Date &

time

Cues Need Nursing

Diagnosis

Objectives of care Nursing intervention Evaluation

Dec.

10,

2014

@ 9:30

am

-Attends regular

prenatal visit x5

-Seeks

necessary

knowledge about

her unborn child

as evidence by

“unsa naman

ako buhaton pag

gawas niya?”

-Reports

managing

unpleasant

symptoms in

pregnancy

-Irritable when

asked about her

baby

-Constantly

crying

S

E

X

U

A

L

I

T

Y

-

R

E

P

R

O

D

U

C

T

I

Readiness

for

enhance

child

bearing

process

After 1 hour span of

care patient would

be able to

A. Verbalize

understanding of

care requirements

to promote health

of self and infant

B. Verbalize that

she in now ready

no matter what’s

the appearance of

her baby

C. Demonstrate

safety precautions

1.Evaluate current knowledge

and cultural beliefs regarding

normal physiological and

psychological changes in

pregnancy, as well as beliefs

about activities, self-care.

2.Determine degree of

motivation for learning.

R-Client may have difficulty

learning unless the need for it is

clear.

3.Identify who provides support

within the clients culture

R- Helps ensure quality and

continuity of care because

support persons may be more

successful than the healthcare

provider in communicating

information.

4.Evaluate the client’s/couples

“Goal partially met”

For patient

10:00 am

a. she had not

verbalized any

understanding about

care requirements

b. verbalizes that

she is now ready no

matter what’s her

child’s appearance

is as evidence by

“dawaton nalang

nako kay blessing

man and baby,

hatag mana sa

Ginoo”

c demonstrated

safety precautions

as evidence by

44 | P a g e

AP: Dr. Tuazon G4 P3 A0 T3 P0 A0 L2Chief Complaint: Labor Pains Diagnosis: polyhydramious

-Do not talk

about her baby.

V

E

P

A

T

T

E

R

N

response to pregnancy,

individual and family stressors,

and cultural implications of

pregnancy/childbirth.

R-The ability to adapt positively

depends on support system,

cultural beliefs, resources and

effective coping mechanisms

developed in dealing with past

stressors.

5.Maintain open attitude toward

beliefs of client/couple.

R-Acceptance is important to

developing and maintaining

relationship and supporting

independence.

6.Provide information about

potential teratogens, such as

alcohol, nicotine, illicit drugs, the

STORCH, group of viruses e.g

rubella, and HIV.

R-Helps client make informed

when walking she

hold her tummy.

45 | P a g e

decisions/choices about

behavior/environment that can

promote healthy offspring.

7.Use various methods for

learning, including pictures, to

discuss fetal development.

R-Visualization enhances reality

of child and strengthens learning

process.

8.Discuss signs of labor onset

how to distinguish between false

and true labor, when to notify

healthcare provider and to leave

for hospital/birth centers, and

stages of labor/delivery.

R-Helps ensure timely arrival

and enhances coping with

labor/delivery process.

46 | P a g e