Client’s name: Roberts, Julia Richards Name of Student: Lomboy, Darius Seymon G.
Age: 19
Sex: Female Date: October 05, 2024
EXPLANATION OF THE
ASSESSMENT PROBLEM PLANNING INTERVENTION RATIONALE EVALUATION
Subjective STO Independent
I feel very worried kasi Deficient knowledge During the 8 hours of Determine the patient’s To assess the client’s At the end of the 8 hours
feeling ko buntis ako kaya associated with pregnancy nursing intervention, the knowledge level. knowledge about of nursing intervention,
nag-iiba figure ko at wala can be caused by client will be able to pregnancy expectations. the goal was met as
ako sapat na ideya sa inadequate knowledge of lessen her wariness. Establish the patient’s To ensure the client is evidenced by verbal
pagbubuntis. normal body changes and capacity, readiness, and mentally and action saying “I feel more
self-care needs. First-time learning obstacles. emotionally ready and in at ease.”
Objective mothers especially often receiving information
misinterpret or lack of Monitor vital signs. To assess the well-being
Nervousness information during of the client.
Crying pregnancy.
Breast enlargement Dependent
Irritable mood
Increase in wariness Perform laboratory test To confirm the
Altered attention – ELISA as ordered. pregnancy of the client.
Fatigue LTO
Vital signs Administer medication To reduce the sign and
BP – 140/90 During the 3 days of as indicated. symptoms of the client. At the end of the 3 days
RR – 22 nursing intervention, the of nursing intervention,
PR – 102 client will be able to the goal was met as
SP02 - 101 verbalize of Educative evidenced by identifying
understanding of the possible changes that
Nursing Diagnosis expected body changes Provide information To educate the client to she might experience
during pregnancy. regarding the stages of have an idea for during pregnancy.
Deficient knowledge pregnancy. possible changes of the
related to inadequate body during pregnancy.
information about body Provide positive To adhere for a follow-
changes as evidenced by reinforcement. up appointment.
verbalization of concerns.
