Name of Patient: E.O. Age/ Sex: F/ 16 Room/ Bed No.
: DR1-2
Chief Complaint: Uterine Contraction Physician: Dr. Ang
Diagnosis (if Discharged):_________________________________________________________________________________________________
Date/ Nursing
Cues Need Nursing Diagnosis Goal of Care Nursing Interventions Evaluation
Time Implication
F Subjective: C Deficient After 8 hours of 1. Assess patient’s/couple’s February 4, 2020
E - “Abi nakog O Knowledge related nursing knowledge of the disease @ 7AM
B normal ra ang G to insufficient intervention, the process. Provide “GOAL MET”
R sakit na akong N information as patient will be able information about
U gina bati” I evidenced by to: pathophysiology of PIH, After 8 hours of
A verbalized by T insufficient - identify implications for mother and nursing intervention
R the patient. I knowledge signs/symptoms fetus; and the rationale for the patient was able
Y - Patient said, V requiring medical interventions, procedures,
3 to:
“Sige daw E Rationale: evaluation. and tests, as needed. a. identify
3 gang pasabti - People need - verbalize R: Establishes data base signs/symptoms
, daw ko ana” P information they understanding of and provides information. requiring medical
2 E can understand disease process Provide information about evaluation.
0 R and use to make and appropriate areas in which learning is b. verbalize
2 C the best decisions treatment plan. needed. Taking information understanding of
Objective:
0 E for their health. - initiate can improve understanding disease process and
-
P “Limited health lifestyle/behavior and reduce fear, helping to appropriate treatment
misinterpretati
@11:30 T literacy” happens changes as facilitate the treatment plan plan.
on
PM U when people’s indicated. for the client. Note: Current c. initiate
- request for
A literacy and research in progress may lifestyle/behavior
information
L numeracy skills provide additional treatment changes as
- statement of
are poorly options, such as using low- indicated.
misconception
matched with the dose (60 mg/day) aspirin to
s
technical, reduce thromboxane
complex, and generation by platelets,
unfamiliar limiting the
information that severity/incidence of PIH.
organizations 2. Provide information
make available or about signs/symptoms
health services indicating worsening of
4
are too complex condition, and instruct
and difficult to patient when to notify
understand and healthcare provider.
use effectively. R: Helps ensure that patient
seeks timely treatment and
may prevent worsening of
Source: preeclamptic state or
Understanding additional complications.
8
Health Literacy. 3. Have patient informed of
(2019, October health status, results of
22). Retrieved
from when tests, and fetal well-
[Link] being.
ov/healthliteracy/l R: Fears and anxieties can
earn/Understandin
be compounded when
[Link]
patient/couple does not
have adequate information
about the state of the
disease process or its
impact on patient and fetus.
4. Educate patient on how
to monitor her own weight
at home, and to notify
5
healthcare provider if gain
is in excess of 2 lb/wk, or
0.5 lb/day.
R: Gain of 3.3 lb or greater
per month in second
trimester or 1 lb or greater
per week in third trimester
is suggestive of PIH.
7
5. Educate and assist
family members in learning
the procedure for home
monitoring of BP, as
indicated.
R: Encourages cooperation
in treatment regimen,
allows immediate
intervention as needed, and
may provide reassurance
that efforts are beneficial.
6. Review techniques for
stress management and
diet restriction.
10
R: Strengthens importance
of patient’s responsibility in
treatment.
7. Provide information
about ensuring enough
protein in diet for patient
6
with possible or mild
preeclampsia.
R: Protein is essential for
intravascular
and extravascular fluid
regulation.
8. Review self-testing of
urine for protein. Reinforce
rationale for and
implications of testing.
9
R: A test result of 2+ or
greater is vital and needs to
be reported to healthcare
provider. Urine specimen
contaminated by vaginal
discharge or RBCs may
produce positive test result
for protein.
9. Determine priority of
learning needs within the
1
overall care plan.
R: This is to know what
needs to be discussed
especially if the patient
already has a background
about the situation.
Knowing what to prioritize
will help prevent wasting
valuable time
10. Assess barriers to
learning (e.g., perceived
change in lifestyle, financial
2
concerns, cultural patterns,
lack of acceptance by peers
or coworkers).
R: The patient brings to the
learning situation a unique
personality, established
social interaction patterns,
cultural norms and values,
and environmental
influences.
NICOLE ANNE M. ALCOBER BSN 2 – E
CLUSTERING
