Scientific

Assessm Diagnosi Interventio

explanatio Planning Rationale Evaluation
ent s n
n
S=Ø Impaired Placenta After Assess vital Provides After hours
O= fetal gas previa is hours of signs q 15 baseline data of nursing
Changes exchang the nursing minutes on the interventio
in fetal e r/t developme interventi maternal bloodns, the
heart altered nt of ons, the loss patient
rate or blood placenta in pt. will Maintain was able
activity flow and the lower verbalize bed rest or Systemic rest is to
decreas uterine understan chair rest mandatory and verbalize
Release ed segment ding of when important understan
of surface partially or causative indicated. throughout al ding of
meconiu area of completely factors Provide phases of dse. causative
m gas covering and frequent to reduce factors
exchang the appropria rest periods fatigue, and and
Slight e at the internal te and improve appropriat
change site of cervical os. interventi uninterrupt strength. e
in vital placenta The cause ons. ed night interventio
signs l is unknown time sleep. Provide ns.
except detachm but a objective
for the ent. possible Monitor evidence o
BP theory amt. and bleeding.
states that type of
the bleeding. To promote
embryo placental
will Position the perfusion.
implant in mother on
the lower her left Prevents
uterine side. tearing of
segment if placenta if
the Restrict placenta previa
deciduas vaginal is the cause of
in the examinatio bleeding.
uterine n.
fundus is
not Assess whether
favorable. labor is present
Complicati and fetal status
ons are Monitor and external
immediate fetal system avoids
hemorrhag contraction cervical
e, shock s and fetal trauma.
and heart rate
maternal by external Support mother
death; monitor. and child
fetal bonding.
mortality .
and post
partum Monitor
hemorrhag positive Provides
e. attitude adequate fetal
about fetal oxygenation
outcome. despite of
lowered
maternal
Administer circulating
oxygen as volume.
indicated
Assessmen Scientific Nursing
Diagnosis Outcomes Rationale Evaluation
t explanation Intervention
S- Ø Fluid Fluid volume After hours Assess color, Provides Pt. has no further
Volume deficient is a of nursing odor, information vaginal bleeding;
O- Deficient state in interventio consistency and about active Blood pressure is
Bleeding r/t Active which an n and amount of bleeding maintained at at
Episodes Blood Loss individual is medical vaginal bleeding; versus old least 100/60 mm Hg;
(amount, Secondary experiencing assistance, weigh pads blood, tissue PR <100 bpm; fetal
duration) to decreased Pt. loss and HR is maintained at
Facial Disrupted intravascular will exhibit degree of 120-160 bpm; UO
Grimace Placental , interstitial signs of Assess hourly blood loss >30ml/hr.
due of Pain Implantatio and/or adequate intake and
or no n intracellular fluid output.
complaint fluid. Active balance Provides
of pain Blood Loss or during information
Abdomen Hemorrhage pregnancy. about
soft/hard due to Assess baseline maternal and
when disrupted data and note fetal
palpated placental changes. Monitor physiologic
Manifest implantation FHR. compensatio
Body during n to blood
Weakness pregnancy loss
Low BP may
Increased manifest Assessment
HR signs and provides
Decreased symptoms of Assess abdomen information
RR fluid vol. for tenderness or about
Fetal HR deficient that rigidity- if possible
>120-160 may later present, infection,
bpm lead to measure placenta
Decreased hypovolemic abdomen at previa or
Urine Out shock and umbilicus abruption.
Increased cause (specify time Warm, moist,
Urine maternal and interval) bloody
Concentrat fetal death. environment
ion Assess SaO2, is ideal for
Pale, Cool skin color, temp, growth of
Skin moisture, turgor, microorganis
Increased capillary refill ms.
Capillary (specify
Refill frequency) Detecting
(specify) increased in
Lab. Assess for measuremen
Results changes in LOC: t of
note for abdominal
complaints of girth
thirst or suggests
apprehension active
abruption

Provide
supplemental O2 Assessment
as ordered via provides
facemask or information
nasal cannula @ about blood
10-12 L/min. vol., O2
saturation
and
Initiate IV fluids peripheral
as ordered perfusion
(specify fluid
type and rate). To detect
signs of
cerebral
perfusion
Position Pt. in
supine with hips
elevated if
ordered or left Intervention
lateral position. increases
available O2
to saturate
decreased
Monitor lab. hemoglobin
Work as
obtained: Hgb &
Hct, Rh and type,
cross match for 2 For
units RBCs, replacement
urinalysis, etc. of fluid vol.
Scheduled for loss
ultrasound as
ordered.

Determine if Pt.
has any Position
objections to decreases
blood pressure on
transfusions- placenta and
inform physician. cervical os.
Left lateral
position
improves
Administer blood placental
transfusion as perfusion
ordered with
client consent.
Lab. Work
Monitor closely provides
for transfusions information
reaction about degree
of blood loss;
prepares for
possible
transfusion.
Provide Ultra sound
emotional provides info
support; keep Pt. about the
and family cause of
informed of bleeding
findings and
continuing plan Pt. may have
of care. religious
beliefs
Administered related to
prenatal vitamins accepting
and iron as blood
ordered: provide products
a diet high in
iron: lean meats,
dark green leafy
vegetables,
eggs, and whole To provides
grains. replacement
of blood
Prepare Pt. for components
cesarean birth if and volume
ordered when
severe To prevent
hemorrhage, for
abruption, Potentially
complete previa life-
at term is threatening
already allergic
experience. reaction may
result from
incompatible
blood

Support and
information
decrease
anxiety and
help Pt. and
family to
anticipate
what might
happen next.
Proper diet
and vitamins
replace
nutrient
losses from
active
bleeding to
prevent
anemia- iron
is a
necessary
component
of
hemoglobin

Cesarean
Birth may be
necessary to
resolve the
hemorrhage
or prevent
fetal or
maternal
injury.
 Scientific
Assessment Diagnosis Planning Intervention rationale evaluation
explanation
S- Ø Anxiety Vague uneasy After hours of Establish To gain the After hours of
O- feeling of nursing rapport. trust and nursing
Elevated BP, discomfort or intervention Provide cooperation of intervention
P, R dread the pt. will reassurance the patient. the manifested
Insomnia accompanied Demonstrate a and comfort. decreased
by an decrease in Identify anxiety AEB
Restlessnes autonomic anxiety A.E.B. Monitor vital physical reduced
response; a reduction in signs. responses presenting
Dry mouth feeling of presenting associated manifestations
apprehension physiological, with both of anxiety and
Dilated pupils caused by emotional, medical and the pt. was
anticipation of and/or emotional able to
Frequent danger. It is cognitive conditions. verbalize a
urination an altering manifestations relief from
signal that of anxiety; and anxiety.
Diarrhea warns of verbalization
impending of relief of This can point
Patient danger and anxiety. Observe the to the clients
complains of enables the clients level of
apprehension, individual to behavior. Note anxiety.
nervousness, take any unusual
tension measures to activities.
deal with This may point
Inability to threat. to
concentrate physiological
source of
Shaking Review results anxiety.
of diagnostic
test.

It may
interfere with
ability to deal
Be aware of with problem.
defense
mechanisms To determine
that the pt. those that
manifests. might be
helpful in the
current
Review coping
circumstance.
skills that was
used in the
past.
Helps client to
identify what
is reality
based.
Provide
accurate
To provide
information
ongoing and
about placenta
timely
previa.
support.

List available
resources or
persons,
including Useful for
hotlines or being
crisis prepared in
managers. dealing with
anxiety
provoking
Review situation.
strategies,
such as role
playing, use of Helps to
visualizations manage the
to practice pt.
anticipated experiencing
events. anxiety.

Administer
anti-anxiety
drugs/sedatives Helps
, as ordered. minimize side
effects of
drugs that
Review may
medications aggravate the
regimen and condition.
possible
interactions,
especially with
OTC
drugs/alcohol,
and so forth.
Discuss
appropriate
drug
substitutions,
changes in
dosage or time
of dose.
 Nursing Scientific
Assessment Planning Intervention Rationale Evaluation
diagnosis explanation
S-Ø Activity Insufficient After hours of Evaluate Provides After hours of
O- Intolerance physiological nursing actual and comparative nursing
Weakness or r/t Enforced or intervention perceived baseline and intervention
fatigue Bed Rest psychological the pt. will limitations of provides the Pt.’s vital
During energy to demonstrate deficient in information signs have
Exertional Pregnancy endure or a decrease in light of about needed returned to
discomfort or Secondary to complete physiological unusual status. interventions normal range
dyspnea Potential for required or signs of regarding and
Hemorrhage desired daily intolerance quality of life. manifested
Abnormal heart activity. AEB normal decreased
rate or blood range of pt.’s Provides physiological
pressure in vital signs. Monitor vital or baseline data signs of
response to cognitive to detect the activity
activity signs, watch changes due intolerance.
for changes of to
Electrocardiogra blood intolerance.
phic changes pressure, heart
reflecting and respiratory
arrythmias or rate; note skin
ischemia pallor and
cyanosis and
the presence
of confusion. Prevents the
pt.’s
Adjust overexertion.
activities.
Reduce
intensity level
of activity or
discontinue
activities that
cause Preserves
undesired conservation
physiological of energy.
changes.

Increase
exercise levels
gradually, such
as stopping to
rest for 3 mins.
during a 10- Helps
minute walk or minimize
sitting down to frustration
brush hair and
instead of rechannel
standing. energy.

Provide
positive Protects the
atmosphere client from
while injury.
acknowledging
difficulty of the
situation of the
client. Gives the
chance for
Assist with the client to
activities and enhance
provide clients’ ability to
use of assistive participate in
devices. activities.

Promote To develop
comfort individually
measures and appropriate
provide relief therapeutic
of pain. regimens.

Provide to Sustains
other clients
disciplines, motivation.
such as O/PT,
exercise
physiologist or
psychological Assess if the
counseling. client is
responding to
Give client the tx.
information
that provides
evidence of
daily progress.

Provide/monito
r response to
supplemental
oxygen and
medications
and changes in
treatment
regimen.
 Scientific
Assessmen Nursing Intervention
explanatio Planning Rationale Evaluation
t diagnosis s
n
S-Ø Fear r/t Response After hours Ascertain Fear is a
Threat to to of nursing clients’s defensive
O- Maternal perceived interventio perception mechanism
Diminished and Fetal threat that ns the pt. of what is in
productivit Survival is will display occurring protecting
y Secondary consciously appropriate and how it oneself but,
to recognized range of affects life. if left
Increased Excessive as danger. feelings unchecked,
alertness Blood Loss and can become
lessened disabling to
Increased fear. the client’s
pulse; Identify life.
vomiting; sensory
diarrhea; deficits that Identify if
muscle may be this affects
tightness present, sensory
such as reception
Increased vision/heari and
RR; ng interpretatio
dyspnea impairment. n of the
environmen
Increased Stay with t.
BP; pallor the client or
make
Increased arrangemen Providing
perspiratio ts to have client with
n and pupil someone usual/desire
dilation. else be d support
there. persons can
diminish
Acknowledg feelings of
e normalcy fear.
of fear, pain,
despair, and Promotes
give attitude of
“permission caring,
” to express opens door
feelings for
appropriatel discussion
y. about
feelings
Modify and/or
procedures, addressing
if possible. reality of
situation.

Limits
Promote degree of
client stress,
control, avoids
where overwhelmi
possible, ng the
and help fearful
client individual.
identify and
accept Strengthens
those things internal
over which locus of
control is control.
not possible.

Explain
procedures
within the
level of
 client’s Prevents
understandi confusion or
ng and overload of
handle. information.

Review use
of
antianxiety To check for
medications correct
and treatment
reinforce as and to
prescribed. assess
efficiency of
tx.

Post-operative NCP
ASSESSMENT DIAGNOSIS PLANNING INTERVENTION RATIONALE OUTCOME
Subjective: Acute pain r/t STG: Independent: Goal met. After
“Sobrang sakit,” as disruption of skin After 1-2hr of 2hrs of nursing
verbalized by the and tissue nursing - Established rapport. -To have a good intervention, the
patient. secondary to intervention, nurse-client patient verbalized
cesarean section. patient will relationship pain decreased
Objective: verbalize decrease - Monitored vital from a scale of
-Pain scale= 8/10 intensity of pain signs. -To establish a 8/10 – 3/20 as
-Teary eyed from 8/10 to 3/10. baseline data evidenced by
-(+) guarding - Assessed quality, (-) facial grimace
behavior characteristics, severity of -To establish (-) guarding
-(+) facial grimace pain. baseline data for behavior.
-Irritable comparison in Frequent small
-Pale palpebral making evaluation talks with
conjunctiva and to assess for significant others
-Skin warm to touch possible internal
-V/S taken as - Provided bleeding.
follows: comfortable
BP= 110/80 environment – -Calm
PR= 80 changed bed environment helps
RR= 22 linens and turned to decrease the
T= 37.6 on the fan. anxiety of the
patient and
promote
- Instructed to put likelihood of
pillow on the abdomen decreasing pain.
when coughing or moving.
- To check for
diastasis recti and
protect the area of
the incision to
improve comfort.
And to initiate
nonstressful
muscle-setting
techniques and
- Instructed patient to progress as
do deep breathing and tolerated, based
coughing exercise. on the degree of
separation.

- For pulmonary
- Provided ventilation,
diversionary activities. especially when
Initiate ankle pumping, exercising, and to
active lower extremity relieve stress and
ROM, and walking promote
relaxation.
Collaborative:
- Administer analgesic - To promote
as per doctor’s order. circulation,
prevent venous
stasis, prevent
pressure on the
operative site.
 -Relieves pain felt
by the patient

ASSESSMENT DIAGNOSIS NURSING PLANNING INTERVENTION RATIONALE EVALUATION

ANALYSIS
Subjective: Risk for Due to an STG: Independent
- none infection elective After 4 hours -Monitor vital -To establish a Patient is
related cesarean of nursing signs baseline data expected to be
Objective: inadequate section, intervention, free of
- dressing dry primary patient’s skin patient will be -Inspect dressing infection, as
-Moist from
and intact defenses and tissue able to and perform evidenced by
drainage can be
-V/S taken as secondary to were understand wound care normal vital
a source of
follows: surgical mechanically causative signs and
infection
T: 37.3 incision interrupted. factors, - Monitor white absence of
P: 80 Thus, the identify signs blood count (WB purulent
- Rising WBC
R: 19 wound is at of infection drainage from
indicates body’s
BP: 120/80 risk of and report wounds,
efforts to combat
developing them to health incisions, and
pathogens;
infection. care provider tubes.
normal values:
accordingly.
4000 to 11,000
mm3
LTG: - Monitor Elevated
After 2-3 days temperature,
-these are signs
of nursing Redness,
of infection
intervention, swelling,
patient will increased pain, or
achieve timely purulent drainage
wound at incisions
healing, be
-Friction and
free of - Wash hands and
running water
purulent teach other
effectively
drainage or caregivers to
remove
erythema, be wash hands
microorganisms
afebrile and before contact
from hands.
be free of with patient and
Washing between
infection. between
procedures
procedures with
reduces the risk
patient.
of transmitting
pathogens from
one area of the
body to another
- Encourage fluid
- Fluids promote
intake of 2000 ml
diluted urine and
to 3000 ml of
frequent
water per day
emptying of
(unless
bladder; reducing
contraindicated).
stasis of urine, in
turn, reduces risk
of bladder
infection or
urinary tract
infection (UTI).
- Encourage
coughing and
- These
deep breathing;
measures reduce
consider use of
stasis of
incentive
secretions in the
spirometer.
lungs and
bronchial tree.
When stasis
occurs,
pathogens can
cause upper
respiratory
infections,
Independent:
including
- Administer
pneumonia.
antibiotics

-Antibiotics have
bactericidal effect
that combats
 pathogens

NURSING
ASSESSMENT PLANNING INTERVENTIONS RATIONALE EVALUATION
DIAGNOSIS
Objective Cues:
• Patient Risk for Short Term Goal: INDEPENDENT After 8º of nursing
has not constipation r/t INTERVENTIONS: interventions, the
yet post pregnancy Within 8º of • Ascertain • This is patient was able
eliminated 2° cesarean nursing normal bowel to to identify
since section interventions, the functioning of determi measures to
delivery patient will be the patient, ne the prevent infection
• Absence able to about how normal as manifested by
of bruit demonstrate many times a bowel client’s
sounds behaviors or day does she pattern verbalization of:
• Normal lifestyle changes defecate “Iinom ako ng
pattern of to prevent • Encourage • To maraming tubig at
bowel has developing intake of foods increas kakain ng prutas
not yet problem rich in fiber e the para makadumi
returned such as fruits bulk of ako.”
the
stool
Long Term Goal: and
• Promote facilitat
Within 3 days of adequate fluid e the
nursing intake. passag
interventions, the Suggest e
patient will be drinking of through
able to maintain warm fluids, the
usual pattern of especially in colon
bowel functioning the morning to • To
stimulate promot
peristalsis e moist
• Encourage soft
ambulation stool
such as
walking within
individual limits

• However, • To
since she has stimula
had cesarean, te
also contrac
encourage tions of
adequate rest the
periods intestin
es and
COLLABORATIVE: prevent
post
• Administer operati
bulk-forming ve
agents or stool complic
softeners such ations
as laxatives as • To
indicated or avoid
prescribed by stress
the physician on the
cesare
an
incision
/
wound

• To
promot
e
defecat
ion