Nursing Problem

Nursing Intervention
*Evaluate medications the client is taking to see if they could be causing activity intolerance.

Activity Intolerance

*Assess nutritional needs associated with activity intolerance. *Provide emotional support and encouragement to the client to gradually increase activity. * Monitor vitals before and after any activity, noting any abnormal changes. *Assess for pain before activity. *Obtain any necessary assistive devices or equipment needed before assisting in ambulation

Fatigue

Sleep Deprivation Ensure fluid intake of at least 3000 ml/day, unless contraindicated y Provide high fiber diet under the direction of a dietitian, unless contraindicated y Manually remove fecal impaction, if present y Encourage mobility or exercise if tolerated y Provide a bedside commode and assistive devices (e.g. cane, walker) or assistance in reaching the commode or toilet y Institute a bowel program y Encourage bowel elimination at the same time every day. y Place patient in an upright position for defecation y Treat any perianal irritation with a moisture barrier ointment. y Discourage the use of pads, diapers, or collection devices as soon as possible y Use a fecal incontinence device selectively over pads, diapers, and rectal tubes. -Pt will be transfused 2 units of Packed Red Blood Cells per MD order and HGB will be rechecked 1 hour after transfusion has completed. -Nursing will measure and accurately record patients input and output hourly. -Pt will be started on Normal Saline IV at 150 cc/hr for 24 hours per MD order and mucous membranes will be reassessed within 24 hours. Assess vital signs and breath sounds every 4 hours. Measure intake and output every 4 hours. Obtain urine specific gravity every 8 hours. Restrict fluids as follows: 350 mL from 0700 to 1500; 300 mL from 1500 to 2300; 100 mL from 2300 to 0700. Prefers water or y

Bowel Intolerance

Fluid deficit/dehydration

Fluid excess/over dehydration

apple juice. Turn every 2 hours,following schedule posted at the head of bed. Inspect and provide skin care as needed; avoid vigorous massage of pressure areas. Provide oral care every 2 to 4 hours (can brush her own teeth, caution not to swallow water); use moistened applicators as desired. Elevate head of bed to 30 to 40 degrees;prefers to use own pillows. Assist to recliner chair at bedside for 20 minutes two or three times a day.Monitor ability to tolerate activity without increasing dyspnea or fatigue. Urge urinary incontinence related to excess intake of caffeine and citrus juices Impaired skin integrity related to constant contact of urine with perineal tissues Ineffective coping related to inability to control urine leakage  Explain the benefits of breast feeding, the mechanisms involve in lactation, the proper breast care and most especially the proper breast feeding position.  Assist the breastfeeding process as needed  Increase fluid intake  Discuss the importance of adequate nutrition during lactation Auscultate bowel sounds, noting absence or hyperactive sounds. Eliminate smells from the environment. Avoid foods that might cause or exacerbate abdominal cramping like caffeinated beverages, chocolate, orange juice. Measure abdominal girth. Observe skin or mucous membrane dryness, and turgor. Note peripheral edema and sacral edema. Assess abdomen frequently for return to softness, appearance of normal bowel sounds, and passage of flatus. Weigh daily. 1 . A s s e s s t h e p r e - pregnancy weight and present weight of the client. 2 . D e t e r m i n e c l i e n t s nutritional history, including her prepregnancy diet. 3 . D e t e r m i n e t h e clients attitude towards eating 4 . E d u c a t e t h e c l i e n t regarding the importance of eating healthy foods during her pregnancy in terms of benefits to her body and especially to her baby.

Urinary incontinence

Ineffective breastfeeding

Nausea

Imbalance Nutrition

Self Care Deficit/Poor Hygiene

5 . E d u c a t e t h e c l i e n t regarding the vitamins and minerals that are important during her pregnancy, such as vitamin C, folic acid, iron, calcium, and protein; and the sources of these nutrients. 6 . P l a n w i t h t h e c l i e n t her desired meals. 7 . S u g g e s t w a y s t h a t may assist the client in eating a . E n s u r e p l e a s a n t environment. b . F a c i l i t a t e p r o p e r positioning. 8 . I n s t r u c t t h e c l i e n t t o avoid caffeinated beverages. 9 . I n s t r u c t t h e c l i e n t t o avoid junk foods. 10.Instruct the client to follow the prescribed number of servings of the meals included in her meal plan. 11.Encourage the client to maintain the intake of the healthy foods needed by her body throughout the pregnancy and also in the post partum period.  Establish rapport on the client  Monitor the vital signs  Provide healt h teaching o n the client regarding the proper way of effective oral hygiene  Explain the procedure of proper bathing and hair brushing on the patient  Guide and support the patient and let her perform the procedure  Encourage her to take a bath everyday and be responsible mother to her physical appearance  Explain the essence o f t he mo ther as a clean and a presentable mother to her baby.  Inform the relatives to help the patient in doing her duty everyday regarding her proper hygiene Assess the client's behavior and cognition systematically and continually throughout the day and night, as appropriate. Provide supportive nursing care including meeting of basic needs such as feeding, toileting, and hydration. Assess level of anxiety Assist client to identify feelings and begin to deal with problems Provide measures to comfort and aid client to handle problematic To promote wellness; teaching/discharge considerations.

Confusion

Anxiety Pain