FIRST TRIMESTER

CUES/EVIDENCES Subjectives: NURSING DIAGNOSIS Imbalanced nutrition; less than body requirements related to appetite change. OBJECTIVES Within our days of care, client will be INTERVENTION RATIONALE EVALUATION At the end of our nursing care, client showed signs of improved condition as evidenced by: Met. Vital signs within normal range: BP: 110/80 mmHg, PR: 82 bpm, RR: 22cpm, Temp: 37.2 o C

Verbalized, mukaon lang gud kung unsa ang naa sa lamesa, pirme bulad lang man amoa sud-an. Medyo napilian nalang ko sukad pagkasamkon nako Verbalized oo, mura mala magmala man akoa panit pero okey lang man akoa paminaw.

having a balanced nutrition as

evidenced by: Independent: 1. Determine clients ability to chew, swallow and taste food. Evaluate teeth b. Display normalization of laboratory values and be free of signs of malnutrition and gums for poor oral health. - all factors that can affect ingestion and/or digestion of nutrients

a. Eating more healthy foods.

Objective

v/s T = 36.9 0C P = 88 bpm R = 22 cpm BP = 150/100 mmHg Usual fluid intake 8-7 glasses/day,

c. . Verbalize understandin g of causative factors when known and necessary interventions

- to determine

Unmet. There is no laboratory results or examination s given.

2. Ascertain
understanding of individual nutritional needs. Also, discuss eating

informational needs of client/significant others. According to Hildegard Peplau, nurses must also assume the role of a teacher that imparts

Met. Verbalized, mao dyud kinahanglan dyud mokaon ko og mga utanon para himsog

decreased to 6-7 glasses skin appears to be pale, dry and warm to touch Hair appears to be scaly Buccal mucosa is pale and dry Breakfast 1cup of rice Sardines Coffee Lunch cup rice 3 pcs. Fried fish cup soup 150 ml of water Dinner cup rice 2 Chorizos 1 cup water d. Demonstrate behaviors, lifestyle changes to regain and or maintain appropriate weight

habits, including food preferences, intolerances/av ersions.

knowledge concerning a need or interest. - to assess body image and congruency with reality

3. Determine
psychological factors/perform psychological assessment, as indicated.

akoang pagmabdos o panglawas, tigtanom bya pod ko og mga lahilahing utanon sa palibot.

- suggesting

4. Note
occurrence of tooth decay, swollen salivary glands, and report of

bulimia/affecting ability to eat

Partially met. Verbalized, mokaon man dyud ko og insakto pero usahay magkulang man ang kwarta, kung unsa ang naa mao lang pod akoa kanon.

Partially met. Mouth and Pharynx PA: Lips: Patients lips are moist, pinkish in color

- to reveal possible

52

constant sore throat 5. Review indicated laboratory data.

cause of malnutrition/changes that could be made in clients intake - to reduce possibility of early satiety - to let the clients know or be aware the importance of eating the right food thus making him avoid unhealthy practices regarding eating habits

6. Evaluate total daily food intake.

7. Emphasize
importance of well-balanced nutrition intake through health teaching.

and slight presence of cracks. Gums or Buccal Mucosa: Upon combined inspection and palpation, patients mucosa is pinkish in color and is soft, moist and smooth. There were no edema, retraction, bleeding and lesions present. There was no tenderness upon palpation. Teeth: Dental carries noted. Yellowish in color. Has 6 false teeth and wears dentures. Hard Palate: Patients palate is whitish and is domed shaped. Presence of

52

wound on hard palate. Tongue: The dorsum of the tongue is dull red, moist and its texture is slightly rough on the top surface, and smooth along the lateral margin. There are no deviations and limitations in movement observed when the patient is asked to move her tongue from side to side. The ventral surface of the tongue is pinkish in color. Large veins are noted between the frenulum folds. Partially met. Skin: Color: Has brown skin complexion and skin color is the same with other body parts. Moisture: Skin is moist due to the lack of

52

For proper management of food intake For immediate medical interventions

Collaborative: Refer to dietician for proper diet

Refer to physician any untoward reactions or abnormal

proper ventilation of the ward. Temperature: Patients skin is cold upon touching due to the presence of sweat. Texture: Patients skin on the posterior forearms is rough due to the presence of lesions. Mobility: asHaHas a good skin mobility and turgor. Edema: mild edema

on the feet noted.

52

SECOND TRIMESTER

52

CUES/EVIDENCES Subjectives: Verbalized, Dili ko kada adlaw makalibang. Verbalized, gahi akong tae ikalibang, mukaon na lamang kog kapayas para man dawn a muhumok ang tae. Verbalized Usahay way gana ikaon, unya pilian napod ko sako mga gipanagaon sukad sakong pagmabdos.

NURSING DIAGNOSIS Constipation related to pregnancy

OBJECTIVES Within our days of care, client will show signs of improved condition as evidenced by: a. Daily bowel movement b. Increase fluid intake c. Ease in defecation solid, soft stool.

INTERVENTION

RATIONALE

Independent Give more fluids

EVALUATION At the end of our nursing care, client showed improved condition as evidenced by: Met. Client was able to defecate everyday without any problems of having a hard stool Met. Verbalized, Pirme nakong gaiinom og tubig og mukaon og mga kapayas haron makahumok sakong tae.

Increase fluid intake will facilitate in easy defecation Increase fluid intake will facilitate in easy defecation

Note color, odor, consistency, amount and frequency of stool

To address the client needs and habits need to be changed. According to Callista Roys Adaptation Model Nursings goal is to contribute to the overall goal healthcare, that is to promoting the health of individuals and society. Adjusting

Objective: v/s T = 36.9 0C P = 87 bpm R = 23 cpm BP = 150/100 mmHg Bowel sounds = 3/min Introduce fiberrich food and interventions that can suit their rconomic status

53

THIRD TRIMESTER

55

CUES AND EVIDANCES Subjective: Verbalized.Nanghu bag akong mga tiil og kamot. Objectives: 9/14/10 PR: 80 bpm RR: 17 cpm Tempe rature: 36.5 oC BP: 140/90 mmHg Edema on extremitie s noted.

NURSING DIAGNOSI S Risk for excess fluid volume related to sodium retention secondary to preeclamps ia

OBJECTIVES Within our days of care, client will maintain adequate fluid volume and electrolyte balance as evidenced by: a. Absence of edema.

INTERVENTIONS

RATIONALE

EVALUATION At the end of our nursing care, the mother manifested improved condition as evidenced by:

Independent: Assess patience hydration status

b. Adequate urinary output of 30ml/hr. c. Increase fluid intake.

Observe urinary output, color, measure the amount, and specific gravity. Review lab data(Hb/hct serum electrolytes) Introduction of fluids.

To obtain baseline data. Determine alteration in fluid volume and electrolyte imbalance.According to Jea Orlandos Nursing Process Theory, nursing is a a cycle wherein assessment does not stop. Serve as baseline data for alterations might need immediate interventions and could serve as danger signs in severe cases

Met. Decreased edema on feet.

Unmet. There had been no U/A data done..

-Met. Verbalized. Gasige rakog inom og tubig, mga 10-12 ka baso na ako ginainom sa isa ka adlaw. -Met. Verbalized. Nilikay nako pagkaon og mga tambok og asgad na mga paskaon.

Collaborative: Referral to the dietician regarding meal modifications avoiding high fat, high salt diet.

Prevent dehydration.

Diet high in fat predisposes the client to preeclampsia.

56