ASSESMENT DIAGNOSIS GOAL INTERVENTION RATIONALE IMPLEMENTATION EVALUATION

Subjective data Asses the patient The assessment Assessed the patient The patient
The patient says Excessive fluid condition. will help the condition bleeding was
that I have and electrolyte The patient will healthcare team slightly reduced
spotting loss related to get relieve from determine if
bleeding as bleeding interventions to
evidenced by prevent early
verbalization labor are possible.

Assess the fetus Any increase or Assessed the fetus for

for distress by decrease of fetal distress by checking
checking the fetal movement can the fetal heart rate
heart rate and indicate fetal FHS-128 beats per
movement. distress that may minute
require further
assessment.

Objective data Provide To reduce Provided comfortable

Bleeding comfortable bleeding position to the patient
position to the supine with hip
patient elevated position.
Administer iv To restore the Administered iv
fluids fluid volume fluids as per the
doctor’s order

Evaluate report Estimation of Evaluated report and

and record blood loss record amount and
amount and nature of blood loss
nature of blood intiate pad count
loss initiate pad weighs pad and under
count weigh pads pad as required.
and underpad as
required

.
Assessment Diagnosis Goal Intervention Rationale Implementation Evaluation
Subjective data Fear and anxiety The patient will Assess the general To get a baseline Assessed the The patient
related to baby’s get relieve from condition of the data general condition relieved from fear
The patient says condition as fear and anxiety patient. of the patient and anxiety
that I have fear evidenced by
and anxiety about anxious face
the baby’s
condition Educate the
patient regarding To get more Educated the
the disease knowledge patient regarding
condition and its the disease and its
management management

Objective data Educate the Educated the

Anxious face patient regarding To promote patient regarding
deep breathing relaxation deep breathing
exercise exercise

Provide calm and To promote Provided the calm

quiet environment relaxation and quiet
to the patient environment to
the patient
Assessment Diagnosis Goal Intervention Rationale Implementation Evaluation
Subjective data Deficit knowledge The patient will get Assess the general To get a baseline Assessed the The patient got
related to disease adequate condition of the data general condition adequate
The patient says and its knowledge patient of the patient knowledge
that I have no management as regarding the regarding the
knowledge about evidenced by condition disease and its
my condition frequently asking Educate the patient To get more Educated the management
questions regarding the information patient regarding
disease and its the disease and its
management management

Provide health To improve the Provided health

education knowledge education
regarding the regarding the
management of management of
placenta previa placenta previa

Objective data

Frequently asking
questions
 Name Dose Route frequency Action Indication contraindication Side effect Nurses
of the responsibility
drug
Livogen Oral Od Iron  Low levels of red Hypersensitivity Iron is likely safe Administer IM
(ferrous blood cells in people for most people or IV iron when
fumarate, with a long-term Hemochromatosis when used in oral iron is
ferrous illness (anemia of doses below the poorly absorbed.
gluconate, chronic disease). Hemosiderosis tolerable upper Perform
ferrous Taking iron intake level (UL) sensitivity
sulfate) is by mouth or by IV of 45 mg testing of IM
used to treat along with Anemia not elemental iron iron injection to
or prevent other medications suc caused by iron daily. It can cause avoid risk
anemia (a h as epoetin alfa can deficiency side effects such of anaphylaxis.
lower than help build red blood as stomach upset, Advise patient
normal cells and prevent or nausea, and to take iron
number of treat anaemia in vomiting. supplements an
red blood people with certain Taking iron hour before
cells) when chronic diseases. IV supplements with meals for
the amount products can only be food seems to maximum
of iron given by reduce side absorption; if
taken in a healthcare provider. effects. But food gastric distress
from the  Low levels of healthy can also reduce occurs, suggest
diet is not red blood cells how well the body taking the
enough. (anaemia) due to iron absorbs iron. supplement with
Iron is a deficiency. Taking Doses above the meals — resume
mineral that iron by mouth or by UL should only be to between-
is available IV is effective for used while under meals schedule
as a dietary treating and medical if symptoms
supplement. preventing anemia supervision. Iron subside.
It works caused by too little is likely unsafe Inform patient
by helping iron in the body. IV when taken in that iron salts
the body to products can only be excessive doses. change stool to
produce red given by dark green or
blood cells. a healthcare provider. black.
 Low iron levels during Advise patient
pregnancy. Taking to take liquid
iron by mouth during forms of iron via
pregnancy reduces the a straw and
risk of anemia caused rinse mouth with
by too little iron in the water.
body.
Name Dos rou Frequ Action Indication contraindica Side effect Nurses responsibility
of the e te ency tion
drug
Calciu 100 Oral Od Calcium plays Taking calcium Constipation Although there  Note number and
m mg a vital role in carbonate by mouth as and upset are no consistency of stools.
the anatomy, an antacid is effective stomach absolute contra  Determine serum and
physiology and for treating Nausea indications to c urine calcium weekly in
biochemistry indigestion. vomiting and alcium supplem patients receiving
of organisms loss of entation, some prolonged therapy and
High levels
and of the cell, appetite conditions in patients with renal
of potassium in the
particularly in Bone and should merit dysfunction.
blood (hyperkalemia).
signal muscle pain special  Record amelioration of
Giving calcium
transduction and weaknes consideration symptoms of
gluconate by IV can
pathways. The Mental and regarding calciu hypocalcemia.
reverse heart problems
skeleton acts mood m supplementat  Observe for signs and
caused by high
as a major changes, ion. These symptoms of
potassium levels. IV
mineral storage confusion, conditions hypercalcemia in
products can only be
site for the lethargy and include patients patients receiving
given by
element and fatigue with renal frequent or high doses,
a healthcare provider.
releases Ca2+ Increased impairment or or who have impaired
ions into the thirst and chronic kidney renal function.
Low levels of calcium
bloodstream disease (CKD)  Strain urine if flank pain
 under urination and history occurs.
in the blood
controlled Kidney of calcium-  Provide safety
(hypocalcemia).
conditions. problems and containing measures, including
Taking calcium by
Circulating kidney stones kidney stones. gentle handling when
mouth and by IV is
calcium is Heart moving clients.
effective for treating
either in the problems and  Identify and restrict
and preventing low
free, ionized irregular sources of calcium
calcium levels. IV
form or bound heartbeat intake such as dairy
products can only be
to blood Excess products, eggs, and
given by
proteins such calcium in spinach and calcium-
a healthcare provider.
as serum the blood containing antacids such
Kidney failure. Taking
albumin. (hypercalcem as Dicarbosil, Tums,
calcium carbonate or
Although ia), which and Titralac, if
calcium acetate by
calcium flow can be indicated.
mouth is effective for
to and from the dangerous if  Maintain bulk in the
controlling high
bone is neutral, not treated. diet.
phosphate levels in the
about 5 mmol
blood in people with
is turned over a
kidney failure..
day.