REPUBLIC of the PHILIPPINES
City of Makati
NAME OF STUDENT: RAMOS, Louwella Faith M. YEAR/GROUP: II-BN CONCEPT: Maternal and Child Nursing
Subjective cues:
"Hindi ako makatulog ng
maayos, halos tatlong oras
lang na deretsong tulog sa
isang araw tapos putol-
putol na". As verbalized
by the Mother.
Objective cues:
-Pale conjunctiva, lips,
palm and skin.
-Frequent yawning
-Dark circles under the
eyes.
UNIVERSITY OF MAKATI
COLLEGE OF ALLIED HEALTH STUDIES
J. P. Rizal Extension, West Rembo, Makati City 1215
Telephone No. : (+632) – 881 – 1571
_____________________________________________________________________________________
CENTER OF NURSING
AREA: OB-Gyne Ward DATE: 18 March 2021
Disturbed sleep Sleep problems are Short Term Goal: Independent: Short Term Goal:
pattern related to common After 4 hours of After 4 hours of
uncomfortable complaints among nursing >advise to nursing
environment as pregnant women. intervention the establish regular >To promote good intervention the
manifested by pale This study was client will bedtime and sleeping pattern client was able to
conjunctiva, lips, designed to demonstrate wakeup time and a demonstrate
palm and skin compare subjective relaxation skills short daytime nap. relaxation skills
frequent yawning sleep problems in and other methods and other methods
and dark circles non-pregnancy to promote sleep. >Advise to take >To promote feeling to promote sleep.
under the eyes. condition, healthy warm bath before of freshness before
and preeclampsia Long Term Goal: bedtime. sleeping. Long Term Goal:
pregnancy as a After 1 day of After 1 day of
major complication nursing >To promote nursing
comfort while
of pregnancy. We intervention the >Advise to wear intervention the
hypothesized that client will be able loose- fitting shirts. sleeping. client was able to
some sleep to sleep at least 8 sleep at least 8
problems are more hours a day. hours a day.
prevalent in
Vital Signs: females with >Advise to drink 1 >Milk contains
-BP 145/100 preeclampsia. glass of warm milk tryptophan, a
-PR 100 bpm before sleeping. precursor of
-RR 18 cpm Source: serotonin, which is
-Temp 36.6 Khazaie, H., thought to induce
Heidarpour, A., and maintain sleep.
Nikray, R., Rezaei,
M., Maroufi, A., >encourage >To avoid
Moradi, B., voiding before interruption in the
Ghadami, M. R., going to sleep. middle of sleep.
Malek-Khosravi, S.,
& Tahmasian, M.
(2013). Evaluation of
Collaborate:
sleep problems in >To reduce noise
>Advise the
preeclamptic, destruction for the
roommates to
healthy pregnant comfortable sleep of
lower their voices
and non-pregnant the patients.
and prevent noise
women. Iranian
journal of psychiatry,
at bedtime
8(4), 168–171.
 Self-care deficit Pregnant women After 2 hours of Independent: Goal met, patient’s
Subjective cues: related to with preeclampsia nursing hygiene was
decreased strength have high blood intervention the >Assess client’s maintained after
and endurance as pressure and signs client will: psychological >Physical pain assisting her and
"Kailan ko kaya maire-
evidence by of liver or kidney status. experience may be encouraging her it
resume ang normal na compounded by
gawain ko". As verbalized inability to damage. Kidney -Verbalized of perform it by
mental pain that
by the Mother. ambulate damage results in inability to interferes with herself.
independently. the presence of participate at level client’s desire and
protein in the desired. motivation to assume
urine. autonomy.
Objective cues: Preeclampsia that -Demonstrate
occurs in women techniques to meet >Offer assistance >Improves self-
-Inability to ambulate
after the 20th week self-care needs. as needed with esteem; increases
independently. feelings of well-
of pregnancy. It hygiene (e.g.,
can be mild or -Identify/use Mouth care, being.
-Patient cannot mobilized
and severe. available Bathing, back rubs
Preeclampsia resources. and perineal care).
Vital Signs: usually resolves
-BP 145/100 after the baby is -Provide and assist
-PR 100 bpm born and the in self-care >Offer choices >allows some
-RR 18 cpm placenta is activities. when possible autonomy, even
-Temp 36.6 delivered. (e.g., selection of though client
However, it may juices, scheduling depends on
persist or even of bath, destination professional
begin after during assistance.
delivery, most ambulation).
often within 48
hours. This is
called postpartum
preeclampsia.
Source: Collaborate: >Reduces
Preeclampsia - self- >Administer discomfort, which
care: MedlinePlus analgesic agent 3-4 could interfere with
Medical hr., as needed. ability to engage in
Encyclopedia self-care.
 Activity Insufficient physiological After 2 hours of Independent: Goal met, as
Subjective cues: Intolerance or psychological energy nursing patient did short
related to to endure or complete intervention the >Assess patient’s >To assess patient’s range of motion
weakness. required or desired daily client will: level of mobility condition exercises and
"Hindi ko na kaya,
pakiramdam ko activities. Physical tolerated the
nanghihina ako". As activity (PA) is -Increase exertion after
verbalized by the hypothesized to reduce tolerance to >Assess potential >To prevent encouraging her.
Mother. the risk of preeclampsia, simple activity. for physical injury potential hazards
but few epidemiologic . with activity (falls
studies have or over exertion).
simultaneously evaluated
Objective cues: leisure time PA (LTPA),
sedentary activity, >Assess patient’s >To assess patient’s
-Decreased activity ability to carry out
occupational activity, and cardiopulmonary
non-occupational, non- status before activities
-Weak appearance
leisure time PA. Thus, we activity
Vital Signs: assessed the independent
-BP 145/100 and combined effects of >To gradually
-PR 100 bpm these different types of >Assist for increase tolerance
-RR 18 cpm PA during pregnancy on ambulation and to activities and
-Temp 36.6 preeclampsia and short range of make patient
gestational hypertension motion exercises independent
risk. as tolerated.

Source:
Spracklen, C. N., Ryckman,
K. K., Triche, E. W., & Saftlas,
A. F. (2016). Physical Activity
During Pregnancy and
Subsequent Risk of
Preeclampsia and Gestational
Hypertension: A Case Control
Study. Maternal and child
health journal, 20(6), 1193–
1202.
https://doi.org/10.1007/s10995-
016-1919-y