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CUES AND

EVIDENCES

NURSING

DIAGNOSIS

SCIENTIFIC

BASIS

GOALS AND

OUTCOME

CRITERIA

NURSING

ACTION/NURSING

ORDERS

RATIONALE EVALUATION

S- Wa pagyud ko nakaihi sukadpagpanganaknako ganina,as verbalizedby thepatient.

O- looksweak

-afebrile-coherent-4 hourspostpartum

Alteredurinaryeliminationrelated toperinealedema anddecreasedbladder

tone fromfetal headpressureduring birth.

During vaginalbirth, the fetalhead exerts agreat deal ofpressure onthe bladderand urethra asit passes on

the bladdersunderside.This pressuremay leave thebladder with atransient lossof tone that,together withedemasurrounding

urethra,decreases awomansability tosense whenshe has tovoid.(Pillitteri;2007:630)

After 8 hours ofnursinginterventions, thepatient will beable to attemptcommonmeasures toinitiate voiding.

The patient willbe able to:

a. Verbalizeunderstandings of thecondition.

b. Identifynegativefactorsaffectingurinaryelimination.

c. Participate indifferent

Nursing Action:Render nursing

measures helpful ininitiating voiding ofthe patient.

Nursing Orders:

1. Assess amountof urine voidedduring labor, andreassess fundalheight andposition.

2. Assess whatmeasures patientthinks would helpher to void.

Appropriatemeasures willbeimplementedto initiatevoiding.

Assessingfundal heightand positionprovidesevidenceabout thedegree ofbladder filling.(Pillitteri;2007:

642)

Respectingclientspreferenceshelps her tomaintainfeeling ofcontrol.

Goal met asevidenced by:

Patient wasable to voidmore than100 ml within2 hours time.

Fundal heightreturns to 1fingerbreadthbelowumbilicusafter voiding.

Patientambulates tothe bathroomto void withassistance

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nursinginterventions.

3. Discuss theimportance ofcontinuing todrink.

4. Discussimportance of

emptyingbladder.

5. Stressimportance ofdrinking extrawater duringpostpartum

period.

(Pillitteri;2007:643)

Helps toinitiate bladderreflex.(Pillitteri;2007:642)

Retention ofurine

predisposes toinfection.(Pillitteri;2007:642)

Womenshould drinkample fluidduring thepostpartum

period, tocounteractnormaldieresis andensure goodurine output.(Pillitteri;2007:643)

Patientconfirms shehas beendrinking 1glass of fluidan hour.

Knows todrink 6 to 8

glasses offluid daily.

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S- Unsa diayang dapatkan-on kaynidaot manko, asverbalized bythe patient.

Imbalancednutrition,less thanbodyrequirements, related tolack ofknowledgeabout

The postpartalperiod is atime ofrebuilding andreadjusting,for which awoman needsboth amplenourishment

After 8 hours ofnursinginterventions, thepatient will beable to acquirebasic knowledgeregarding herbodys nutritionalrequirements.

6. Teach normalphysiologic

changes thatoccur after birthand theimportance ofpreventingcomplicationssuch as urinaryretention orthrombophlebitis.

7. Instruct patient todo Kegelexercises oncevoiding pattern isreestablished.

Nursing Action:Render nursing

measures helpful inpromoting abalanced nutritionof the patient.

The moreinformed

patients are,the more theycan participatein self-care.(Pillitteri;2007:643)

Kegelexercises helpstrengthenperinealmuscle.(Pillitteri;2007:643)

Appropriatemeasures willbeimplementedto provideknowledgeregardingpropernutrition.

Goal met asevidenced by:

Patient wasable to showunder-standingsaboutimportance of

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O-sleepy- looks tired

-weighs 90lbs-50 inheight-conscious-BMI is 18.2

postpartalneeds.

and adequatefluid intake.

Most mothersare hungryduring theimmediatepostpartalperiod andconsume anadequate dietwithout urging..

(Pillitteri;2007:641)

The patient willbe able to:

a. Verbalizeunderstandingsabout theimportance ofproper nutrition.

b. Identifyinterventions topromote a

balancednutrition.

c. Demonstratetechniquesand lifestylechanges topromotepropernutrition.

Nursing Orders:

1. Document actualheight andweight.

2. Obtain nutritional

history; includefamily, significantothers, orcaregiver inassessment.

3. Monitor orexplore attitudestoward eatingand food.

Patients maybe unaware oftheir actualweight andheight orweight loss.(Gulanick;2007:135)

The patients

perception ofactual intakemay differ.(Gulanick;2007:135)

Manypsychological,psychosocial,and cultural

factors:determine thetype, amount,andappropriate-ness of foodconsumed.(Gulanick;2007:135)

proper andbalanced

nutrition.

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4. Encourage totake foods, which

is high in protein,vitamins andminerals.

5. Encourage tohave anadequate supplyof roughage.

6. Suggest liquiddrinks forsupplementalnutrition.

7. Discouragebeverages thatare caffeinated or

Thesenutrients are

needed forgood tissuerepair.(Pillitteri;2007:641)

It is importantto help restorethe peristalticaction of the

bowel.(Pillitteri;2007:641)

Suchsupplementalcan be used toincreasecalories andprotein without

interfering withvoluntary foodintake.(Gulanick;2007:136)

These maydecreaseappetite and

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carbonated.

8. Encourageexercise.

9. Discuss theimportance ofmaintainingadequate caloricintake and thefour basic foodgroups, as wellas the need forspecific minerals

and vitamins.

lead to earlysatiety.

(Gulanick;2007:136)

Metabolismand utilizationof nutrientsare enhancedby activity.(Gulanick;2007:137)

Patients maynotunderstandwhat isinvolved in abalanced diet.They arebetter able toask questions

and seekassistancewhen theyknow basicinformation.(Gulanick;2007:137)

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S- Malipongko inig lakaw

nako, asverbalized bythe patient.

O-sleepy- looks tired-generalizedweaknessnoted

-with thefollowingvital signs:

T-36.5 0CP-75bpmR-20cpmBP-110/70mmHg

Activityintolerance

related tostressduring laborand birth.

By the time

the date ofbirthapproaches, awoman isgenerally tiredfrom theburden ofcarrying somuch extraweight with

her. Inaddition, mostwomen do notsleep wellduring the lastmonth ofpregnancy.Near thepregnancy,she probably

was unable tofindcomfortableposition in bedbecause of thefetus activityor thepresence ofback or leg

After 8 hours ofnursing

interventions, thepatient will beable to tolerateactivities withinlevel of ownability.

The patient willbe able to:

a. Identifynegativefactorsaffectingperformance.

b. Adapt lifestyleto increaseenergy level.

c. Verbalizeunderstandingof potentialloss of abilityin relation toexistingcondition.

Nursing Action:Render nursing

measures helpful inincreasing energylevel of the patientto tolerate activitieswithin level of ownability.

Nursing Orders:

1. Assess sleeppatterns andnote changes inthought process.

2. Assess thepatients level of

Appropriatemeasures will

beimplementedto increaseenergy level.

Multiplefactors canaggravatefatigue,including sleepdeprivation,emotionaldistress, sideeffects ofmedication,

andprogression ofdiseaseprocess.(Doenges;2002:87)

This aids indefining what

Goal met.Patient was

able totolerateactivitieswithin level ofown ability asevidenced by:

Patientanswered tothe questionasked andidentifiedfactorsaggravatingfatigue.

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pain. Allduring labor,

she has eatenvery little, ifanything, andhas workedvery hard withlittle or nosleep.(Pillitteri;2007:510)

d. Develop anactivity and

rest patternthat promotesoptimalindependenceand minimizesfatigue.

mobility.

3. Monitor patientssleep patternand amount of

sleep achievedover the pastfew days.

4. Encouragepatient to do

whateverpossible likeself-care and sitin chair.

5. Suggest that theclient perform

the patient iscapable of,

which isnecessarybefore settlingrealistic goal.(Gulanick;2007:8)

Difficultiessleeping needto be

addressedbefore activityprogressioncan beachieved.(Gulanick;2007:8)

Provides forsense of

control andfeeling ofaccomplish-ment.(Doenges;2002:83)

Shorter activityperiods

Patient can sitand can do

toothbrushing byherself.

Patientmoves slowly

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activities moreslowly and for

shorter times,resting moreoften, and usingmore assistanceas required.

6. Encourageproper nutritionalintake.

7. Plan time to be

with the patient,and listenactively to theclients concern.

performedmore slowly

and morefrequent restperiodspromoteoptimalperformanceandachievementlevels.(Doenges;2002:87)

Necessary tomeet energyneeds foractivity.(Doenges;2002:83)

Appropriate

assistanceensuressafety.(Kozier;2002:908)

and rest moreoften.

Patient eatsthe right kindand nutritiousfoods.

Patient

verbalizeswhat are herconcerns onher conditionto the nurse.

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