm After 12 hours of
BP: 140/100  Active listening to
effective nursing  To promote
mmHg client’s concerns
intervention, the atmosphere of
SpO2: 99% patient will be able caring and
to: permits
explanation or
 Acknowledge  Speak in simple correction of
and discuss sentences misperceptions
fears,  To facilitates
recognizing understanding Goals are
healthy versus  Acknowledge
partially met.
unhealthy fears normalcy of fear,
 To promote an Patient were
 Demonstrate pain, and despair,
understanding and give attitude of caring able to stay
through use of permission to and opens door active and
for discussion follows the
effective coping express feelings
about feelings guidelines
behaviors and appropriately and
and addressing given.
resources freely
 Provide and reality of
opportunity for situation.
questions and  Enhances trust
 Display
answer honestly and rapport
lessened fear
as evidenced  Provide presence
by appropriate and physical  To soothe fears
range of contact and provide
feelings and assurance
relief of
signs/symptoms
 Goals are
DEPENDENT: partially met.
Patient were
 Administer able to stay
medication as  To promote active and
prescribed pharmacologic follows the
 Exercise regimen. guidelines
patients right to  For patient to be given.
medication aware of the
medications
given

A. Nursing managements, these include:

 encouraging women providing instructions on changing positions

 using deep mouth breathing techniques and exercises
 providing psychological support
 performing sacral massage


B. Medications Once you're in labor, there are no medications or surgical procedures to stop labor, other than
temporarily. However, your doctor might recommend the following medications:

Corticosteroids. Corticosteroids can help promote your baby's lung maturity. If you are between 23 and 34 weeks,
your doctor will likely recommend corticosteroids if you are thought to be at increased risk of delivery in the next
 one to seven days. Your doctor may also recommend steroids if you are at risk of delivery between 34 weeks and
37 weeks.
You might be given a repeat course of corticosteroids if you're less than 34 weeks pregnant, at risk of delivering
within seven days, and you had a prior course of corticosteroids more than 14 days previously.

Magnesium sulfate.
Your doctor might offer magnesium sulfate if you have a high risk of delivering between weeks 24 and 32 of
pregnancy. Some research has shown that it might reduce the risk of a specific type of damage to the brain
(cerebral palsy) for babies born before 32 weeks of gestation.

Tocolytics.
Your health care provider might give you a medication called a tocolytic to temporarily slow your contractions.
Tocolytics may be used for 48 hours to delay preterm labor to allow corticosteroids to provide the maximum benefit
or, if necessary, for you to be transported to a hospital that can provide specialized care for your premature baby.
Tocolytics don't address the underlying cause of preterm labor and overall have not been shown to improve
babies' outcomes. Your health care provider won't recommend a tocolytic if you have certain conditions, such as
pregnancy-induced high blood pressure (preeclampsia)

Exogenous progesterone supplementation is indicated for women at risk for preterm labor and birth.
Specifically, progesterone lowers the risk of preterm labor and birth by maintaining uterine inactivity.

CUES/
2. Actual NURSING
Diagnosis: SCIENTIFIC
Decreased hemoglobin level related to noncompliance of taking prescribed medication.
OBJECTIVES INTERVENTION RATIONALE EVALUATION
NEEDS DIAGNOSIS BASIS

SUBJECTIVE: Decreased Not getting GENERAL: INDEPENDENT:

hemoglobin enough iron in
The patient level related to your diet is the After 2 days of  Note vital signs  To monitor if Goal partially
said that she noncompliance common cause student nurse- there are any met.
felt dizzy and of taking of low patient interaction, abnormalities
didn’t take her prescribed hemoglobin, the patient will be during pain
vitamins that medication. inadequate RBC able to understand  Assess the
was prescribed production may the importance of  Each
factors of information is
by the cause taking prescribed noncompliance
physician. abnormalities for medication and unique to each
to medication patient and it
not taking the gradually increase being prescribed.
OBJECTIVE: prescribe its hemoglobin allows
medicine. level. individualizing
Decreased corrective plan.
 Develop a
hemoglobin Waterbury, L. SPECIFIC:  This allows the
therapeutic
level (89g/L) (2007). Anemia. patient to gain
relationship
In N. H. After 12 hours of trust from the
between and
Fiebach, et al. student nurse student nurse
among the Goal partially
(Eds.). intervention, the and will boost
patient and met.
Principles of patient will be able confidence in
significant
ambulatory to: the completion
others.
medicine (7th  Verbalize and of the
ed.). understand the treatment.
Philadelphia: possible
Lippincott complications
Williams & of having
Wilkins. decreased  Explain the
hemoglobin significance, Goal partially
 This will help
level during possible effects met.
the patient be
pregnancy. of taking aware and
medications and gather
the possible necessary
 Verbalize one complications if information of
or more risk(s) not the medication
of she is taking.
noncompliance  Provide specific Goal partially
of prescribed instructions as  Information met.
medication indicated. allows the
necessary patient to
during better take
pregnancy. control in
selecting and
 Verbalize the implementing
important in required
taking the changes in
prescribed behavior (food,
medications activities, etc.,)
during DEPENDENT:
pregnancy.  Encourage and
assist patient to
take
 To promote
medications as
pharmacologic
prescribed.
regimen and to
 Exercise
prevent
patients right to pregnancy
medication complications
 For patient to
be aware of
the
 medications
given

CUES/
2. Risk Diagnosis:NURSING SCIENTIFIC
Risk for injury/falls related to dizziness secondary to low hemoglobin level.
OBJECTIVES INTERVENTION RATIONALE EVALUATION
NEEDS DIAGNOSIS BASIS

SUBJECTIVE: Risk for During GENERAL: INDEPENDENT

injury/falls pregnancy, the
“Nalipong ko” related to volume of blood After 2 days of  Screen patient for  It is helpful to Goal partially
as verbalized dizziness in your body student nurse- balance and determine the met.
by the patient. secondary to increases, and patient mobility skills client’s
decreased so does the interaction, the functional
OBJECTIVE: hemoglobin amount of iron patient will be abilities and then
level. you need. Your able to plan for ways to
Decreased demonstrate improve problem
hemoglobin body uses iron
to make more behaviors and areas or
level (89g/L) lifestyle changes determine
blood to supply
oxygen to your to reduce risk methods to
baby. If you factors and ensure safety.
 Place items used
don't have protect self from by the patient
injury.  Stretching to get
enough iron within easy reach. items from the
stores or get
SPECIFIC: bedside tables
enough iron
that are out
during After 12 hours of reach can
pregnancy, you student nurse disrupt the
could develop  Remove excess
intervention, the patient’s balance Goal partially
iron deficiency furniture and
anemia. patient will be equipment. and contribute to met.
able to:  Put side rails. falls
Susceptible to  Verbalize  To provide
increase [risk for understanding space and to
injury and/or of individual avoid injuries.
falling, which risk factors  To reduce the
may cause that contribute risk of falling
physical harm  Orient patient Goal partially
to the when
and compromise regarding her met.
possibility of unexpected
health. falls. environment. dizziness
occurs.
 Modify DEPENDENT:
www.mayoclinic.
com.org/healthy-
environment  To let the patient Goal partially
 Instruct patient to met.
as indicated to to be familiar
lifestyle/ call for assistance
enhance with her
pregnancy/ when moving.
safety. surroundings.
week-by-week  Encourage patient
 Cautious for to eat iron-rich
NANDA 15th injury fruits and  To prevent
Edition vegetables. patient from
 Exercise patients falling.
right to medication  To help increase
blood level.

 For patient to be
aware of the
medications
 given

CUES/
2. Psychological NURSING
Diagnosis: SCIENTIFIC
Knowledge Deficit related to Non-compliance of Prescribed Medication
OBJECTIVES INTERVENTION RATIONALE EVALUATION
NEEDS DIAGNOSIS BASIS

SUBJECTIVE: Knowledge Absence of GENERAL: INDEPENDENT:

Deficit related cognitive
“wala ko kabalo to Non- information After 2 days of  Note for vital  To identify Goal partially met.
sa medisina compliance of related to student nurse- signs. physical
maong wala ko Prescribed specific topic. patient responses
mu tumar” as Medication interaction, the associated
verbalized by patient will be with both
the patient ref: NANDA 15th able to know the medical and
Edition purpose of the  Provide written emotional Goal partially met.
OBJECTIVE: medication. information or conditions
guidelines and  Reinforce the
Decreased SPECIFIC: learning
self-learning
hemoglobin process and
modules to
level (89g/L) After 12 hours of allows the
patient Goal partially met.
student nurse client to
intervention, the  Begin with understand
patient is able to: information the more.
client already
 Understand the  Can arouse
knows then
importance of interest
proceed to
the medication
what the client
 Verbalize did not know
 understanding
of condition,  Repeat  For the patient
disease guidelines to understand
Goal partially met.
process, and more
treatment  Include the  For the family
family or SO to to know the
 Identify more the plan pros and cons
possible risks in regards the Goal partially met
for low health of the
hemoglobin DEPENDENT: patient
level

 Take the  Exercise patients

medication right to medication  Patient may be
accurately as unable to
prescribed comprehend
anything more
than simple,
clear and brief
instructions.

A. Nursing Management may relieve the dizziness:

 Encourage patient to move or stand slowly to allow equilibrium to adjust
  Encourage patient to sit of lay down to avoid the risk of falling
 Instruct patient to eat foods high in folate like liver, avocado, spinach, strawberries, orange, and
orange juice.
 Encourage patient to take the prescribed medication needed to increase the hemoglobin level and
reduce risk of pregnancy complications

B. Ascertain client understanding of individual nutritional needs and way client is meeting those needs then
advice patient to eat rich iron food

C. Hemoglobin is a protein that's the main component of red blood cells (erythrocytes). Hemoglobin contains
iron, which allows it to bind to oxygen. Hemoglobin enables your red blood cells to carry oxygen from your
lungs to other tissues and organs throughout your body, If a hemoglobin test reveals that your hemoglobin
level is lower than normal, it means you have a low red blood cell count as the patient laboratory result
found out that patient hemoglobin level is 89 which below the normal range (120/160 L)

As interpretation for this as it was stated in the scenario that the pregnant patient stops taking her vitamin
supplement because of some reason. We all know that. The hemoglobin concentration, hematocrit and red
cell count fall during pregnancy because the expansion of the plasma volume is greater than that of the red
cell mass. However, there is a rise in total circulating hemoglobin directly related to the increase in red cell
mass. This in turn depends partly on the iron status of the individual. That’s why pregnant women are
recommended to have a hemoglobin level of 12-16g/DL and any value below 12 is considered as iron
deficiency and below 10.5 as anemia.
It has been shown in the scenario that the pregnant patient stops the vitamin supplement to be taken leads
her to low hemoglobin level. As hemoglobin is a protein in your red blood cells. Your red blood cells carry
oxygen throughout your body. If you have a condition that affects your body’s ability to make red blood
 cells, your hemoglobin levels may drop. Low hemoglobin levels may be a symptom of several conditions,
including different kinds of anemia and cancer.
3.CUES/
Actual NEEDS NURSING
Diagnosis: Vision Disturbance related to Elevated Blood Pressure as evidenced by blurring vison secondary to PIH.
SCIENTIFIC
DIAGNOSI OBJECTIVES INTERVENTION RATIONALE EVALUATION
BASIS
S

SUBJECTIVE: Vision Pregnancy- GENERAL: INDEPENDENT:

Disturbance Induced
The patient said related to hypertension is After 2 days of  Monitor blood  To monitor if Goal partially
she Elevated a form of high effective nursing pressure of the there are any met.
experienced Blood blood pressure intervention, the patient. abnormalities
blurring of Pressure as in pregnancy. patient will be able during pain
vision, dizziness evidenced Hypertension to reduce her  Encourage or  To avoid the
and stopped by blurring damages blood blood pressure and Instruct patient risk of injury
taking her vison vessels minimize the not to walk or and falls.
medications secondary throughout your occurrence of stand alone.
to PIH. body including having blurred
OBJECTIVE:  Educate patient  They will be
those in your vision.
the importance aware of its
VS taken as eyes. When benefits of
SPECIFIC: of taking
follow: blood pressure taking it and
antihypertensive
increases, the After 12 hours of disadvantages
medication.
T: 36.8°C lining inside the effective nursing of not taking it
PR: 98bpm vessels intervention, the during
RR: 20bpm becomes patient will be able pregnancy. Goal partially
BP: 180/110 damaged and DEPENDENT: met.
to:
mmHg plaque begins
SpO2: 99% to accumulate.  Encourage  To avoid
Know the
 symptom of patient to have a worsening the
Blurred vision hypertension healthy diet - less situation. Goal partially
may occur during pregnancy cholesterol and met.
because of too and its possible less sodium.
much maternal-fetal
constriction in  Encourage the  To avoid
complications if dehydration
the blood left untreated. increase of fluid
vessels of the intake. that may
eyes that red Verbalize the result to Goal partially
blood cells importance of dizziness or to met.
carrying oxygen taking the faint.
cannot pass prescribed
through. antihypertensive  Encourage  To promote
medication by the patient to pharmacologic
ref: NANDA physician. continue regimen and
15th Edition taking the to prevent
Demonstrate prescribed pregnancy
lifestyle changes medication. complications
to maintain the
blood pressure  Exercise  For patient to
within normal patients right be aware of
range. to medication the
medications
given
 CUES/ NURSING
3. Risk Diagnosis: Risk for maternal injury related to pregnancy complication as evidenced by blurry
SCIENTIFIC
vision
NEEDS DIAGNOSI OBJECTIVES INTERVENTION RATIONALE EVALUATION
BASIS
S

SUBJECTIVE: Risk for injury Susceptible to GENERAL: INDEPENDENT:

related to physical
The patient blurred vision damage due to After 2 days of  Monitor vital  Abnormal vital Goals are
complained as evidenced environmental student-nursing signs signs could put partially met.
that she's by elevated conditions intervention, the the patient at
having a blood interacting with patient will risk of falls
blurry vision pressure. the individual's maintain BP within resulting in
and slightly adaptive and individually injuries due
dizziness for defensive acceptable range elevated blood
past weeks. resources, to reduce the risk pressure causes
And stopped which may of injuries to the blurred vision Goals are
 Implement fall
taking her compromise neonate and and dizziness. partially met.
precautions as
medications. health. mother cause by  Patients at an
appropriate.
blurred vision. increased risk of
OBJECTIVE: Pregnancy- falling are also at
induced SPECIFIC: an increased risk
VS taken as hypertension of injury. By
follow: (PIH) refers to After 12 hours of identifying
a potentially student-nursing patients that are
T: 36.8ᵒC interventions:
severe and at an increased
PR: 98bpm
even fatal risk of falls the
RR: 20bpm  Patient will
elevation of nurse can
BP: 180/110 understand the
blood pressure implement
mmHg importance of
SpO2: 99% that occurs taking  Educate measures to
during medications patient the prevent falls
pregnancy. prescribed with from occurring Goals are
importance
Several her physician initially. partially met.
and benefits of
symptoms for the better adequate rest  Lack of rest is
signal that PIH health and during more than an
is developing safety for them pregnancy. inconvenience.
such as both. New research
dimness or suggests that
blurring vision. Patient will women who
understand the don’t get enough
Reference: effects of rest during
Nurse's Pocket working when pregnancy may
Guide: you're pregnant have higher risks
Diagnosis, and having DEPENDENT: of developing
Prioritized inadequate rest. pregnancy
Interventions  Encourage complications Goals are
and patient to avoid including; partially met.
Rationales(11th extravagant preeclampsia or
ed.).F.A. Davis jobs during high blood
Company pregnancy. pressure, & etc.
Ref: NANDA
15th Edition  Women who
continue to work
at strenuous
jobs during
pregnancy or Goals are
perform shift
  Educate patient work that leads partially met.
the importance to extreme
of taking fatigue may
medications have a higher
prescribed with incidence of
your physician preterm labor
for maintaining than others.
blood pressure.  Stopping your
blood pressure
DEPENDENT: medicine without
first talking to
 Administer your health care
medication as team could lead
prescribed. to serious health
consequences.

 To promote
pharmacologic
regimen

CUES/
3. NURSING
Psychological SCIENTIFIC
Diagnosis: Fear related to the unknown outcome of the situation
OBJECTIVES INTERVENTION RATIONALE EVALUATION
NEEDS DIAGNOSIS BASIS

SUBJECTIVE: Fear related Response to GENERAL: INDEPENDENT:

to the perceived
“Nahadlok ko unknown threat that is After 2 days of  Note for vital  To monitor if Goals are
ma’am kay outcome of consciously effective nursing signs there are any partially met.
sigi kog the situation recognized as intervention, the abnormalities Patient were
kalipong, a danger. patient will be able during pain able to stay
bayn maunsa to verbalize  Ascertain  Fear is active and
nani akong ref: NANDA accurate client’s/significant defensive follows the
baby” 15th Edition knowledge of and other’s perception mechanism in guidelines given.
verbalized the sense of safety of what is protecting
patient. related to current occurring and oneself, but if
situation. how this affects left unchecked,
OBJECTIVE: life it can become
SPECIFIC: disabling to
VS taken as
 Active listening to client’s life.
follow: After 3 hours of
client’s concerns  To promote
effective nursing
T: 36.8ᵒC atmosphere of
intervention, the
PR: 98bpm caring and
patient will be able
RR: 20bpm permits
to:
BP: 180/110 explanation or Goals are
mmHg  Acknowledge  Speak in simple correction of partially met.
SpO2: 99% and discuss sentences misperceptions Patient were
fears,  Acknowledge  To facilitates able to stay
recognizing normalcy of fear, understanding active and
healthy versus pain, and despair,  To promote an follows the
unhealthy fears and give attitude of guidelines given
 Display permission to caring and
lessened fear express feelings opens door for
as evidenced appropriately and discussion
by appropriate freely about feelings
 range of and Goals are
feelings and addressing partially met.
relief of  Provide an reality of Patient were
signs/symptoms opportunity for situation. able to stay
questions and  Enhances trust active and
answer honestly and rapport follows the
 Provide presence guidelines given
and physical
contact  To soothe
fears and
DEPENDENT: provide
 Administer assurance
medication as
prescribed  To promote
 Exercise patients pharmacologic
right to regimen.
medication  For patient to
be aware of
the
medications
given

A. Priority nursing management:

 Assist patient when moving, standing, or walking.
Rationale: To prevent patient from falling because blurry vision

 Monitor blood pressure

 Encourage patient to have a healthy diet – with less cholesterol content and less sodium
 Encourage to have minimal or appropriate exercise for her
 Encourage patient to continue taking her antihypertensive medication to avoid maternal – fetal
complications during pregnancy