AssessmentNursing diagnosisGoalNursing interventionRationaleEvaluation

Subjective Objective

Altered nutritional status less than body requirements related to pregnancy as evidenced by refusal to eat food.

Patient demonstrates progressive weight gain towards goal.Nursing care planned Nursing care given To determine what information to provide to client.

To identify the interest of client.

Provide us the baseline data.

Helps in further care of the client.

Helps to maintain the adequate nourishment required.To increase the intake of diet to improve nutritional status.

Helps the client to develop interest in having food.

To see the effectiveness of intervention.

The client demonstrated interest in having food.

Patient complaining of not feeling of urge to eat.Patient looks very weak.To ascertain the understanding of individual nutritional needs for pregnancy.

To discuss eating habits, including food preferences to appeal clients likes and dislikes.

To assess weight and activity/rest level.

To assess the total daily food intake and maintain diary of calories intake.

To provide diet modifications with increase protein, carbohydrate and calories.

Encouraging client to take small and frequent diet in small -2 intervals of time.

To encourage client to choose foods that are appealing to stimulate appetite.

Reassessment

Ascertained the understanding of individual nutritional needs of pregnancy.

Discussed eating habits including food preferences to appeal clients likes and dislikes.

Assessed weight and activity/rest level. Wt-45 Kg.

Assessed the total daily food intake and maintain diary of calorie intake.

Provided diet modifications with adequate amount of protein, carbohydrate and calories.

Client is ready to take small-2 diet in frequent interval of time.

Encouraged client to choose foods that are appealing to stimulate appetite.

Reassessment done.

AssessmentNursing diagnosisGoalNursing interventionRationaleEvaluation

Subjective Objective Activity intolerance related to imbalance to between oxygen supply and demand secondary to pregnancy as evidenced by exhibition by client. The client will report measurable increase in activity intolerance. Nursing care planned Nursing care given

This provides a comparative baseline data about the activity level of the client.

To reduce over exertion and fatigue.

Helps to conserve energy

This helps to minimize frustration and rechannel energy. This protects the clients from injury.

This helps in effective planning.

This enhances the well-being of the client. The client reported measurable increase in activity tolerance.

The client complaints of weakness.Patient looks pale. To evaluate the current limitations of deficit in light of usual status.

To monitor the vital signs.

To adjust activates and plan care with rest periods between activities.

To increase exercise level gradually

To provide atmosphere while acknowledging difficulty of the situations for the client.

To assist with activities of the client.

To provide information about the effect of lifestyle and overall health factors on activity intolerance.

To encourage client to maintain positive attitude. Evaluated the current limitations of deficit in light of usual status.

Monitor the vitals signs. T- 98.40FP-80/min R-22/min BP-130/90 mmHg

Adjust activities with rest periods in between.

Exercise level gradually increased.

Provide atmosphere while acknowledging difficulty of the situations for the client.

Assisted with activities of the client.

Provide information about the effect of lifestyle and overall health factors on activity intolerance.

Encouraged client to maintain a positive attitude.

AssessmentNursing diagnosisGoalNursing interventionRationaleEvaluation

Subjective Objective Disturbed sleep pattern related to shortness of breath and frequent urination secondary to pregnancy.

The client verbalizes understanding on the cause of sleep disturbance and reports increased sense of wellbeing and feeling of rested. Nursing care planned Nursing care given Elevated blood pressure is usually observed in sleep disturbed clients.

Voiding before bedtime limits the sleep disturbance.

A quiet environment promotes continuation of sleep without disturbance.

This promotes relaxation and readiness for sleep.

To check change in condition.

The client reported of being rested and more relaxed.

Patient verbalized that she easily wakes up whenever she hears noise. Furthermore, she reported frequent awakenings during the night to go bathroom due to increase urge to urinate which happened around 5 times. She felt slight pain on the area near her buttocks due to the pressure she feels on her chest which affects her breathing. Patient is not sleeping during night and day. Assess vitals signs of the client.

Encourage client to void before sleeping.

Provided a quiet environment conducive for sleeping.

Encouraging client to drink a glass of milk or to take bath before sleeping.

Reassessment

Assessed the vitals signs of the mother.T-980FP-88/min R-28/minBP-140/90mmHg

Encouraged client to void before sleeping.

Provided a quiet environment conducive for sleeping.

Encouraged client to drink a glass of milk or to take care before sleeping.

Reassessment done.

AssessmentNursing diagnosisGoalNursing interventionRationaleEvaluation

Subjective Objective Disturbed body image related to change of appearance associated with pregnancy. The client will express positive feeling towards self and significant others.

The client will verbalize acceptance of body image. Nursing care planned Nursing care given This gives a mother a sense of control over the situation.

This improves the nurse patient relationship with the client.

This creates a sense of trust and at the same time educate the client about the changes during the pregnancy.

This creates a positive outlet for expression of feelings. This helps to overcome maladaptive behaviour.

This provides a base line data.

To check change in condition. The client perceived the pregnancy in a positive manner and claimed that she is excited to see her baby.

The mother verbalized that she feels sad about her physique and body image. Contour of the abdomen changes and presence of linea nigra on the abdomen. To assess the readiness of the client to accept changes in body image.

To employ a care calm, confident and non judgemental approach towards the mother.

To discuss with client the physiological changes during pregnancy.

To allow client to express her feeling towards her pregnancy.

To teach client coping strategies.

To monitor the vitals signs of the client.

Reassessment. Assessed the readiness of the mother to accept the changes in the body image.

Employed a caring calm confident and non judgmental approach towards the mother.

Discussed with the client the physiological changes during the pregnancy.

Allowed the client to express her feeling towards her pregnancy.

Taught the client coping strategies.

Monitored the vital signs of the mother.T-980Fp-82/minr -28/min BP- 130/90 mmHg.

Reassessment done

AssessmentNursing diagnosisGoalNursing interventionRationaleEvaluation

Subjective Objective Anxiety related to hospitalization and child birth The client will acknowledge and discuss fears Recognizing healthy and unhealthy fears verbalizes control over the situation.

Nursing care planned Nursing care given This helps to identify the areas of concern that might interfere with interfere with the normal progress labour.

This enhances the nurse-client relationship.

This promotes healthy outletsOf emotions and relives anxiety.Adequate explanation reduces anxiety and soothes fear and provides assurance.

This provides a sense of security and trust between the nurse and the client. The client verbalized a decrease in the anxiety level.

The client verbalized concern about the upcoming delivery and express worries about childbirth.The client exhibits poor eye contacts To assess the level of anxiety through verbal and non-verbal cues.

To employ a caring a calm and non judgemental approach.

To allow the client to express fears and feelings of anxiety appropriately.

To acknowledge normalcy of fear and provide opportunity of questions and answer honestly within clients level of understanding

To offer support by staying close to the mother.Assessed the level of anxiety through verbal and non-verbal cutes.

Employed a caring, calm and non-judgemental approach

Allowed client to express her fears and feelings of anxiety appropriately.

Acknowledged normalcy of fears and provided opportunity for questions and answered honestly within mothers level of understanding.

Offered support by staying close to the mother.