College of Allied Health Sciences School

Nursing
 NURSING
ASSESSMENT NURSING DIAGNOSIS PLANNING RATIONALE EVALUATION
INTERVENTIONS

Subjective Data: Risk for disturbed maternal- After 3 hours of nursing - Assess the patient’s history of - A healthy pregnancy can After 3 hours of nursing
fetal dyad related to intervention, the patient will: prenatal visits and compliance. be achieved when the patient intervention, the goal was
The 31 year old female insufficient prenatal care and receives early and consistent met as evidenced by:
patient reported that she has compromised fetal oxygen Short Term Goals: - Review the patient’s health prenatal care. Lack of
a very light vaginal bleeding support as evidenced by history and risk factors. prenatal care might endanger Short Term Goals:
at 5 6/7 weeks age of smoking 10 cigarettes per - The patient will be the mother and the fetus.
gestation. She also felt dizzy day. encouraged and feel supported - Assess the patient’s knowledge Hence, adherence to prenatal - The patient was
and lightheaded. In addition, to stop smoking. of conditions that may disturb the visits is crucial. encouraged and felt
she says that she had a left maternal-fetal dyad. supported to stop
uterine tubal ectopic - The client will be educated on - Uteroplacental blood flow smoking.
pregnancy managed with the effects of smoking on their - Monitor fetal activity and heart and gas exchange are
laparoscopic salphingectomy. body, lungs, and to the fetus. rate. directly affected by other - The client was educated
She says that she is certain of comorbidities. on the effects of smoking
her last menstrual period date - The patient will verbalize - Offer resources for substance on their body, lungs, and
and has regular cycles. Her acceptance of health status abuse. - Pregnant patients can to the fetus.
last pap smear test was changes and the need to quit actively prevent or manage
normal and she has not used smoking. - Intervene when psychological conditions that may disturb - The patient verbalized
any contraception since her needs arise. the maternal-fetal dyad if acceptance of health
last pregnancy last 3 years Long Term Goals: they are well-informed. status changes and the
ago. She says that she need to quit smoking.
smokes 10 cigarettes per day. - The patient will be able to - Assess the status of the
verbalize understanding of fetus including the fetal heart Long Term Goals:
conditions that disturb the rate (FHR), growth, and
Objective Data: maternal-fetal dyad. activity as well as measuring - The patient verbalized
amniotic fluid and placenta understanding of
- The patient will be able to health through routine conditions that disturb the
- Initial Vital Signs:
identify her risk factors for the ultrasounds. maternal-fetal dyad.
BP = 130/80
HR = 75 disturbed maternal-fetal dyad.
- The cessation of smoking, - The patient identified
RR = 20
- The patient will be able to alcohol, and drugs is vital to her risk factors for the
Temp = 37.2’C
practice preventive measures maternal and fetal health. disturbed maternal-fetal
- Abdomen is not distended
against disturbed maternal-fetal Offer support groups and dyad.
and
dyad. resources for help in
no tenderness is elicited on
controlling addiction and - The patient practiced
palpation.
substance use. preventive measures
against disturbed
- The cervix is closed and the
- Depression and other maternal-fetal dyad.
uterus feels normal size,
mental health conditions can
anteverted and
worsen during pregnancy.
mobile, and there is no
Routinely assess for
cervical excitation.
increased stress and changes
in mood and alert the
- Gentle adnexal examination
healthcare provider.
Name: Cabauatan. Zeeya Aleeya Maree C. Section: BSN 2-7 Date: September 07, 2023