nursing diagnoses for maternity

ENGLISH FOR NURSING (Ratna Ning Hanoom 1210322007)2

NURSING DIAGNOSES, OUTCOMES, AND INTERVENTION OF THE CASES

1. MATERNITY NURSING CASEHarriet, a 33-year-old client at 28 weeks gestasional with her fourth pregnancy, is being evaluated in the health care providers office. During her second and third pregnancies, Harriet developed pregnancy-induced hypertension (PIH) managed with bed rest at home for several weeks. Her obstetric history (GTPAL) is documented as 41203. My last two babies were born at 34 and 33 weeks because of my blood pressure problems, she reported. Her children are 2, 4, and 7 years old.

Supporting Data : Blood Pressure Rate : 180/100 mmHg, RR : 20x/min, T : 36,5oC, Pulse : 70x/min, Haemoglobin amount : 8,5 gr/dl, has hystory consumed of Fe tablets.NANDA (NURSING DIAGNOSE)

Risk for Disturbed Maternal-Fetal Dyad r/t number of blood pressure at this rate is 180/100 mmHg (hypertension) e/b hystory of pregnancy-induced hypertension during second and third of pregnancy, and laboratory results of haemoglobins amount is 8,5 gr/dl.Data Analysis :Objective DataHarriets blood pressure at this rate is 180/100 mmHg (hypertension), she has hystory of pregnancy-induced hypertension (PIH) during her second and third pregnancies. Amount of her haemoglobin is 8,5 gr/dl from laboratory result.Subjective DataHarriet said that she ever managed with bed rest at home for several weeks because of pregnancy-induced hypertension (PIH) during her second and third of pregnancies, and she said that her last two babies were born at 34 and 33 weeks because of her blood pressure problems. She also said that she consumed Fe tablet because of anemia.

NOC (NURSING OUTCOMES)

Maternal Status : AntepartumIndicators : Emotional attachment to fetus Coping with discomforts of pregnancy Mood lability Weight change Cognitive status Visual acuity Neurological reflexes Blood pressure Radial pulse rate Respiratory rate Body temperature

Urine protein Urine glucose Hemoglobin Blood count Edema Headache Nausea Vomiting Abdominal pain Epigastric pain Vaginal bleeding/discharge Heartburn

NIC (NURSING INTERVENTION)

High Risk Pregnancy CareActivities : Determine the presence of medical factors thatare related to poor pregnancy outcome (In case : hypertension) Review obstretrical hystory of pregnancy-related risk factors Determined clent knowledge of identified risk factors Discuss fetal risks associated with preterm birth t various gestational ages Write guidelines for signs and symptoms that require immediate medical attention

2. MENTAL HEALTH NURSINGDavid is a 26-year-old male with an explosive, angry personality. He has had repeated hospitalizations. This hospitalization was necessary because he was angry with his parents because of their pending divorce. He become suicidal and took an overdose of anti depressant. After hospitalization and following a visit from his mother, he become violently angry, threw a chair in the day room and threatened the staff when they attempted to subdue him.NANDA (NURSING DIAGNOSE)

Risk for Other-Directed Violence r/t explosive and angry personality e/b suicidal behavior and anti depressan-abuse.Data Analysis :Objective DataDavid violently angry, threw a chair in the day room and threatened the staff when they attempted to subdue him when his mother come to Davids following a visit activity. David had ever tried to suicide his self during hospitalization, he took an overdose of anti depresan.Subjective DataDavids mother said that David become an angry personality and have to hospitalization because he was angry with her and her husband, this was happened because of their pending divorce.


Aggression Self-ControlIndicators : Identifies when angry Identifies when frustated Identifies situations that precipitate hostility Identifies responsibility to maintain control Identifies when feeling aggressive Identifies alternatives to aggressions Identifies alternatives to verbal outburst Use effective conflict resolution skills Expresses needs in a non-destructive manner

Refrains from verbal outburst Avoid violating others personal space Refrains from striking others Refrains from harming others Refrains from harming animals Refrains from destroying property Controls impulses Use physical activity to reduce pent-up energy Uses technique to control anger Uses technique to control frustation Maintains self-control without supervision


Anger Control AssistanceActivities : Establish basic trust and rapport with patient Use a calm, reassuring approach Assist patient in identiying the source of anger Identify the function that anger, frustation, and rage serve for the patient Assist patient in planning strategies to prevent inapropriate expression of anger Instruct on use of calming measures Establish expectation that patient can control his/her beavior Support patient in implementing anger control strategies and in the appropriate expression of anger

3. CHILD HEALTH NURSINGBarry is a 2 year old diagnosed with celiac disease that you see at birthday party. His abdomen is protuberant, yet his arms and legs seem thin and wasted. He refuses to eat a piece of birthday cake even though his mother sits beside him insisting on it. See the problem I have with him?, she asks you. He eats nothing. When he does, he gets diarrhea.NANDA (NURSING DIAGNOSE)

Imbalanced Nutrition : Less Than Body Requirement r/t anorexia and gastrointestinal impairment e/b malabsorpsion of nutrient because of the reaction autoimun that make worse the absorption proccess in the intestinal tract.Data Analysis :Objective DataBarry was diagnosed with celiac disease, from physical assesment his abdoment is protuberant, yet his arms and legs seem thin and wasted. Bodys image poor, anorexia, when eat something, he gets diarrhea.Subjective DataBarrys mother said that Barry refuses to eat a piece of birthday cake even though she was sit beside him insisting on it. She also said that Barry eats nothing, but when he did, he got diarrhea.


Nutritional StatusIndicators : Nutrient Intake Food intake Fluid intake Energy Weight/height ratio Hematocrit Muscle tone HydrationNuritional Status : Nutrient IntakeIndicators : Caloric intake Protein intake Fat intake Carbohydrate intake Fiber intake Vitamin intake Mineral intake Iron intake Calcium intakeChild Development : 2 YearsIndicators : Walks quickly Stoops well Walks backwards Kicks a ball Feeds self with spoon and fork


Nutrition ManagementActivities : Inquiry the patients food that make allergy (from this case the food that compose from cereal can make the digestive proccess worse) Determine, in collaboration with dietican number of callories and type of nutrients needed to meet nutrition requirement Provide food selection Weight patient at appropriate intervals

4. MEDICAL SURGICAL NURSINGMrs. Sheryl, age 58 years, is seen in the clinic for her yearly physical examination. She says, I hardly have energy to get up and dress in the morning. Cleaning the house and doing the laundry make me exhausted. She does not work and she is not involved in the community activities. Her daily routine involves cooking for her husband, reading and watching TV for 6 to 8 hours. She loves to bake fresh breads and pastry. She had history of being overweight and does not exercise. She says, I eat because I have nothing to else to do. Assesment reveal : height : 53, weight 166 pounds, weigh gains 14 pounds in the past year. Sedentary lifestyle, eat in response to having nothing to do.NANDA (NURSING DIAGNOSE)

Imbalanced Nutrition : More Than Body Requirements r/t weight 20% over ideal for height and frame, as well as sedentary lifestyle (supporting by BMIs data) e/b her weight now is 166 pounds, and weigh gains 14 pounds in past year.Data Analysis :Objective DataMrs. Sheryl (58 y), has hystory of being overweight and does not exercise. Her weigh is 166 pounds (74,7 kg) and her height is 53 feet (161,5 cm). Mrs. Sheryl does not work, not involved in the community activities.Mrs. Sheryls BMI is := = kg/m2 (overweight)Subjective DataMrs. Sheryl said that she hardly have energy to get up & dress in the morning, cleaning house & doing laundry make her exhausted. She also said that she ate in response because theres nothing to do, her daily activities involves cooking for her husband, reading and watching TV for 6 to 8 hours.


Nutritional StatusIndicators : Nutrient Intake Food intake Fluid intake Energy Weight/height ratio Hematocrit Muscle tone HydrationNuritional Status : Nutrient IntakeIndicators : Caloric intake Protein intake Fat intake Carbohydrate intake Fiber intake Vitamin intake Mineral intake Iron intake Calcium intakeWeight Loss BehaviorIndicators : Obtains information on weight loss strategies from health professional Selects a healthy target weight Commits to a healthy target weight Establish an exercise routine


Weight ManagementActivities : Discuss with individual the relationship between food intake, exercise, weight gain, and weight loss Discuss with individual the habits and customs and cultural and heredity factors that influence weight Determine individuals ideal body weight Inform individual about whether support groups are avaible for assistance Encourage individual to chart weekly weightsWeight Reduction AssistanceActivities : Determine patients desire and motivation to reduce weight or body fat Assist with adjusting diets to lifestyle and activity level Plan an exercise program, taking into consideration the patients limitation Developed a daily meal plan with a well-balanced diet, reduced calories, and reduced fat Refer to a community weight control program

5. MEDICAL SURGICAL NURSINGMrs. Shiva, a 48-year-old woman, injured her back 3 years ago while lifting some boxes of paper at work. Since that time she has had four epidural steroidal injections for the pain associated with two ruptured discs. Her pain has been intermittent, with some elevation from the epidural injections. Her last epidural was 3 months ago. She arrive at the clinic stating, I just do not know I can go on like this. The pain has been tolerable until last night. I am hurting so bad. She is tearful and facing saying. It is hurt too much when I sit down. Verbalize pain is 9 on 1 to 10 pain intensity scale. Blood pressure is 148/90. Pulse is strong and regular at 92. She has guarded movements.

NANDA (NURSING DIAGNOSE)

Acute Pain r/t intermittent pain e/b that because of her hystory of rupture discs that happened 3 years ago that injured when lifting some boxes of paper at work and her last epidural was 3 months ago.Data Analysis :Objective DataMrs. Shiva arrive at the clinic, came with back pain, she was tearful and facing saying. Her verbalize pain is 9 on 1 to 10 pain intensity scale. Blood pressure is 148/90 mmHg, pulse is strong and regular at 92.Subjective DataMrs. Shiva said that she ever injured her back 3 years ago while lifting some boxes of paper at work. Since that time she has had four epidural steroidal injections for the pain associated with two ruptured discs. Her pain has been intermittent, with some elevation from the epidural injections. Her last epidural was 3 months ago. Mrs. Shiva said that she just do not know she can go on with her pain, and the pain has been tolerable until last night, she hurted so bad.


Pain ControlIndicators : Recognizes pain onset Describes causal factors Uses diary to monitor symptoms over time Uses non-analgesic relief measures Uses analgesic relief merecommended Reports changes in pain symptoms to health professional Reports pain controlledPain LevelIndicators : Reported pain Length of pain episodes Rubbing affected area Moaning and crying Facial expressions of pain Restlessness Agitation Irritability Wincing Tearing Blood pressure Radial pulse rate


Analgesic AdministrationActivities : Determine pain location, characteristic, quality, and severity before medicating patient Check medical order for drug, dose, and frequency of analgesic prescibed Check history for drug allergies Monitor vital signs before and after

Pain ManagementActivities : Perform a comprehensive assesment of pain to include location, characteristics, onset/duration, frequency, quality, intensity or severity of pain, and precipating factors Assure patient attentive analgesic care Explore patients knowledge and belief about pain Teach the use of nonpharmacological techniques Encourage patient to use adequate pain medication

Fakultas Keperawatan | Universitas Andalas - 2014

nursing diagnoses for maternity

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