ASSESSMENT

DIAGNOSIS

SCIENTIFIC BACKGROUND

PLANNING

IMPLEMENTATION RATIONALE Established rapport Identified presence of factors known to interfere with sleep Encouraged patient to void before going to sleep To reduce the amount of urine in the bladder therefore decreasing To promote trust To determine appropriate

EVALUATION

SUBJECTIVE: Konti lang ang tulog ko kasi madalas ako magising sa

Disturbed sleep pattern related to physiological interruptions such as

Frequency of urination may return at the end of pregnancy as lightening occurs and the fetal head exerts renewed pressure on the

SHORT TERM GOALS: After 20-30 minutes of nursing intervention the patient will identify at least one individual appropriate

Goal met as evidenced by interventions identified by the patient to increase and

gabi para umihi. nocturia - as verbalized by the patient

interventions promote her duration of sleep.

OBJECTIVE: 37 5/7 weeks AOG Easy fatigability Sleepy appearance Urinary output: 3 4x/ night

bladder.

(maternal and child health nursing volume 1. Page 236)

intervention to promote sleep

LONG TERM GOALS: To promote optimal activity: Advised patient

the number of voiding at night Drinking

exercise, rest and sleep

to limit fluid intake especially during night

fluids at night increases the chance to void since the bladder will be full

Advised patient to take afternoon naps

Afternoon naps will help reduce fatigue due to lack of sleep

ASSESSMENT

DIAGNOSIS

SCIENTIFIC BACKGROUND

PLANNING

IMPLEMENTATION RATIONALE Established rapport Obtained pain level To promote trust To determine pain relieving measures Advised patient to drink plenty of water during the day. Water is essential to help flush the bacteria form the urinary tract and to fight infection.

EVALUATION

SUBJECTIVE: Nakakaramdam ako ng sakit pag umiihi ako dahil siguro sa sonda -as verbalized by the patient

Impaired comfort related to mild pain felt during urination secondary to urinary infection

A burning sensation or tingling during urination may indicate the presence of infection in the urinary tract.

SHORT TERM GOALS: After 20-30 minutes of nursing intervention the patient will identify at least one

Goal met as evidenced by interventions identified by the patient to reduce pain when urinating and to reduce spread of infection.

OBJECTIVE: Increased wbc of 10.47 Pyuria Pain scored 2, mild pain on a pain scale of 110 (www.mdtips .com/pains/135)

intervention to reduce pain, reduce spread of infection to enhance comfort

LONG TERM GOALS: To maintain Advised patient not to strain

Straining causes irritation and

good hygiene and physical comfort

when urinating Advised patient not to douche

more pain Douching will only make the infection worse and increase the pain

Advised patient to blot dry after urinating and make sure to keep genital area clean and make sure to wipe from the front toward the back. Advised patient

To reduce spread of infection

To inhibit growth of

to change underwear everyday and to wear cotton underwear.

bacteria

ASSESSMENT

DIAGNOSIS

SCIENTIFIC BACKGROUND

PLANNING

IMPLEMENTATION

RATIONALE EVALUATION

SUBJECTIVE: Mababa daw ang Hemoglobin ko kelangan ko daw magpablood transfusion OBJECTIVE: Capillary refill more than 5 seconds Observable pallor noted in mucous membrane Hgb 71 gm/dL observed Vital Signs as follows: BP: 110/70 mmHg

Impaired gas exchange related to altered oxygencarrying capacity of blood secondary to decrease level of hemoglobin in the blood

Hemoglobin is SHORT the oxygen TERM GOAL carrying capacity of the RBC. Decreased amount of hemoglobin compromises the RBCs ability to bind with oxygen (

 T: 36.2 c PR: 80 bpm RR: 31 cpm