DATA NURSING

Diagnosis
OBJECTIVES NURSING
INTERVENTIONS
RATIONALE EVALUATION
Ineffective
tissue
perfusion
related to
vasoconstrictio
n of blood
vessels
After 8 hours
of nursing
interventions
the patient will
be able to
maintain
normal blood
pressure
INDEPENDENT:

Support bed rest





Monitor maternal
well being. Take
blood pressure
frequently

Monitor output by
inserting urinary
catheter; and measure
urinary proteins and
specific gravity







Support a nutritious
diet




Bed rest provide, relaxation to
the patient, and it prevents from
any stress that may trigger to
increase the patient blood
pressure

To detect any increase, which is
a warning that patients
condition is worsening


To allow accurate recording of
output and comparison with
intake; urinary output should be
more than 600mL/24hrs
(>30mL/hr). A 24hr urine
sample may be collected to
evaluate kidney function; mild
pre-eclampsia 0.5g
protein/24hrs , and severe
pre-eclampsia 5g/24hrs


Patient needs a diet moderate to
high in protein and moderate in
sodium to compensate for the
protein the patient is losing in
urine.




























Constipation
related to
inadequate
intake of fluid
and bulk




























At the end of 8
hours of
nursing
intervention
the patients
elimination
pattern will
DEPENDENT:

Oxygen
administration to the
patient



Initiate and maintain
an intravenous fluid
line




Administer
medications as
ordered such as
Hydralazine,
Nifedepine





INDEPENDENT
Monitor and record
frequency and
characteristic of
stools


Record intake and


To maintain adequate fetal
oxygenation and prevent fetal
bradycardia.



To serve as an emergency route
for drug administration as well
as to administer fluid to reduce
hemoconcentration and
hypovolemia.


To prevent eclampsia. These
drugs are hypotensive drugs to
reduce hypertension.








Careful monitoring form the
basis of an effective treatment
plan



To ensure correct fluid


































return to
normal































output accurately


Unless
contraindicated,
encourage fluid
intake of 2,500 ml
daily


Place patient on
bedpan or commode
at specific times
daily, as close to
usual evacuation time
(if unknown) as
possible


Instruct patient and
family in relationship
of diet, exercise and
fluid intake to
constipation, develop
plan and provide for
mild exercise periods


DEPENDENT
Administer laxative
or enema, as order

Consult with dietitian
replacement


significantly increase fluid
intake can increase frequency of
stools




To aid adaptation to routine
physiologic function







These measures promote
muscle tone and circulation








To promote elimination of
solids and gases from GI tract

This will improve intestinal








Risk for
deficient fluid
volume related
to excessive
fluid losses
secondary to
operative
delivery

























At the end of 8
hours of
nursing
intervention
the patient will
be able to
a. The intake
and output
will be
balance
within
normal
limits
b. Pt. will
exhibit
appropriate
elimination
pattern







about increasing fiber
and bulk in diet to
maximum prescribed
by physician.


INDEPENDENT

Record intake and
output


Assess skin turgos
and mucus
membranes



Monitor vital signs
frequently if needed






Encourage patient to
drink frequently


DEPENDENT
Check urine specific
gravity
muscle tone and promote
comfortable elimination






To obtain fluid status



Fluid loss occurs in
extracellular space, resulting in
poor skin turgos and dry mucus
membranes


Increased temperature and
increased respiratory rate
contribute fluid loss. A weak
and thread pulse and drop in
blood pressure indicate
dehydration


To replace the loose electrolytes
and water of the body



Increased specific gravity
indicates lack of fluids to dilute










Hyperthermia
related to
infection






























At the end of 2
hours of
nursing
intervention
the patient will
be remain
afebrile



















Monitor Laboratory
studies( electrolytes,
pH and hematocrit)




INDEPENDENT
Take axillary or oral
temperature every 1
to 4 hours


Use non
pharmacologic
measures to reduce
high fever such as
removing sheets,
blankets, placing cool
cloths on axillae and
groin and sponging
with tepid water



Describe the
complications of the
fever to the patient
and explain which
signs and symptoms
in urine


During fluid loss electrolytes
are excreted, which may lead to
electrolyte imbalance





To obtain accurate temperature




Non pharmacologic measure
lower body temperature and
promote comfort. Sponging
reduces body temperature by
increasing evaporation from
skin. Tepid water is used
because cold water increases
shivering, thereby increasing
metabolic rate and causing the
temperature to rise.


Early recognition of fever
reduces the risk of
complications, such as
dehydration and febrile
seizures.













Impaired skin
integrity
related to
abdominal
incision




























At the end of 8
hours of
nursing
intervention
the patient will
demonstrate
understanding
of self care
activities,
perform skin
care routine
and regain skin
integrity



they had to report to
the nurse or physician


DEPENDENT
Administer
antipyretic
medication as ordered
and record
effectiveness


INDEPENDENT
Inspect the incision
every shift using the
REEDA (redness,
edema, ecchynosis,
discharge and
approximation)
method.



Perform the
prescribed treatment
regimen. Monitor
progress and report
favorable and adverse
responses


Instruct and assist the
patient with general





Antipyretic act on the
hypothalamus to regulate
temperature.





Frequent assessment can detect
signs and symptoms of possible
infection.







Periodic cleaning decreases
bacterial concentrations aiding
the healing process. Monitoring
response to treatment can help
identify a possible need for
alternative interactions.


Proper hand washing is the
effective method o f disease



hygiene, including
hand washing and
toileting practice


Provide a splinting
pillow to the patient.




Help patient assume a
comfortable position


Instruct the patient
and partner in the
possible danger signs
and symptoms that
should be reported to
the physician
immediately. These
include:
-temperature above
100.4F (38C) on
two consecutive
readings
-incisional drainage
-reddened or warm
skin surrounding at
incision site

prevention. Bacteria from hands
can easily contaminate other
areas.


Splitting provides support to the
area, minimizing discomfort
and encouraging patient to
move.


To minimize the _____ pain-
induced mobility.


Prompt reporting of danger
signs and symptoms may help
prevent major complication.