Hyperemesis Gravidarum

ASSESSMENT DIAGNOSIS PLANNING IMPLEMENTATION EVALUATION

SUBJECTIVE DATA Risk for Deficient Fluid Short Term Goal Independent After Nursing
Patient verbalizes: Volume related to After nursing -Monitor fluid input and intervention
“Lagi po akong prolonged Nausea and intervention Output, and weigh it - The patient
naduduwal” Vomiting - The patient's daily. increased her
fluid volume will - This will help fluid intake
“Palagi rin po ang maintain in a you monitor how
pagsusuka ko, minsan normal level much the body - The patient
tatlong beses o apat na - The patient will loses fluid. monitored and
beses po sa isang araw” understand the -Instruct the Patient to listed her fluid
importance of increase the fluid intake intake and
“Bago po ako magbuntis drinking enough output as well as
63kg po ako, ngayon 61 fluid will help her -Monitor Vital Signs her weight daily.
na lang po.” body in especially Blood
maintaining the pressure, heart rate and - The patient was
OBJECTIVE DATA fluid volume in temperature. able to monitor
-Decreased skin turgor the body. After - It is important to and list her vital
nursing monitor the vital signs daily, no
-Vital Signs intervention the signs because a signs of above
Temperature: 37.7 patient will Decrease in normal or below
Blood pressure: 110/70 increase her blood pressure normal vital
mmHg fluid intake and an increase signs.
Pulse rate: 80 bpm - After nursing in heart rate and
intervention the temperature is a - The patient has
patient will have sign of no signs of dry
a normal vital dehydration. skin, has a moist
signs mucous
- After nursing -Inspect for dry skin, membrane and
intervention the mucous membranes, no signs sunken
patient will have and sunken eyes. eyes.
a good skin
turgor, a moist
mucous
membrane, and
 will not have any
signs of
dehydration
such as sunken
eyes.

Placenta Previa
ASSESSMENT DIAGNOSIS PLANNING IMPLEMENTATION EVALUATION

SUBJECTIVE DATA Fluid Volume Deficit After Nursing After nursing

Patient Verbalizes: related to blood loss as intervention: intervention
“Dinugo po ako bigla at evidenced by excessive Short Term Goal - The Patient vital
madami dami po kada vaginal bleeding. Independent signs became
tatanggalin ko po ang - The patient will -Monitor and record normal
pad, kaya pumunta na have a stable vitals signs - The patient skin
po kami ng hospital” vital signs - This will be the skin color
baseline date in became normal
“Pangtatlo pads po ko monitoring your - The bleeding
na po heto ngayon, patient’s decreased
halos mapuno po lahat bleeding - The fetus is free
ng pad.” -Give O2 mask as per from distress
doctor's order
“Nahihilo na rin po ako” - this will help you
maintain your
OBJECTIVE DATA O2 sat and to
-Cool clammy skin avoid having
- Pale your baby in
- Capillary refill within 2 distress
seconds Patient is for continuous
 - The patient will -Inspect the patient’s monitoring and
Vitals signs: have a good skin skin, nail bed, and reassessment until full
Temperature: 38.0 color capillary refill, as well as term.
Blood Pressure: weighing the used pads
100/70mmHg - This will also
Respiratory Rate: help you
23cpm determine the
Pulse Rate: 110 bpm severity of the
O2: 90% bleeding
- Weighing pads
will help you
measure the
blood loss. This
will also help
them determine
if the patient will
be needing
blood
transfusion

-Advice the patient to

have bed rest, and
avoid sexual intercourse

Long term goal

- The patient will -Give medications and
be free from any IV fluid as per doctor's
signs of fluid order
volume deficit - Monitor the IV
intake and the
output of the
patient, and also
monitor the
patient in any
signs of
 contraction.
- Fetal heart rate
monitoring -Monitor and record
fetal heart rate
- It is important to
monitor and
record the fhr to
monitor any
signs of fetal
distress, and this
will also
determine if the
mother will
undergo
emergency c
section due to
bleeding and
fetal distress.
-