Assessment Nursing Diagnosis Scientific Planning Implementation Rationale Evaluation

Background
Subjective data: Hyperglycemia Production of hCG After 8 hours of  Admitted  Patient can After 8 hours of
 Back pain related to lack of in placenta nursing this 37 give birth nursing
insulin as intervention, the years old, anytime intervention, the
Objective data: evidenced by patient’s OGGT will female to patient’s OGGT
 Bleeding pregnancy and Insulin not working be decreased to 97 the labor was decreased to
 OGGT high OGGT of 191 effectively/insulin mg/dL room 97 mg/dL
result – mg/dL (1st) and 181 deficiency ambulatory
190 mg/dL (2nd) Goal met
(1st hour  Assisted  To lessen
reading), Build up of glucose and proper risk of injury
and 181 in blood positioning and to
on 2nd done prepare for
hour labor
 BP –  IVF of D5LR  IVF D5LR is
110/60 1L inserted used for
mmHg and maintenance
 HR 86 regulated of body
bpm to run for 8 fluids and
 20 bpm hours nutrition
 36.5
degrees  IVF to
Celsius follow
 FHT 135 D5LR 1L to
bpm run for 8
 IE 5 cm hours
dilated
 NPO  To manage
maintained blood sugar

 Insulin  Help prevent

given as high blood
ordered sugar

 Request  To check for

for CBC other health
 with ABO problems,
and Rh blood type,
typing, infections,
HBsag, Hep etc.
B
forwarded
to the
laboratory

 Urine  To ensure
specimen proper
collected intake of
for UA and fluid and
sent to the adequate
Laboratory output of
 I and O urine and
measured normal
and defecation
recorded
 VS taken  To detect
and any health
recorded problems
every 30
mins
 FHT taken
and
recorded
every 30
mins

 HCG  To check
monitoring whether
every 1 pregnancy is
hour while still ongoing
on NPO by
the
laboratory
done
 Monitored  To check for
progress of abnormal
labor and discharges
discharges