Assessment Nursing Goals Interventions Rationale Evaluation

Diagnosis Outcome
Criteria
Subjective: Altered nutrition Patient will 1.Nurse will 1.Adequate
related to obtain adequate assess normal weight
pregnancy nutrients patient’s contributes to
needed during weight gain or the tissue
Objective: pregnancy as weight loss at expansion
evidenced by: each visit to and growth of
Height the both mother
Weight clinic/doctor’s and fetus. .
Age office Inadequate
weight gain
has been
Breastfeeding/bottle -Gaining 25-35 associated
feeding: lbs during with preterm
How much: pregnancy, 3.5- birth and is
How often: 5 lbs during first related to
Type: tri and 1 lb per problems for
week during the the newborn.
last two tri’s. (Olds, p.421)
Weight gain:
-adding 300
H&H: kcal/day to diet 2.Iron
during 2.Nurse will deficiency
assess for anemia is the
Fundal Height -Taking prenatal pica. most common
measurement vitamins as concern with
prescribed pica. Eating
ice or freezer
Vitamins -having normal frost often
Folic Acid intake H and H levels leads to poor
weight gain
because lack
Foods to avoid of appetite.
Starch
BP: ingestion is
Pulse: associated
Respiration: with weight
gain.
Nausea/vomiting: Indigestion of
Amount large
Onset amounts of
Frequency clay could .
cause fecal
Skin Turgor: impaction.
(Olds, p. 435)

3.Eating
3.Inform crackers or
patient on toast before
ways to reduce rising and
nausea and changing
vomiting. positions
slowly
throughout
the day
prevents
nausea and
vomiting.
(Olds, p.372)

4.Vitamins
4.Educate are organic
patient on substances
importance necessary for
Assessment Nursing Goals Interventions Rationale Evaluation
Diagnosis Outcome
Criteria
Subjective: Knowledge Patient will have 1.Nurse should 1.Patient
deficit related to an increase encourage should visit
lack of knowledge prenatal visits. MD every 4
information about weeks for the
Objective: about pregnancy pregnancy as first 28 weeks
evidenced by: of gestation,
Age: every 2
weeks until .
Educational level: -verbalizing 36 weeks
importance of gestation and
prenatal visits every week
Family support after 36
system: weeks.(Olds,
-understanding p.359)
importance of
Number of recognizing
children(gravida): danger signs 2.Inform 2.Communitie
and when to patient about s often have a
notify MD community wealth of
resources or services and
referral educational
-verbalize the agencies. opportunities
awareness of available for
community pregnant
resources that women and
are available their families.
This allows
the family to
-verbalize the assume equal
importance of responsibility
aminocentesis with health
and the risk care
involved providers(WI
C, Food bank,
-verbalize the Health dept).
importance of
an ultrasound
3.Explain the 3.Ultrasounds
ultrasound determine
-verbalize the procedure to fetal
importance of the patient. presentation .
CVS and risk before or
involved during labor,
locate the
-verbalize placenta,
importance of confirm fetal
alpha feto viability,
protein and risk determine
involved amniotic fluid
index,
diagnosis
-verbalize multiple
importance of gestation and
CST and risk help guide
involved amniocentesi
s. Patient
should not
-verbalize urinate before
importance of ultrasound(Ol
cordeocentesis ds, p.544)

4.Explain 4.Amniocente
procedures for sis is used for
amniocentesis genetic
and risk. Make diagnosis.
sure patient Test is used
empties to detect
bladder. neural tube
defects, blood
typing and
DNA testing
and validate
abnormalities
found. 30-35
weeks
amniocentesi
s may be
done for lung
maturity
studies.(Olds,
p. 564, 565)

5.Explain 5.This test

procedure for involves using
nonstress test, an electronic
the information fetal monitor
provides and to obtain a
process for tracing of the
completing the fetal heart
test. rate and
observation of
acceleration
of the FHR
with fetal
movement.
Women
shouldn’t
smoke before
test is
performed
because
smoking
adversely
affect the test
 results.(Olds,
p.552, 553)

6.Explain the 6.AFP is done

procedure for to detect
alpha- neural tube
fetoprotein to defects. The
patient. levels will be
elevated if the
fetus has
neural tube
defects. This
test is done
about 16-18
weeks
gestation.
(Olds, p.564)

7.Explain 7.CVS is
chorionic villus used to detect
sampling to genetic,
client and risk metabolic and
involved. DNA
Explain that abnormalities
she must have between 10
a full bladder and 12 weeks
before gestation.
procedure is There is a risk
done. of having a
spontaneous
abortion with
CVS. Other
risk include
ROM,
leakage of
amniotic fluid,
bleeding,
intrauterine
infection.
Having a full
bladder will
help displace
the uterus for
catheter
insertion.
(Olds, p. 568,
570)

8.Explain 8.Cordeocent
procedure for esis is a
cordeocentesis technique
and risk used to obtain
involved. pure fetal
blood from
 umbilical cord
while the
fetus is in
utero. The
test is done to
diagnosis
hemophilias,
fetal
infections,
chromosome
abnormalities.
Risk include
oversedation
and deep
breathing by
mother
related to any
medication
given.(Olds,
p. 570)

9.Explain 9.Contraction
procedure for stress test
contraction evaluates
stress test and respiratory
risk involved functions. It
identifies
fetus at risk
for
intrauterine
asphyxia by
observing
responses of
FHR to stress
of uterine
contractions.
Test is done
after 28
weeks
gestation(Old
s, p. 556)
.