College of Allied Health Sciences School

Nursing

ASSESSMENT
Subjective Data:
The 31 year old female
patient reported that she has compromised fetal oxygen
a very light vaginal bleeding support as evidenced by
at 5 6/7 weeks age of
gestation. She also felt dizzy day.
and lightheaded. In addition,
she says that she had a left
uterine tubal ectopic
pregnancy managed with
laparoscopic salphingectomy.
She says that she is certain of
her last menstrual period date
and has regular cycles. Her
last pap smear test was
normal and she has not used
any contraception since her
last pregnancy last 3 years
ago. She says that she
smokes 10 cigarettes per day.
Objective Data:
- Initial Vital Signs:
BP = 130/80
HR = 75
RR = 20
Temp = 37.2’C
- Abdomen is not distended
and
no tenderness is elicited on
palpation.
- The cervix is closed and the
uterus feels normal size,
anteverted and
mobile, and there is no
cervical excitation.
- Gentle adnexal examination
NURSING DIAGNOSIS
Risk for disturbed maternal-
fetal dyad related to
insufficient prenatal care and
smoking 10 cigarettes per
PLANNING
After 3 hours of nursing
intervention, the patient will:
Short Term Goals:
- The patient will be
encouraged and feel supported - Assess the patient’s knowledge Hence, adherence to prenatal - The patient was
to stop smoking.
- The client will be educated on
the effects of smoking on their - Monitor fetal activity and heart and gas exchange are
body, lungs, and to the fetus. rate.
- The patient will verbalize
acceptance of health status
changes and the need to quit
smoking.
Long Term Goals:
- The patient will be able to
verbalize understanding of
conditions that disturb the
maternal-fetal dyad.
- The patient will be able to
identify her risk factors for the
disturbed maternal-fetal dyad.
- The patient will be able to
practice preventive measures
against disturbed maternal-fetal
dyad.
NURSING
INTERVENTIONS
- Assess the patient’s history of - A healthy pregnancy can After 3 hours of nursing
prenatal visits and compliance.
- Review the patient’s health
history and risk factors.
of conditions that may disturb the visits is crucial.
maternal-fetal dyad.
- Offer resources for substance
abuse.
- Intervene when psychological conditions that may disturb - The patient verbalized
needs arise.
RATIONALE EVALUATION
be achieved when the patient intervention, the goal was
receives early and consistent met as evidenced by:
prenatal care. Lack of
prenatal care might endanger Short Term Goals:
the mother and the fetus.
encouraged and felt
supported to stop
- Uteroplacental blood flow smoking.
directly affected by other - The client was educated
comorbidities. on the effects of smoking
on their body, lungs, and
- Pregnant patients can to the fetus.
actively prevent or manage
the maternal-fetal dyad if acceptance of health
they are well-informed. status changes and the
need to quit smoking.
- Assess the status of the
fetus including the fetal heart Long Term Goals:
rate (FHR), growth, and
activity as well as measuring - The patient verbalized
amniotic fluid and placenta understanding of
health through routine conditions that disturb the
ultrasounds. maternal-fetal dyad.
- The cessation of smoking, - The patient identified
alcohol, and drugs is vital to her risk factors for the
maternal and fetal health. disturbed maternal-fetal
Offer support groups and dyad.
resources for help in
controlling addiction and - The patient practiced
substance use. preventive measures
against disturbed
- Depression and other maternal-fetal dyad.
mental health conditions can
worsen during pregnancy.
Routinely assess for
increased stress and changes
in mood and alert the
healthcare provider.
Name: Cabauatan. Zeeya Aleeya Maree C. Section: BSN 2-7 Date: September 07, 2023