ASSESSMENT NURSING SCIENTIFIC GOALS OUTCOMES NURSING EVALUATION

DIAGNOSIS BASIS CRITERIA INTERVENTION

Subjective: Excess fluid If proteinuria is of Visibly After 24 hours of INDEPENDENT: After 24 hours of
“Ma’am, murak ni surok ako volume related to sufficient amount, and reduce nursing nursing interventions,
dugo kay labad unya lipong kidney damage persists for long edema in interventions, the  Instruct and explain the patient
kayo ako pamati”, as secondary to enough, then a series the face and patient to the patient the
verbalized by the patient. preeclampsia as of consequences feet and need to restrict  Was able to
evidenced by arises which is called reduce  Will have sodium in the diet. reduce edema in
weight gain the nephrotic weight from edematous Rationale: To reduce the face and feet
Objective: greater than syndrome. The most excess fluid tissues visibly the amount of fluid in the around 50%
BP: 180/100 mmHg normal, presence notable consequence volume. reduced by edematous tissues and
T: 37.4 C of protein in the of massive proteinuria 50% gain patient’s  Was able to lose
RR: 22 cpm urine, and edema is salt and water cooperation. weight of 0.2 kg
PR: 120 bpm in the face and retention leading to  Will achieve
Ht: 165 cm feet. edema formation. weight loss of  Inform and  Was able to
Wt: 89 kg This edema is found at least 0.2 kg encourage patient to explain the need
in association with incorporate exercise to reduce sodium
Weight gain of 1.5 kg within proteinuria usually  Will be able to in her daily routine in the diet.
one week; which is 1 kg greater than 3.5 explain the such as walking or as
more than the expected g/day, accompanied reason behind what she can
weight gain per week during by hypoalbuminemia, the restriction tolerate.
third trimester usually less than 25 of sodium in Rationale: Exercise
g/l. the diet. helps pump fluid back to
Visibly edematous face and the heart and reduce
feet edema.

Presence of albumin in urine  Instruct the patient

from dipstick test and to elevate feet above
urinalysis heart level for 30
minutes 3 to 4 times
a day.
Rationale: To help
reduce or eliminate
edema in the feet.
 Weigh the patient
daily at the same
time per day.
Rationale: To assess
the effectiveness of
interventions in
eliminating excess fluid.

DEPENDENT:

 Administer
medications as per
doctor’s order.
Rationale: Medications
such as diuretics are
provided to aid in fluid
elimination by increasing
urine output.

COLLABORATIVE:

 Refer to the
physician.
Rationale: to confirm
nursing diagnosis and
interventions
 ASSESSMENT NURSING SCIENTIFIC GOALS OUTCOMES NURSING EVALUATION
DIAGNOSIS BASIS CRITERIA INTERVENTION

Subjective: Excess fluid If proteinuria is of Visibly After 24 hours of INDEPENDENT: After 24 hours of
“Nanghupong man akong volume related to sufficient amount, and reduce nursing nursing interventions,
nawng ug tiil maam. Mura kidney damage persists for long edema in interventions, the  Instruct and explain the patient
nuon kog tambok kaayo tan secondary to enough, then a series the face and patient to the patient the
awn”, as verbalized by the preeclampsia as of consequences feet and need to restrict  Was able to
patient. evidenced by arises which is called reduce  Will have sodium in the diet. reduce edema in
weight gain the nephrotic weight from edematous Rationale: To reduce the face and feet
greater than syndrome. The most excess fluid tissues visibly the amount of fluid in the around 50%
Objective: normal, presence notable consequence volume. reduced by edematous tissues and
BP: 180/100 mmHg of protein in the of massive proteinuria 50% gain patient’s  Was able to lose
T: 37.4 C urine, and edema is salt and water cooperation. weight of 0.2 kg
RR: 22 cpm in the face and retention leading to  Will achieve
PR: 120 bpm feet. edema formation. weight loss of  Inform and  Was able to
Ht: 165 cm This edema is found at least 0.2 kg encourage patient to explain the need
Wt: 89 kg in association with incorporate exercise to reduce sodium
Wt (previous week): 87.5 kg proteinuria usually  Will be able to in her daily routine in the diet.
greater than 3.5 explain the such as walking or as
Weight gain of 1.5 kg within g/day, accompanied reason behind what she can
one week; which is 1 kg by hypoalbuminemia, the restriction tolerate.
more than the expected usually less than 25 of sodium in Rationale: Exercise
weight gain per week during g/l. the diet. helps pump fluid back to
third trimester the heart and reduce
edema.
Visibly edematous face and
feet  Instruct the patient
to elevate feet above
Presence of albumin in urine heart level for 30
from dipstick test and minutes 3 to 4 times
urinalysis a day.
Rationale: To help
reduce or eliminate
edema in the feet.

 Weigh the patient

daily at the same
time per day.
Rationale: To assess
the effectiveness of
interventions in
eliminating excess fluid.

DEPENDENT:

 Administer
medications as per
doctor’s order.
Rationale: Medications
such as diuretics are
provided to aid in fluid
elimination by increasing
urine output.

COLLABORATIVE:

 Refer to the
physician.
Rationale: to confirm
nursing diagnosis and
interventions
 ASSESSMENT NURSING SCIENTIFIC GOALS OUTCOMES NURSING EVALUATION
DIAGNOSIS BASIS CRITERIA INTERVENTION

Subjective: Disturbed Pregnancy and To provide After 8 hours of Independent: After 8 hours of nursing
“Tungod sa labad ulo nga sleeping pattern perinatal period patient with nursing interventions, the
sakit sa batok maam kay related to represent particularly comfort and interventions, the  Explain to the patient
wala jud koy tarung tulog headache and vulnerable periods help her ease patient patient what
dizziness as for women, due to into sleep in nursing  Have slept for 4
ay. Maglisod kog tulog nya
evidenced by anatomical, order to  Will have at least interventions you hours straight
kadyut rapud akong tulog patient’s hormonal, and obtain quality 4 hours of are about to do
kung makatulog man gani.” verbalization of psychological rest. uninterrupted with her.  Have verbalized she
insufficient sleep changes that sleep Rationale: To gain has had good rest
Objective: due to headache influence women’s patient
BP: 180/100 mmHg and dizziness, a global health. Poor  Will verbalize understanding and  Eye bags have
T: 37.4 C tired demeanor sleep is a common that she is well compliance slightly lightened.
RR: 22 cpm and presence of condition during this rested.
PR: 120 bpm eye bags. period especially  Manipulate
during the third  Will have her eye patient
Patient shows a tired trimester. 52-61% of bags environment
demeanor when women during the lightened/reduce such as adjusting
communicating. last eight weeks of d slightly air conditioner
pregnancy show according to
Patient has evident bags under reduced and poor patient’s comfort,
her eyes sleep quality. About switching off
25% of pregnant lights, help the
women report patient change
significant sleep into new bed
disturbances during sheets and into
the first trimester, clean clothing,
with rates rising up assist patient in
to almost 75% attaining proper
during the third hygiene (bath
trimester. and toothbrush),
and minimizing
noises from
surroundings like
turning down the
TV and closing
the doors.
Rationale: To help
the patient ease into
sleep and get quality
rest.

 Encourage
patient to lie
supine on bed
rather than on
chairs nearby.
Rationale: This
position supports
better sleep.

Dependent:
 Administer
medications as
ordered by the
doctor.
Rationale: To treat
the main cause of
sleep disruptions of
the patient.

COLLABORATIVE:

 Refer to the
 physician.

Rationale: to
confirm nursing
diagnosis and
interventions