ASSESSMENT DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATION

Objective Data: Imbalanced NOC: Nutritional NIC: Weight Gain Goal Met:
nutrition: less than Status: Nutrient Assistance/ Weight
Height: 180cm body requirements Intake Management
Weight: 57kgs related to
BMI: 17.59 insufficient dietary Short Term: Assess weight at each Provides information Short term:
intake as evidenced After 1 hour of visit and compare with about weight gain and After 1 hour of
by reports of BMI nursing interventions, previous weight and pattern of gain to nursing interventions,
below normal range the client will be able expected gains. monitor weight gain the client was able to
to verbalize progress. understand the
understanding of the Assess the client’s typical importance of weight
importance of weight dietary intake for over 24 Assessment will gain appropriate for
gain appropriate for hours. determine nutritional stage of pregnancy
stage of pregnancy intake and patterns so and pregnancy
and pregnancy that weight.
weight. suggestions/modification
s can be individualized.
Assess skin (texture, Long Term:
Long Term: turgor), hair, eyes, mouth Assessment provides After 1-2 weeks of
After 1-2 weeks of and nails for signs of additional information nursing interventions,
nursing interventions, inadequate nutrition. about general nutrition the client was able to:
the client will be able status. - obtain an
to: Assist client to compare acceptable
- obtain an her usual diet with the Involving the client in weight gain
acceptable food guide pyramid assessment and planning pattern.
weight gain recommendations for encourages compliance.
pattern. pregnancy. - ingest
adequate
- ingest Ask the client to list foods amount of
adequate in each food groups that Ascertaining food nutrients for
amount of she enjoys cooking or preferences and cultural maternal and
nutrients for eating. influences provides a fetal well-
maternal and baseline for future foods being.
LOYZ ANTONETTE V. SAQUING
KEITH APRIL T. TUMALIUAN
BSN – 2B
fetal well- selections and
being. suggestions.

Encourage the client to Ingestion of mentioned

increase her intake of foods are beneficial to
foods high in vitamin B6, ensure adequate
such as meat, poultry, nutrition is obtained by
banana’s, fish, green leafy the mother and fetus.
vegetables, peanuts,
raisins, walnuts and
whole grains, as tolerated.

Educate client to avoid Unprocessed, natural

highly-processed foods or foods contain the most
those with many artificial nutrients. Additives may
additives. adversely affect the fetus.

Reinforce needs for Provides additional

prenatal vitamins and nutrients that may be
iron, if prescribed. difficult to obtain by diet
alone.

Reinforce positive Reinforcement motivates

nutrient habits at each the client to maintain a
prenatal visit. healthy diet during
pregnancy.

Discuss the relationship Understanding the fetal

with optimal fetal growth needs provides incentive
and development. for obtaining optimum
nutrition.

Ask the client to record Keeping a journal

LOYZ ANTONETTE V. SAQUING
KEITH APRIL T. TUMALIUAN
BSN – 2B
 all food and fluid intake provides concreate
for 1 week; review with evidence of client’s
patient at next visit. adherence to nutrition
plan.

Consult with nutritionist Caloric

about recommended recommendations may
caloric and mineral need to be increased in
requirements. light of client’s BMI and
pregnancy weight, as
well as to assist with
proper and effective diet
planning.

ASSESSMENT DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATION

Subjective Data: Impaired urinary NOC: Urinary NIC: Urinary Elimination Goal Met:
elimination related Elimination Management
Patient reported to frequency
voiding frequently secondary to Short Term: Assess the client’s usual To establish a baseline Short Term:
at night. physiologic changes After 1 hour of bladder elimination data for comparison. After 1 hour of nursing
of pregnancy as nursing interventions, patterns. interventions, the client
evidenced by the client will be able was able to:
reports of frequent to: Review with client the This will promote - verbalize
urination at night. - verbalize physiologic basis for the understanding of the causative
causative increased frequency problem. factors related
factors related during pregnancy; inform to distended
to distendedclient that frequency bladder.
bladder. should abate during the
second trimester and it - identify
- identify will return during her measures to
measures to third trimester. address and
address and prevent
LOYZ ANTONETTE V. SAQUING
KEITH APRIL T. TUMALIUAN
BSN – 2B
 prevent Encourage the client to Emptying bladder impaired
impaired empty bladder when first helps to minimize risk urinary
urinary feeling a sensation of for urinary retention. elimination.
elimination. fullness.

Suggest client to avoid This can further Long Term:

Long Term: caffeinated drinks. stimulate the need to After 5 days of nursing
After 5 days of void. interventions, the client
nursing interventions, was able to report
the client will report Have client reduce her Reducing fluid intake decrease in urinary
decrease in urinary fluid intake 2-3 hours before going to bed complaints, as
complaints, as before bedtime. reduces night time evidenced by decrease
evidenced by decrease urination. in number of times she
in number of times she voided and reported
voids and reports Encourage the client to having empty bladder
empty bladder after maintain a dry and clean A dry and clean after voiding.
voiding. perineal area. perineal area prevents
irritation and
excoriation from any
leakage.
Educate the client about
the signs and symptoms Being knowledgeable
of urinary tract infection regarding the signs
and urge her to report if and symptoms ensures
ever they occur. early detection and
prompt intervention.

ASSESSMENT DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATION

LOYZ ANTONETTE V. SAQUING

KEITH APRIL T. TUMALIUAN
BSN – 2B
Subjective Data: Risk for deficient NOC: Fluid Balance NIC: Fluid/Electrolyte Goal Met:
fluid volume related Management
Patient reported of to gestational Short Term: Short term:
experiencing hormonal changes After 2 hours of Obtain weight and This is to determine After 2 hours of
nausea and as evidenced by nursing interventions, compare to baseline data. effects of nausea and nursing interventions,
vomiting reports of frequent the patient will be able vomiting to nutritional the patient was able to:
episodes of nausea to: intake. - identify
and vomiting. - identify measures to
measures to Assess skin temperature Indicators assisting in reduce
reduce and turgor, mucous evaluation of frequency and
frequency and membranes, temperature, hydration level/needs. severity of
severity of intake/output and urine nausea and
nausea and specific gravity. vomiting.
vomiting.
Examine 24-hour recall Documenting the - verbalize signs
- verbalize signs history and analyze for problem best identifies and symptoms
and symptoms fluid and nutrition its extent. of dehydration.
of dehydration. deficits.
Provides data
Determine regarding extent of
Long Term: frequency/severity of condition. Long Term:
After 5 days of nausea and vomiting. After 5 days of nursing
nursing interventions, Assists in ruling out interventions, the client
the client will be able Review history for other other causes and in was able to:
to: possible medical identifying - decrease the
- decrease the problems (e.g., peptic interventions to number of
number of ulcer, gastritis, address specific episodes of
episodes of cholecystitis) problems. nausea and
nausea and vomiting.
vomiting. It is important to stay
hydrated to restore - ingest
- ingest Ensure adequate fluid fluid losses and to individually
individually intake. maintain normal fluid appropriate
LOYZ ANTONETTE V. SAQUING
KEITH APRIL T. TUMALIUAN
BSN – 2B
 appropriate volume. amounts of
amounts of fluids daily.
fluids daily. It helps in minimizing
nausea. - demonstrate
- demonstrate Suggest to eat dry measures to
measures to crackers, toast, cereal, or maintain normal
maintain cheese and/or drink small fluid volume.
normal fluid amount of lemonade
volume. before arising. To reduce stimulation
of the vomiting center.
Encourage the client to
arise slowly from bed in
the morning and avoid
sudden movements. To prevent her
stomach from
Encourage the client to becoming empty.
eat five or six small Empty stomach can
frequent meals throughout worsen nausea and
the day. vomiting.

To avoid
overdistention of the
Advise client to drink abdomen and
fluids between meals subsequent increase in
rather than with meals. abdominal pressure.

Beverages like coffee

and other carbonated
Inform the client to avoid drinks causes acid
drinking coffee and other reflux/heart burn that
carbonated drinks. trigger nausea and
vomiting.

LOYZ ANTONETTE V. SAQUING

KEITH APRIL T. TUMALIUAN
BSN – 2B
 Ingesting these foods
leads to
Educate the client to gastrointestinal upset.
avoid greasy, fried, or
highly spiced foods and to
avoid strong odors,
including foods such as Wearing loose
cabbage. clothing minimizes
pressure on the
Encourage the client to expanding abdomen.
avoid wearing tight or
restricting clothes. Recognizing that
symptom is normal
can help a patient
Discuss with patient how accept discomfort.
nausea, although Nausea of pregnancy
uncomfortable, is a usual responds to many self-
symptom of early help measures.
pregnancy.
Nausea and vomiting
can become extreme if
not recognized as
Consult with nutritionist potentially-serious in
if nausea and vomiting early pregnancy.
interferes with eating
pattern in 1 week.

ASSESSMENT DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATION

LOYZ ANTONETTE V. SAQUING

KEITH APRIL T. TUMALIUAN
BSN – 2B
Subjective Data: Anxiety related to NOC: Anxiety control NIC: Anxiety reduction Goal met:
pregnancy and and coping
Patient expressed parenting. Establish therapeutic To build trust and to
anxious feelings After 3 hours of relationship, conveying gain cooperation in After 3 hours of
with regards to the nursing interventions, empathy, and positive dealing the problem. nursing interventions,
pregnancy and the patient will be able regard. the patient:
parenting roles and to: - demonstrated
responsibilities. - demonstrate Ask the client to rate To have a basis in decrease in
decrease in anxiety on a scale 1 to 10. assessing if the anxiety level of anxiety.
level of 1 as the lowest and 10 as lowers or worsens
anxiety. the highest. after implementing - discussed her
different nursing feelings.
- discuss her intervention.
feelings. Assess for physical signs - identified,
of anxiety like tremors, May cause the “fight verbalized, and
- identify, palpitation, nausea, or or flight” sympathetic demonstrated
verbalize, and tachycardia. response of the techniques for
demonstrate patient. controlling
techniques for Assess for mental and anxiety.
controlling emotional signs of
anxiety. anxiety. Some changes may - posture, facial
interfere with its expressions, and
- have a physical Encourage verbalization normal functioning. gestures
appearance that of fear or any feelings. reflected
reflect Communication can decreased
decreased alleviate level of anxiety.
anxiety. Communicate in a calm, anxiety.
simple and, brief manner.
Anxious patient may
not be able to
understand anything
more than simple,
clear, and brief
LOYZ ANTONETTE V. SAQUING
KEITH APRIL T. TUMALIUAN
BSN – 2B
Avoid asking too much or instruction.
forcing the patient to
make decisions. Anxiety can affect the
patient’s ability to
Explain all activities, make a sound
procedures, and issues decision.
that may occur in a
pregnant patient. Patient education
lessens anxiety,
emotional distress,
Consider the patient’s use and enhances coping
of coping strategies that abilities.
the patient has found
effective in the past. Enhances patient’s
sense of self-reliance.
Assist the patient to plan
new coping strategies for
anxiety during pregnancy.
To provide the client
Encourage patient to do variety of ways to cope
positive self-talk. with anxiety.

Positive self-
Provide nursing comfort statements aids to
measures like changes in reduce anxiety.
position, back rubs, and
therapeutic touch. Aids in reduction of
anxiety.
Encourage relaxation
exercises or activities.

Relaxation exercises
are effective
LOYZ ANTONETTE V. SAQUING
KEITH APRIL T. TUMALIUAN
BSN – 2B
 Encourage the patient to nonchemical ways to
listen to their choice of reduce anxiety.
music.
Music is a pleasing
Teach patient to visualize measure in alleviating
about the successful anxiety.
experience of the
situation. Guided imagery
reduces level of
anxiety.

ASSESSMENT DIAGNOSIS PLANNING IMPLEMENTATION RATIONALE EVALUATION

LOYZ ANTONETTE V. SAQUING

KEITH APRIL T. TUMALIUAN
BSN – 2B
Objective Data: Risk for NOC: Bowel NIC: Constipation Goal met:
Constipation related Elimination and Management
Folic Acid to effects of iron Hydration
supplement once a supplement Establish therapeutic To build trust and gain Short Term:
day. medication Short Term: relationship with the patient. cooperation. After 1 hour of
After 1 hour of nursing
nursing interventions, the
interventions, the Assess usual pattern of To have a baseline for patient was able to
patient will be able defecation, and stool what is normal to the identify measures
to identify measures consistency and frequency. patient. that prevent
that prevent constipation.
constipation. Discuss to the patient that To make the patient
constipation is a common understand why Long Term:
Long Term: side effect of the drug. constipation may occur. After 2 days of
After 2 days of nursing
nursing Assess usual dietary habits, Irregular mealtime, interventions, the
interventions, the eating habits, eating type of food, and patient maintained
patient will be able schedule, and liquid intake. interruption of usual a passage of soft,
to maintain passage schedule can lead to formed stool
of soft, formed stool constipation. without straining.
without straining. Assess the patient’s activity
level. Prolonged inactivity
can increase the risk
for constipation.
Encourage physical activity
within the client’s current Movement promotes
ability to mobilize. peristalsis.

Palpate for abdominal Bowel sounds can

distention, percuss for indicate occurrence of
dullness, and auscultate constipation.
bowel sounds.
LOYZ ANTONETTE V. SAQUING
KEITH APRIL T. TUMALIUAN
BSN – 2B
 Teach clients of the Ignoring this urge will
importance of responding result in decreased
promptly to the urge to bowel movement
defecate. frequency, stool weight,
and transit time.

Encourage the patient to Sufficient fluid is

take in 6 to 8 glasses of needed to keep the fecal
fluid daily. mass soft.

Encourage patient to intake Fiber adds bulk to the

dietary fiber. stool and makes
defecation easier.

Educate the client how to Correct position

adopt the best posture for facilitates an increase
defecation in abdominal pressure,
which makes defecation
more effective.

ASSESSMENT DIAGNOSIS PLANNING IMPLEMENTATION RATIONALE EVALUATION

Subjective Data: Readiness for NOC: Parenting, NIC: Attachment Goal met:
enhanced Parent-Infant Promotion,
Patient reported that parenting Attachment, Role Developmental
they have been Performance, Infant Enhancement, Parenting
planning a child for Development, Safety Promotion, Infant Care

LOYZ ANTONETTE V. SAQUING

KEITH APRIL T. TUMALIUAN
BSN – 2B
over a year now. Behavior: Home
Physical Environment Establish good rapport To create a level of
Patient expressed with the patient. trust and understanding
excitement to her Short Term: that will allow a good Short Term:
husband who is After 5 hours of communication After 5 hours of
feeling the same nursing interventions, nursing
upon confirming the the patient will be able Assess patient’s To have a basis on interventions, the
pregnancy. to: knowledge about where to start the patient:
- assess risks in parenting. intervention. - was able to
home/ identify risks
environment Assess for the influence What the client in home/
and identify of cultural beliefs, norms, considers normal environment
strategies to and values on the client's parenting may be based and made
prevent perception of parenting. on cultural steps to
possibility of perceptions.  prevent
harm to the Assess for maternal self- possibility of
child. efficacy. Negative feelings about harm to the
oneself is likely to child.
- desire to negatively influence
develop parenting. - affirmed
parenting skills Allow and validate desire to
to further patient’s feelings Promotes sense of develop
support infant regarding parenting. being heard and parenting
growth and understood. skills to
development. Encourage the patient to further
develop and acquire support
- verbalize positive parenting skills. Helps in achieving infant growth
realistic family relationship. and
information of Facilitate modeling and development.
parenting role. role-playing to help
family improve parenting To practice parenting - verbalized,
- identify own skills. skills in a safe “Parenting
strengths, environment before may be
LOYZ ANTONETTE V. SAQUING
KEITH APRIL T. TUMALIUAN
BSN – 2B
 needs, and trying them in real-life difficult, but
methods to Teach patient and situations  I am sure it is
meet them. significant other in worth it.”
developmental tasks. To provide information
that assists in - verbalized,
Long Term: responding realistically “Having
After 3 days of and appropriately to optimistic
nursing interventions, child’s needs at attitude can
the patient will be able Teach patients and different age level go a long
to: significant other in home way.”
- initiate and environment safety. To reduce the risk for
appropriate injury and promote
measures to Instruct patient and infant safety. Long Term:
develop a safe, significant other to After 3 days of
nurturing maintain their own It is important for the nursing
environment. health. parents meet their own interventions, the
needs to enable them to patient was able to:
- acquire better care their child. - initiate
positive Provide information appropriate
parenting about time management Promotes ability of measures to
behaviors. and stress reduction oneself to deal with the develop a
techniques. problems that may safe,
arise in the course of nurturing
family relationship. environment.

- acquire
positive
parenting
behaviors.

LOYZ ANTONETTE V. SAQUING

KEITH APRIL T. TUMALIUAN
BSN – 2B