College of Nursing

Name: James Matthew A. Macanlalay Date: 23/09/2021

Year & Section: BSN 2-A Submitted to: Prof Rufina Salvador

Assessment Nursing Diagnosis Planning Intervention Rationale Evaluation

Activity Short term: Independent:  To provide Short term

intolerance baseline data
Subjective: After of 4 hours of  Assess the After of 4 hours of
related to for future
nursing intervention the status of the nursing intervention the
“My abdomen was ligament pain as comparisons.
abdominal pain client and the patient show improve
aching that radiate to my evidenced of
experienced by the fetus. condition as evidenced of
lower back and urge me to narrowed focus
patient will be lessened
push to facilitate labor” as and facial  To help relives
and used identified to
verbalized by the patient grimacing pressure of the
enhance activity  Encourage bed a.) Normal facial
fetus to the
intolerance. rest with expression, and can focus
cervix.
patient in side well.
Objective: Possible
lying position
preeclampsia as
-Narrowed focus Long term:
evidenced of  Uterine and
130/90 mmhg  Apply external b.) Used identified to
-Continued Uterine fetal wellbeing
uterine and enhance activity
contraction provide
After of 2 days of fetal intolerance.
evidence of
-Facial grimacing nursing intervention the monitoring.
maternal and
patient will be free from
-Body malaise fetal wellbeing.
abdominal pain and Long term:
safely deliver the baby.
 Maternal pulse
V.s taking as follows over 120 beats
BP- 130/90 mmhg  Monitor patient per minutes can After of 2 days of nursing
vital signs lead to chest intervention patient was
PR- 90 bpm
closely, every pain, dyspnea, not showing abdominal
RR- 24 cpm 15 minutes. and pain and successfully
adventitious deliver the baby.
Temp.- 36.9 degrees breath sound.
centigrade

 Early
recognition of
possible
adverse effect
allows for
 Instruct patient prompt
to report any intervention,
feelings of
difficulty of
breathing,
chest pain, or
dizziness.

 Monitor of
uterine
contraction
provides
 Monitor uterine evidence of
contraction effective
including therapy.
frequency and
domain.
  To lower high
blood pressure.

Dependent:

 Administer
antihypertensiv
es as prescribed
by the
physician

Collaborative:  Urine, vaginal

and cervical
cultures help to
rule out
 Obtain
infection as a
diagnostic
causative factor
including
for early term
complete blood
labor.
count,
hemoglobin,
and hematocrit,
urine, vaginal
and cervical
cultures as
ordered.