ASSESSMENT NURSING RATIONALE GOAL NURSING RATIONALE EVALUATION
DIAGNOSIS INTERVENTION
Objective data: Deficient Build - This After 2 hours of
BP: 140/80 knowledge related after 2 hours of rapport with establishes nursing
PR: 105 to prenatal check- nursing the patient patient’s trust intervention, Goal
W: 65 kg ups as evidenced intervention and was met as
by severe pre- patient will be cooperation evidenced by the
Obstetric history: eclampsia able to: patient’s capability
G1P0 - This helps on to express
- Verbalize the Assess the determining understanding of
Subjective data: significance of patient’s the information
Patient prenatal care level of appropriate gained.
verbalized and obtaining knowledge intervention
that she is checkups. to the unique
unable to needs of each
obtain a - Verbalize patient.
check up understanding
since her of the risk and Educate
husband is benefits of patient
working undergoing about sever
and no one cesarean e pre-
is available delivery eclampsia
to look information
after her - Express
children. readiness for
the upcoming Promote the - This reduces
surgery importance pregnancy risk
of acquiring complications
- regular and ensures
check ups. healthy
growth and
development
of the fetus.
- Addressing
Encourage patients
the patient concerns and
to verbalize anxiety
questions, promotes a
feelings, and smoother
concerns recovery and
with regards improved
to surgery. outcomes.
Monitor - Establishes
vitals signs baseline data
every hour. and evaluate
patient’s
improvement
during care
Instruct
patient not - Smoking
to smoke impedes the
prior to body's ability
surgery to heal
properly by
reducing
blood flow
and oxygen
supply to
tissues.
Inform
patient on - This enables
what to do patient to
after surgery actively
this includes participate.
- Non-
- Performing pharmacologic
deep therapy
breathing manages pain
exercise, and
incentive discomfort,
spirometry, restores
and the mobility,
importance strength and
of early function
ambulation which leads to
and shorter
repositioning hospital stay
and promotes
Administer
prescribed
medication
prior to
surgery
Anxiety related to deficient knowledge regarding pregnancy care,
Promote the patient's engagement in relaxation techniques like deep breathing, guided imagery, and meditation.
Assessment Nursing dx RATIONALE GOAL INTERVENTION RATIONALE EVALUATION
Acute pain After 4 Consistently Establishes Goal was
Objective: related to hours of monitoring baseline data met.
Pain scale disruption nursing vital signs and and evaluate Patient’
of 8/10 of skin and intervention pain levels at patient’s pain was
Facial tissue , the patient regular improvement relieved as
grimace secondary will be able intervals. during care evidenced
to surgical to express a by
incision as reduction of Monitor Temperature
evidenced pain temperature changes may
by facial etntensity reegularly indicate signs
grimace from 8 /10 of infection.
Objective: to 3/10
(-) Vomiting
(-)
Abdominal Monitor for Recognizing
pain signs of hypothermia
hypothermia promptly
that may helps prevent
result from complications
anesthesia, a such as
cool operating impaired
room, or blood
exposure of clotting,
the skin and slowed
internal metabolism,
organs during and
surgery increased
susceptibility
to infections.
Adjust room Fosters a
temperature sense of
and provide relaxation
warm while also
blankets to preventing
the patient patients from
acquiring
hypothermia.
Monitor IV
fluid
administration
as prescribed.
Monitor
accurate
intake and
output
Provide a "A serene
calm and and tranquil
peaceful environment
environment enables
with no patients to
disruptions. rest
comfortably
and
undisturbed."
Provide Helps avoid
adequate rest exhaustion
and
preserves
energy for
the purpose
of recovery
Instruct the Improves
patient to blood
perform early circulation
ambulation and reduces
the risk of
DVT and
pulmonary *
embolism
Assess the Early
surgical site, detection for
drains and signs of
wound infection
dressing allows nurses
to prompt
Assess the immediate
skin for intervention
redness, reduces the
abrasions, or risk of
breakdown infection
that may have spreading or
resulted from becoming
surgical severe.
repositioning.
Maintain a dry
and intract
dressing
Administer
prescribed
pain
medications
as needed.
