assessment Explanation of the objectives Nursing intervention rationale evaluation

problem
SUBJECTIVE - pain in the pelvis, STO; Dx - GOAL MET
- Napakasakit abdomen, or even After 6 hrs of -assess present -to have a general the patient
ng tiyan ko the shoulder or neck providing nursing health status knowledge of demonstrate
verbalized by (if blood from a intervention the patient’s health relief of pain
the patient ruptured ectopic patient’s pain level as evidenced
- pregnancy builds up will decrease to 5/10 -Assess the patient’s -to monitor the by a pain
OBJECTIVE and irritates certain vital signs and effectiveness of score of 0 out
nerves). The pain can LTO characteristics of medical treatment of 10, absence
-abdominal pain range from mild and - Within 72 hrs pain atleast 30 mins for the relief of of
-abdominal rigidity dull to severe and of providing after administration abdominal pain restlesseness
restlessness sharp. nursing of medication
intervention
Nursing diagnosis the pain will Tx
- Acute pain be free from Elevate the head of -to increase the
related to pain the bed and position oxygen level by
ectopic the patient in semi allowing optimal lung
pregnancy as fowlers expansion
evidenced by
pain score -Maintain bed rest -to provide optimal
9/10 comfort to the
patient
Edx
-encouraged the
patient to have no - To reduce
strenuous activity for post-surgical
few weeks pain and
allow full
recovery and
healing

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Ectopic pregnancy

assessment Explanation of the objectives Nursing intervention rationale evaluation

problem
Subjective; - hemorrhagic shock STO; dx. -The skin is another -GOAL MET
- ‘Nanghihina is a medical condition After 7 hrs. of - Assess skin turgor organ that might The patient re
ako’ resulting from a providing nursing and oral mucous reveal the beginning establish a functional
verbalized by decreased blood intervention the membranes for signs stages of dryness. body fluid volume
the patient volume caused by patient’s verbalized of dehydration. Therefore, the and a balanced input
blood loss, which awareness of sternum or the inner and output status
Objective; leads to reduced causative factors and thighs are the best
- Body cardiac output and behavior essential to places to evaluate
weakness inadequate tissue correct fluid deficit the turgor of the skin.
- Decreased perfusion Around the tongue,
urinary output Lto you could notice
-hypotension Within 72 hrs of some furrows
nursing intervention running in a
Nursing diagnosis; the patient’s body longitudinal
Deficient fluid volume fluid volume will re direction.
related to heavy establish Tx.
vaginal bleeding as - Weigh daily with
evidenced by body the same scale, and -Weight is the best
weakness and preferably at the assessment data for
decreased urinary same time of day. possible fluid volume
output imbalance. An
increase in 2 lbs a
week is considered
normal.
-Provide a
comfortable -Drop situations
environment by where patients can
covering the patient experience
with light sheets. overheating to
prevent further fluid
loss.
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 Edx
Encourage the -consuming salt
patient to have a low between 2 to 4g per
salt inatke day is ideal as a very
low salt intake may
increase dehydation

H.MOLE

assessment Explanation of the Objectives Nursing intervemtion Rationale

problem
Subjective -"The condition in STO dx. -Nutritional - GOAL MET
which an individual -Patient will verbalize - Assess energy requirements change -the patient gain
experiences or runs understandinf of the expenditure depending on a knowledge about
the danger of effcts of substance pregnant woman's demonstrating
Objective; experiencing lower dependence and activity level. In a progressive weight
- Weight loss weight as a result of insufficient dietary dose-dependent gain toward the goal
- Weak insufficient intake or Intake on the manner, and preventing signs
muscle tone metabolism of nutritional status and neurobehavioral of malnutrion,
-below nutrients necessary pregnancy after the 8 characteristics of verbalizing
maternal for the body's hrs shift lower arousal, understanding the
pre=pregnant metabolic needs." increased tension, effects of substance
weight LTO and poor quality of abuse, reducing
- Witin 72 hrs movement were dietary intake on
Nursing diagnosis the patient found to be nutritional status
-imbalanced will gain associated with
nutrition; less than knowledge prenatal exposure to
body requirement about methamphetamine.
demonstrating
progressive
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 weight gain -Note and record the -This provides
toward the client’s weight information regarding
goal and weekly the current status or
preventing effectiveness of the
signs of dietary plan.
malnutrion,
verbalizing
understanding Tx --the use of this
the effects of -allow the patient to method encourages
substance select foods and patient participation
abuse, snacks that fit his or or a feeling of control,
reducing her nutritional needs and it may contribute
dietary intake to the recovery from
on nutritional malnutrition.
status
-In order to properly
Edx manage pregnant
-educate the client women who are
about outreach and dependent on
food assistance substances, it is
necessary to address
the needs of
pregnant women who
are malnourished,
homeless, and/or
incarcerated.
SUBSTANCE USE

assessment Explanation of the objectives Nursing interventyion rationale evaluation

problem

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Subjective; - The symptoms of - After 30 mins dx -disorientation, - GOAL MET
hyperemesis The patient -Assess signs of tenting skin, and dry Sto
‘ilang beses na akong gravidarum include will be able to dehydration membranes. any - After 30
sumusuka’ as persistent nausea, verbally indication of minutes The
verbalized by the vomiting, and express dehydration patient was
patient dehydration. understanding Vomiting and an able to
of the inability to accept verbally
Objecrives; - There could be underlying oral fluids might express
- Weak in malnutrition as well causes and the result in significant understanding
appearance as other severe intended fluid loss in the of the
complications like effects of the patient. underlying
fluid and electrolyte drug causes and the
Nursing diagnosis imbalance. - -Assess Vital Signs  -HR, RR, BP. Get intended
Altered fluid and - After receiving baseline vitals and effects of the
electrolyte balance - The disorder known nursing care for 48– note any changes drug
potassium loss as hypocalimia, often 72 hours, the patient (tachycardia,
related to vomiting referred to as will be able to reach a hypotension, Lto
hypotasemia, is functioning fluid tachypnea) - After receiving
characterized by a volume. nursing care
low level of Tx for 48–72
potassium in the -Administer IV -To help control hours, the
blood (less than 3,5 fluids/Medications electrolyte balance patient was
med/L). and maintain proper able to reach a
hydration, functioning
- can result in intravenous fluids fluid volume.
weakness, anorexia, will be required. It is
nausia, and vomiting. possible to give
Leg cramps, medication to treat
decreased bowel nausea.
movement,
paresthesias, and a -Provide a -Loose-fitting
numb-and-tingling comfortable garments
dysrhythmia environment Decrease
decrease in tendon environmental
reflexes and muscle stimulation
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 strength. (light/noise)

Edx -potassium may be

- encourage intake of replaced through this
food that are high in
potassium

3545
assessment Explanation of the objectives Nursing intervention rationale evaluation
problem

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Subjective Sto dx - PROM may be - GOAL MET
- May biglaang The patient Assess for signs of brought on by
bumulwak na will verbalize infection maternal and fetal STO;
tubig galling 6 signs and infection, which - The patient
sa ari ko” as symptoms of needs to be treated was able
verbalized by infection to very once to prevent verbalize 6
the patient the nurse fetal impairment. signs and
after 3 hrs of symptoms of
Objective rendering - Obtain history from - Treatment is infection to
nursing care patient regarding influenced by the the nurse
Vital signs complications and gestational age and after 3 hrs of
-hr = 90 Lto; status of pregnancy any existing rendering
Bp= 130/80 - The patient will be problems. nursing care
Temp= 37.1 free from any signs If the patient is
- Positive ferns and symptoms of preterm, she could
test infection need to continue her LTO;
Nursing diagnosis such as foul-smelling pregnancy while still -- The patient was
- Risk for vaginal drainage. in bed, or delivery able to free from any
infection elevated might be induced. signs and symptoms
related to loss temperature, uterus of infection
of protective tenderness or Tx such as foul-smelling
barrier rigidness, diminished - Administer - PPROM may vaginal drainage.
fetal movement. medications and IV indicate a need for elevated
tachycardia, and fluids as appropriate: corticosteroids to temperature, uterus
hypotension Prophylactic speed up the fetal tenderness or
throughout rest of antibiotics lung maturity rigidness, diminished
pregnancy after 48- Antibiotics are given fetal movement.
72 hrs of rendering Corticosteroids prophylactically to tachycardia, and
nursing care prevent infection hypotension
Tocolytics throughout rest of
Tocolytics may be pregnancy after 48-
Magnesium sulfate given to stop preterm 72 hrs of rendering
labor nursing care

Magnesium sulfate
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 may be given if prior
to 32 wks gestation
to prevent fetal
neurological
dysfunction

- Patient will
Edx probably stay in the
- Provide patient hospital till delivery is
education if preterm: an option if delivery
Pelvic rest is not indicated (34
wk gestation).
Avoid tampons and Regardless of
intercourse location, the patient
will need to stay in
Avoid tub baths bed and get
(showers ok) prophylactic
antibiotics all the way
up to birth.
prom

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