Assessment Subjective: Patient verbalized: Kapag nagbibiyahe ako o nasa labas, nahihilo ako, tapos parang naduduwal ako

o lagi, kaya naman lagi akong dumudura at kumakaen ng candy . Client experienced headache associated with nausea. Objective: Increased

Nursing Diagnos is Nausea related to pregnan cy associate d by headach e.

Scientific Analysis Nausea is a subjective unpleasant, wavelike sensation in the back of the throat, epigastrium, or abdomen that may lead to the urge or need to vomit.

Goal and Objectives Goal: After the nursing intervention, the patient will be free of nausea. Objectives: After the nursing intervention the patient will be able: To know the cause of nausea. To provide necessary information for client to manage her own care To limit dwelling on unpleasant sensation.

Nursing Interventio n Note systemic conditions that may result in nausea. Determine if nausea is potentially selflimiting and/ or mild or is severe and prolonged Provide clean, peaceful environme nt and fresh air w/ fan or open window.

Scientific Rationale Helps to determine appropriat e interventi ons of underlying condition. Indicates degree of effect on fluid/ electrolyte balance and nutritional status. As they may stimulate or worsen nausea.

Evaluation Maintain weight as appropriat e. Able now to know ways to avoid/ manage it. Be free of nausea.

swallowing. Increase salivation. Increased perspiration .

Measurement: BP: Temp: PR: RR:

Avoid offending odors, smells, smoke, perfumes, mechanic al emissions. Review individual factors/ triggers causing nausea and ways to avoid it.

Provides necessary informatio n for client to manage own care

Drug Name

Dosage, Route, Frequen cy

Actions

Indication

Adverse Reaction

Contraindicati on

Nursing Responsibilit y

Phytomenadi one (Vitamin K, Phylloquinon e, menaquinone )

0.1 cc via IM to the Vastus Lateralis of the newborn.

Vitamin K is used to treat and prevent low levels of certain substances (blood clotting factors) that your body naturally produces. These substances help your blood to thicken and stop bleeding normally Helps to treat and prevent unusual bleeding by increasing the body's production of blood clotting factors

>To stimulate the clotting factors of the newborn >To prevent hemorrhagic disease of the Newborn.

>The synthetic form of Vitamin K and Vitamin K3 (Menadione ) can cause allergic reaction, Hemolytic Anemia, and Cytotoxicity in liver cells.

>Contraindicate d to those who are hypersensitive to any component of Vitamin K containing products.

>Ensure that the adequate dose is given while following the proper IM Drug Administration. >Apply pressure to the injection site to prevent further bleeding. >Document the giving of the medication to newborn to prevent an accidental doubling of the dose.