Assessment Nursing Goal Nursing intervention Rationale Evaluation

diagnosis
Subjective Objective Nursing care planned Nursing care given To determine The client
Patient Patient looks To ascertain the understanding of Ascertained the understanding what information demonstrated
complaining very weak. Altered Patient individual nutritional needs for of individual nutritional needs to provide to interest in
of not feeling nutritional status demonstrates pregnancy. of pregnancy. client. having food.
of urge to eat. less than body progressive weight
requirements gain towards goal. Discussed eating habits To identify the
related to To discuss eating habits, including food preferences to interest of client.
pregnancy as including food preferences to appeal client’s likes and
evidenced by appeal clients likes and dislikes. dislikes.
refusal to eat
food. To assess weight and activity/rest Assessed weight and Provide us the
level. activity/rest level. Wt-45 Kg. baseline data.

To assess the total daily food Assessed the total daily food Helps in further
intake and maintain diary of intake and maintain diary of care of the client.
calories intake. calorie intake..
Helps to maintain
To provide diet modifications Provided diet modifications the adequate
with increase protein, with adequate amount of nourishment
carbohydrate and calories. protein, carbohydrate and required.
calories. To increase the
intake of diet to
Encouraging client to take small Client is ready to take small-2 improve
and frequent diet in small -2 diet in frequent interval of time. nutritional status.
intervals of time.
Helps the client to
develop interest in
Encouraged client to choose having food.
To encourage client to choose foods that are appealing to
foods that are appealing to stimulate appetite. To see the
stimulate appetite. effectiveness of
intervention.
Reassessment done.
Reassessment

Assessment Nursing Goal Nursing intervention Rationale Evaluation

diagnosis
Subjective Objecti Nursing care planned Nursing care given The client
 ve Risk for growth The client will reported that
The client Patient retardation report To assess the fetal well Evaluated the fetal Helps to know fetus is
complaints looks related to measurable being. condition. the fetal moving
about size tensed. oligohydraminos increase in wellbeing. normally.
of abdomen . abdomen sie. To assess the fetal heart Monitor the vitals signs.
not rate. T- 98.40F
according to P-80/min To reduce over
gestational To advice patient to R-22/min exertion and
period. adequate rest. BP-130/90 mmHg fatigue.
FHS- 136/min
To administer parental Helps to
nutrition such as nutriflex. Advice patient to take rest conserve
properly. energy
To assess the daily fetal
movements. Advice patient to take food
on time and eat properly.
This enhances
the well-being
Encouraged client to of the client.
maintain a positive
attitude.

Assessment Nursing Goal Nursing intervention Rationale Evaluation

 diagnosis
Subjective Objective Disturbed sleep Nursing care planned Nursing care given The client
Patient Patient is not pattern related The client Assess vitals signs of the client. Assessed the vitals signs of the Elevated blood reported of
verbalized that sleeping to shortness of verbalizes mother. pressure is usually being rested and
she easily during night breath and understanding on T-980F observed in sleep more relaxed.
wakes up and day. frequent the cause of sleep P-88/min disturbed clients.
whenever she urination disturbance and R-28/min
hears noise. secondary to reports increased BP-140/90mmHg
Furthermore, pregnancy. sense of wellbeing Voiding before
she reported and feeling of Encourage client to void before bedtime limits the
frequent rested. sleeping. Encouraged client to void sleep disturbance.
awakenings before sleeping.
during the
night to go A quiet
bathroom due environment
to increase Provided a quiet environment promotes
urge to urinate conducive for sleeping. Provided a quiet environment continuation of
which conducive for sleeping. sleep without
happened disturbance.
around 5
times. She felt This promotes
slight pain on relaxation and
the area near Encouraging client to drink a readiness for
her buttocks glass of milk or to take bath Encouraged client to drink a sleep.
due to the before sleeping. glass of milk or to take care
pressure she before sleeping. To check change
feels on her in condition.
chest which Reassessment
affects her Reassessment done.
breathing.

Assessment Nursing Goal Nursing intervention Rationale Evaluation

diagnosis
Subjective Objective Nursing care planned Nursing care given This gives a The client
The mother Contour of Disturbed body The client will To assess the readiness of the Assessed the readiness of the mother a sense of perceived the
verbalized that the abdomen image related to express positive client to accept changes in body mother to accept the changes in control over the pregnancy in a
she feels sad changes and change of feeling towards self image. the body image. situation. positive manner
about her presence of appearance and significant and claimed that
physique and linea nigra associated with others. To employ a care calm, confident Employed a caring calm This improves the she is excited to
body image. on the pregnancy. and non judgemental approach confident and non judgmental nurse patient see her baby.
abdomen. towards the mother. approach towards the mother. relationship with
the client.
The client will Discussed with the client the
verbalize To discuss with client the physiological changes during This creates a
acceptance of body physiological changes during the pregnancy. sense of trust and
image. pregnancy. at the same time
educate the client
about the changes
during the
pregnancy.
Allowed the client to express
To allow client to express her her feeling towards her This creates a
feeling towards her pregnancy. pregnancy. positive outlet for
expression of
Taught the client coping feelings.
To teach client coping strategies. strategies. This helps to
overcome
maladaptive
behaviour.
To monitor the vitals signs of the Monitored the vital signs of the
client. mother. This provides a
T-980F base line data.
p-82/min
r -28/min
BP- 130/90 mmHg.

Reassessment. Reassessment done

To check change
in condition.

Assessment Nursing Goal Nursing intervention Rationale Evaluation

diagnosis
Subjective Objective The client will Nursing care planned Nursing care given This helps to The client
The client The client Anxiety related acknowledge and To assess the level of anxiety Assessed the level of anxiety identify the areas verbalized a
verbalized exhibits poor to discuss fears through verbal and non-verbal through verbal and non-verbal of concern that decrease in the
concern about eye contacts hospitalization Recognizing cues. cutes. might interfere anxiety level.
the upcoming and child birth healthy and with interfere
delivery and unhealthy fears with the normal
express verbalizes control progress labour.
worries about over the situation.
childbirth. This enhances the
To employ a caring a calm and Employed a caring, calm and nurse-client
non judgemental approach. non-judgemental approach relationship.

This promotes
To allow the client to express Allowed client to express her healthy outlets
fears and feelings of anxiety fears and feelings of anxiety Of emotions and
appropriately. appropriately. relives anxiety.
Adequate
To acknowledge normalcy of fear Acknowledged normalcy of explanation
and provide opportunity of fears and provided opportunity reduces anxiety
questions and answer honestly for questions and answered and soothes fear
within clients level of honestly within mother’s level and provides
understanding of understanding. assurance.

Offered support by staying close This provides a

To offer support by staying close to the mother. sense of security
to the mother. and trust between
the nurse and the
client.