CUES DIAGNOSIS NURSING NURSING RATIONALE OUTCOME

OBJECTIVE INTERVENTION
S

Subjective Gestational Short Term Independent -monitored the Goal met

-”nanlalabo po ang hypertension - after 2 - check bp bp to after 2 hours
paningin ko at related to hours of bed - advice to eat determine any my patient's bp
masakit ang ulo ko” preeclampsia. rest the healthy food rich changes for returned to
as verbalized by the patient's bp in calcium such her bp. normal 120/80
client should be as grapefruit,
120/80 oranges, and -to lower her -After 3 days
Objectives: - lemons. hypertension. the patient’s no
150/100 longer take
uncontrolled Long-term Dependent -Labetalol is methyldopa and
hypertension - patients will - order for better tolerated labetalol.
take a methyldopa and than
Methyldopa labetalol methyldopa, - the patient is
and labetalol - order gives more continuing her
for 3 days. collaboration for efficient control diet plan.
a diet plan for of blood
- patients will patients. pressure
maintain
healthy food Collaboration - nutritional
rich in - dietitian consult can
calcium, help determine
potassium, the patient's
and rich in need/ dietary
iron such as plan.
grapefruit,
oranges, and
lemons. Dried
fruits (raisins,
apricots)
Beans,
lentils.
Potatoes.
oats.
tofu.
cues Diagnosis Nursing objectives Intervention rationale outcome

Subjective Risk for Short term Independent -to help in evaluating Goal met
- Diabetes altered -Patient will the client's
mellitus nutrition: less verbalize - Assess and understanding of - The sugar
than a body understanding of record dietary compliance to a strict level of my
Objective requirement individual treatment patterns, and dietary regimen patient is
- sugar level 199 regimen and the caloric intake 99mg/dl.
mg/dl need for frequent using 24
self-monitoring hours recall. - weight gain serves - the patient
as an indicator for maintains
Long-term - weigh the determining caloric taking her
-patient will maintain client every adjustment. insulin.
fasting serum blood prenatal
glucose levels prenatal visit. -Eating very frequent - the patient's
between 60-100 Encourage small meals improves still continuing
mg/dl. the client to insulin function. her plan to
periodically maintain her
-Patient will be free monitor -insulin needs for the sugar level.
of signs and weight at day can be adjusted
symptoms of home based on periodic
diabetic between serum glucose
ketoacidosis ( fruity- visits. readings. Reflectance
scented breath, - teach the meters maybe 10-
excessive thirst, importance of 15% lower/higher than
frequent urination.) regularity of plasma
meals, and
snacks when -Division of insulin
taking insulin dosage considers
basal maternal needs
- Teach and and mealtime insulin-
demonstrate to-food ratio and
to clients how allows more freedom
to monitor in meal-scheduling.
sugar using a Total daily dosage is
finger-stick based on gestational,
method.
current maternal
body weight, and
-discuss the
type of insulin serum glucose
dosage and levels.
schedule
(usually 4 -Diet-specific to the
times/day) individual is
necessary to
 maintain
- dependent normoglycemia and
Order insulin to obtain desired
Order for a weight gain. In-depth
dietary plan. teaching promotes
understanding of
one's own needs and
Collaboration clarifies
- dietitian misconceptions,
especially for a client
with gestational
diabetes. Note: New
recommendations set
dietary needs at 255
kcal/kg depending on
the client’s current
pregnant weight.

cues diagnosis Nursing objective intervention rationale outcome

Subjective Maternal risk for Short term Independent -to Partially met
- verbalize by infection related - the patient should - assess the temperature determine
the patient to LTCS verbalize she avail any
“masakit po to clean her wound changes to - she avail to
yung hiwa ko every-day - advise the patient to her clean her
sa tiyan” eat food rich in iron such temperature wound at her
Long-term as nuts, dried fruit, and house
-patient will take tofu. And take vitamin - ‍Iron-rich
Ketorolac 30mg c. food helps - it takes
Objectives Q6H x4 for pain regain the around 1
- slight reddish blood lost year to
Dependent
of the wound - patient will take completely
- order for Ketorolac, during
celecoxib 200 mg/ 1
paracetamol, delivery heal from her
cap Q12h after the
last dose of
cefuroxime, celecoxib. C-section
- dietary plan
ketorolac, to treat
mild to moderate - prevent
pain the
Collaboration infection
- dietitian
- take cefuroxime and for
500 mg to prevent pain killer
infection.

-effective prevention
of infection to the
client.