CUES AND NURSING SCIENTIFIC GOALS AND NURSING

EVIDENCES DIAGNOSIS BASIS OUTCOME ACTION/NURSING RATIONALE EVALUATION

CRITERIA ORDERS

S- “Wa pa Altered During vaginal After 8 hours of Nursing Action: Appropriate Goal met as
gyud ko naka urinary birth, the fetal nursing Render nursing measures will evidenced by:
ihi sukad elimination head exerts a interventions, the measures helpful in be
pagpanganak related to great deal of patient will be initiating voiding of implemented Patient was
nako ganina”, perineal pressure on able to attempt the patient. to initiate able to void
as verbalized edema and the bladder common voiding. more than
by the decreased and urethra as measures to 100 ml within
patient. bladder it passes on initiate voiding. Nursing Orders: 2 hours’ time.
tone from the bladder’s
fetal head underside. 1. Assess amount Assessing Fundal height
O- looks pressure This pressure The patient will of urine voided fundal height returns to 1
weak during birth. may leave the be able to: during labor, and and position fingerbreadth
-afebrile bladder with a reassess fundal provides below
-coherent transient loss a. Verbalize height and evidence umbilicus
-4 hours of tone that, understanding position. about the after voiding.
postpartum together with s of the degree of
edema condition. bladder filling.
surrounding (Pillitteri;2007:
urethra, b. Identify 642)
decreases a negative
woman’s factors 2. Assess what Respecting Patient
ability to affecting measures patient client’s ambulates to
sense when urinary thinks would help preferences the bathroom
she has to elimination. her to void. helps her to to void with
void. maintain assistance
(Pillitteri;2007: c. Participate in feeling of
630) different control.
nursing (Pillitteri;2007:
interventions. 643)

3. Discuss the Helps to Patient

importance of initiate bladder confirms she
continuing to reflex. has been
drink. (Pillitteri;2007: drinking 1
642) glass of fluid
an hour.

4. Discuss Retention of Knows to

importance of urine drink 6 to 8
emptying predisposes to glasses of
bladder. infection. fluid daily.
(Pillitteri;2007:
642)

5. Stress Women
importance of should drink
drinking extra ample fluid
water during during the
postpartum postpartum
period. period, to
counteract
normal
dieresis and
ensure good
urine output.
(Pillitteri;2007:
643)
 6. Teach normal The more
physiologic informed
changes that patients are,
occur after birth the more they
and the can participate
importance of in self-care.
preventing (Pillitteri;2007:
complications 643)
such as urinary
retention or
thrombophlebitis.

7. Instruct patient to Kegel

do Kegel exercises help
exercises once strengthen
voiding pattern is perineal
reestablished. muscle.
(Pillitteri;2007:
643)

S- “Unsa diay Imbalanced The postpartal After 8 hours of Nursing Action: Appropriate Goal met as
ang dapat nutrition, period is a nursing Render nursing measures will evidenced by:
kan-on kay less than time of interventions, the measures helpful in be
nidaot man body rebuilding and patient will be promoting a implemented Patient was
ko”, as requirement readjusting, able to acquire balanced nutrition to provide able to show
verbalized by s, related to for which a basic knowledge of the patient. knowledge under-
the patient. lack of woman needs regarding her regarding standings
knowledge both ample body’s nutritional proper about
about nourishment requirements. nutrition. importance of
O-sleepy postpartal and adequate The patient will Nursing Orders: proper and
- looks tired needs. fluid intake. be able to: balanced
-weighs 90 Most mothers 1. Document actual Patients may nutrition.
lbs are hungry a. Verbalize height and be unaware of
-5’0” in during the understandings weight. their actual
height immediate about the weight and
-conscious postpartal importance of height or
-BMI is 18.2 period and proper nutrition. weight loss.
consume an (Gulanick;2007
adequate diet b. Identify :135)
without urging. interventions to
. promote a 2. Obtain nutritional The patient’s
(Pillitteri;2007: balanced history; include perception of
641) nutrition. family, significant actual intake
others, or may differ.
c. Demonstrate caregiver in (Gulanick;2007
techniques assessment. :135)
and lifestyle
changes to 3. Monitor or Many
promote explore attitudes psychological,
proper toward eating psychosocial,
nutrition. and food. and cultural
factors:
determine the
type, amount,
and
appropriate-
ness of food
consumed.
(Gulanick;2007
:135)
4. Encourage to These
take foods, which nutrients are
is high in protein, needed for
vitamins and good tissue
minerals. repair.
(Pillitteri;2007:
641)

5. Encourage to It is important
have an to help restore
adequate supply the peristaltic
of roughage. action of the
bowel.
(Pillitteri;2007:
641)

6. Suggest liquid Such

drinks for supplemental
supplemental can be used to
nutrition. increase
calories and
protein without
interfering with
voluntary food
intake.
(Gulanick;2007
:136)

7. Discourage These may

beverages that decrease
are caffeinated or appetite and
 carbonated. lead to early
satiety.
(Gulanick;2007
:136)

8. Encourage Metabolism
exercise. and utilization
of nutrients
are enhanced
by activity.
(Gulanick;2007
:137)

9. Discuss the Patients may

importance of not
maintaining understand
adequate caloric what is
intake and the involved in a
four basic food balanced diet.
groups, as well They are
as the need for better able to
specific minerals ask questions
and vitamins. and seek
assistance
when they
know basic
information.
(Gulanick;2007
:137)
S- “Malipong Activity After 8 hours of Nursing Action: Appropriate Goal met.
ko inig lakaw intolerance By the time nursing Render nursing measures will Patient was
nako”, as related to the date of interventions, the measures helpful in be able to
verbalized by stress birth patient will be increasing energy implemented tolerate
the patient. during labor approaches, a able to tolerate level of the patient to increase activities
and birth. woman is activities within to tolerate activities energy level. within level of
generally tired level of own within level of own own ability as
O-sleepy from the ability. ability. evidenced by:
- looks tired burden of
-generalized carrying so
weakness much extra The patient will Nursing Orders:
noted weight with be able to:
-with the her. In 1. Assess sleep Multiple Patient
following addition, most a. Identify patterns and factors can answered to
vital signs: women do not negative note changes in aggravate the question
sleep well factors thought process. fatigue, asked and
T-36.5 0C during the last affecting including sleep identified
P-75bpm month of performance. deprivation, factors
R-20cpm pregnancy. emotional aggravating
BP-110/70 Near the b. Adapt lifestyle distress, side fatigue.
mmHg pregnancy, to increase effects of
she probably energy level. medication,
was unable to and
find c. Verbalize progression of
comfortable understanding disease
position in bed of potential process.
because of the loss of ability (Doenges;2002
:
fetus’ activity in relation to 87)
or the existing
presence of condition. 2. Assess the This aids in
back or leg patient’s level of defining what
pain. All d. Develop an mobility. the patient is
during labor, activity and capable of,
she has eaten rest pattern which is
very little, if that promotes necessary
anything, and optimal before settling
has worked independence realistic goal.
very hard with and minimizes (Gulanick;2007
little or no fatigue. :8)
sleep.
(Pillitteri;2007: 3. Monitor patient’s Difficulties
510) sleep pattern sleeping need
and amount of to be
sleep achieved addressed
over the past before activity
few days. progression
can be
achieved.
(Gulanick;2007
:8)

4. Encourage Provides for Patient can sit

patient to do sense of and can do
whatever control and tooth
possible like feeling of brushing by
self-care and sit accomplish- herself.
in chair. ment.
(Doenges;2002
:
83)

5. Suggest that the Shorter activity Patient

client perform periods moves slowly
 activities more performed and rest more
slowly and for more slowly often.
shorter times, and more
resting more frequent rest
often, and using periods
more assistance promote
as required. optimal
performance
and
achievement
levels.
(Doenges;2002
:
87)

6. Encourage Necessary to Patient eats

proper nutritional meet energy the right kind
intake. needs for and nutritious
activity. foods.
(Doenges;2002
:
83)

7. Plan time to be Appropriate Patient

with the patient, assistance verbalizes
and listen ensures what are her
actively to the safety. concerns on
client’s concern. (Kozier;2002: her condition
908) to the nurse.