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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
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
OBJECTIVE: 37 5/7 weeks AOG Easy fatigability Sleepy appearance Urinary output: 3 4x/ night
bladder.
fluids at night increases the chance to void since the bladder will be full
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)
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 inhibit growth of
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 (