NURSING CARE PLAN

(O.B.)
Submitted by: BSN 3Y2- 9B
Nesnel Martin
Katherine Mondero
Danity Medina
Aiza Osabel
Jave Miolata
Joana Matitu
Frederick Murillo
Ezalene Palo
Jaypee Tesalona
Mark Mercado
Neil Montefalcon
Christine Samin
Nico Manio

Assessment Background Diagnosis Planning Intervention Rationale Evaluation

 knowledge
Decreased in Altered bowel After 8 hours of -Established -To gain cooperation After 8 hours
Subjective: normal movement nursing rapport to the through out the of nursing
“hirap akong frequency of related to intervention the client care. intervention
madumi ngayon ang defecation pregnancy as client will be the client were
tigas kasi minsan.” accompanied by evidenced by able to defecate -assess current -change in meal able to
As verbalized by the dry, hard stool. eating 3 meals atleast once in activity level and time, type of foods, defecate
client. in a day and my shift. tolerance in eating disruption of atleast once in
Increased insufficient unusual schedule my shift.
Objective: progesterone physical activity. can lead to
-Client in Regular level due to constipation.
diet Eating 100% pregnancy -encourage to take -easily soften the
3meals in a day. of atleast 8 glass stool and
of water /day. dehydration can
-Slow in general Decreased contribute to
movement even peristaltic constipation.
while at bed rest. movement of -encourage to eat -to increase
the Gastro or add in a diet peristaltic movement
Intestinal tract foods rich in fiber and soften the stool.
(fruits,cereals and
green leafy
Constipation vegetables.)
-encourage -ambulation
ambulation with strengthen the
assist in tolerance. abdominal muscle
that facilitates
defecation.
-evaluate -iron supplements
medication if any and other can
usage that may contribute to
contribute to constipation.
constipation.

Assessment Background Diagnosis Planning Intervention Rationale Evaluation

 knowledge
Edema means Fluid Volume After 8 hours of -Established -To gain cooperation After 8 hours
Subjective: swelling in the Excess related Nursing rapport to the throughout the care. of Nursing
“nagmamanas yung small spaces to Pregnancy as Interventions client. Interventions
binti ko at paa.” that surround evidenced by the client will be -regular -to more accurately the client was
As verbalized by the the body tissues edema able to: monitoring of I&O determine the fluid able to:
patient. and organs. formation, visual and weight same excess.
Edema can changes and -maintain fluid time using hospital -maintained
Objective: occur nearly stretched shiny volume at a gowns everyday. fluid volume at
-visual anywhere in the skin. functional level. -encourage to -A high sodium level a functional
changes body. Reduce sodium causes or level.
-demonstrate a intake aggravates fluid
-edema formation Increased positive attitude In the diet. retention. -demonstrated
on progesterone toward the the positive
the lower level due to nurse’s -encourage -regular exercise attitude toward
extremities pregnancy. teaching. ambulation or stimulates the health
exercise. circulation. teaching.
-stretched shiny
skin. Increased
aldosterone that, -Elevation of the - stimulates excess
legs. Placing the fluid re-entry into
legs at least 12 the circulatory
Increased inches (30.5 cm) system
sodium (Na) and above the level of
water retention. the heart for 10-15
minutes, three to
four times a day.
Formation of -Use of support -it will compress the
Edema. stocking. Elastic leg vessels,
stockings. promoting
circulation and
decreasing
pooling of fluid due
to gravity.
- Massage the - Massaging the
 affected part or body part can help
muscles. to stimulate the
release of excess
fluids, but should be
avoided if the
patient has blood
clots in the veins.

-Avoidance of -it facilitates

prolong standing formation of edema.
without moving.

Assessment Background Diagnosis Planning Intervention Rationale Evaluation

 knowledge
High blood Ineffective After 8 hours of -Monitor VS -To identify After 8 hours of
Subjective: pressure tissue perfusion Nursing particular BP physiological Nursing
“nahihilo ako disorders of r/t constriction Intervention the responses Intervention the
masakit ulo at batok pregnancy. of blood vessel client will able to associated with client was able
ko “ as manifested display medical to display
“ang bilis kong Vasospasm by elevated hemodynamic conditions. hemodynamic
mapagod” Blood Pressure blood pressure blood pressure
As verbalized by the as evidenced by within normal -Monitor I/O -To determine within 130/80.
patient. discomfort due range or if not the fluid volume
Vasoconstriction to headache. decline into balance.
Of the blood 130/80.
Objective: vessel -Promote adequate -To maximize
rest by decreasing rest and sleep
-BP- 140/190 stimuli.

- Discomfort due to Decreased tissue -Encourage -To reduce

headache. perfusion relaxation anxiety
technique.

-Administer -To decrease

Decreased antihypertensive and control the
oxygen supply drug analgesic as Blood Pressure.
prescribed by the
physician
Decreased
Cardiac -Administer -To prevents or
Output(CO) magnesium sulfate control seizures
as ordered in pre-
eclampsia.
Increased blood
pressure