CUES AND NURSING SCIENTIFIC GOALS AND NURSING

EVIDENCES DIAGNOSIS BASIS OUTCOME ACTION/NURSING RATIONALE EVALUATION

CRITERIA ORDERS

S- Altered During vaginal After 8 hours of Nursing Action: Appropriate Goal met as
urinary birth, the fetal nursing Render nursing measures will evidenced by:
elimination head exerts a interventions, the measures helpful in be
O- looks related to great deal of patient will be initiating voiding of implemented Patient was
weak perineal pressure on able to attempt the patient. to initiate able to void
-afebrile edema and the bladder common voiding. more than
-coherent decreased and urethra as measures to 100 ml within
-4 hours bladder it passes on initiate voiding. Nursing Orders: 2 hours’ time.
postpartum tone from the bladder’s
fetal head underside. 1. Assess amount Assessing Fundal height
pressure This pressure The patient will of urine voided fundal height returns to 1
during birth. may leave the be able to: during labor, and and position fingerbreadth
bladder with a reassess fundal provides below
transient loss a. Verbalize height and evidence umbilicus
of tone that, understanding position. about the after voiding.
together with s of the degree of
edema condition. bladder filling.
surrounding (Pillitteri;2007:
urethra, b. Identify 642)
decreases a negative
woman’s factors 2. Assess what Respecting Patient
ability to affecting measures patient client’s ambulates to
sense when urinary thinks would help preferences the bathroom
she has to elimination. her to void. helps her to to void with
void. maintain assistance
(Pillitteri;2007: c. Participate in feeling of
630) different control.
nursing (Pillitteri;2007:
interventions. 643)

3. Discuss the Helps to Patient

importance of initiate bladder confirms she
continuing to reflex. has been
drink. (Pillitteri;2007: drinking 1
642) glass of fluid
an hour.

4. Discuss Retention of Knows to

importance of urine drink 6 to 8
emptying predisposes to glasses of
bladder. infection. fluid daily.
(Pillitteri;2007:
642)

5. Stress Women
importance of should drink
drinking extra ample fluid
water during during the
postpartum postpartum
period. period, to
counteract
normal
dieresis and
ensure good
urine output.
(Pillitteri;2007:
643)
6. Teach normal The more
physiologic informed
changes that patients are,
occur after birth the more they
and the can participate
importance of in self-care.
preventing (Pillitteri;2007:
complications 643)
such as urinary
retention or
thrombophlebitis.

7. Instruct patient to Kegel

do Kegel exercises help
exercises once strengthen
voiding pattern is perineal
reestablished. muscle.
(Pillitteri;2007:
643)
S- Imbalanced The postpartal After 8 hours of Nursing Action: Appropriate Goal met as
nutrition, period is a nursing Render nursing measures will evidenced by:
less than time of interventions, the measures helpful in be
body rebuilding and patient will be promoting a implemented Patient was
requirement readjusting, able to acquire balanced nutrition to provide able to show
O-sleepy s, related to for which a basic knowledge of the patient. knowledge under-
- looks tired lack of woman needs regarding her regarding standings
-weighs 90 knowledge both ample body’s nutritional proper about
lbs about nourishment requirements. nutrition. importance of
-5’0” in postpartal and adequate The patient will Nursing Orders: proper and
height needs. fluid intake. be able to: balanced
-conscious Most mothers 1. Document actual Patients may nutrition.
-BMI is 18.2 are hungry a. Verbalize height and be unaware of
during the understandings weight. their actual
immediate about the weight and
postpartal importance of height or
period and proper nutrition. weight loss.
consume an (Gulanick;2007
adequate diet b. Identify :135)
without urging. interventions to
. promote a 2. Obtain nutritional The patient’s
(Pillitteri;2007: balanced history; include perception of
641) nutrition. family, significant actual intake
others, or may differ.
c. Demonstrate caregiver in (Gulanick;2007
techniques assessment. :135)
and lifestyle
changes to 3. Monitor or Many
promote explore attitudes psychological,
proper toward eating psychosocial,
nutrition. and food. and cultural
 factors:
determine the
type, amount,
and
appropriate-
ness of food
consumed.
(Gulanick;2007
:135)
4. Encourage to These
take foods, which nutrients are
is high in protein, needed for
vitamins and good tissue
minerals. repair.
(Pillitteri;2007:
641)

5. Encourage to It is important
have an to help restore
adequate supply the peristaltic
of roughage. action of the
bowel.
(Pillitteri;2007:
641)

6. Suggest liquid Such

drinks for supplemental
supplemental can be used to
nutrition. increase
calories and
protein without
 interfering with
voluntary food
intake.
(Gulanick;2007
:136)

7. Discourage These may

beverages that decrease
are caffeinated or appetite and
carbonated. lead to early
satiety.
(Gulanick;2007
:136)

8. Encourage Metabolism
exercise. and utilization
of nutrients
are enhanced
by activity.
(Gulanick;2007
:137)

9. Discuss the Patients may

importance of not
maintaining understand
adequate caloric what is
intake and the involved in a
four basic food balanced diet.
groups, as well They are
as the need for better able to
specific minerals ask questions
 and vitamins. and seek
assistance
when they
know basic
information.
(Gulanick;2007
:137)

Appropriate Goal met.

measures will Patient was
be able to
implemented tolerate
to increase activities
energy level. within level of
own ability as
evidenced by:

S-
O-sleepy Activity After 8 hours of Nursing Action: Multiple Patient
- looks tired intolerance By the time nursing Render nursing factors can answered to
-generalized related to the date of interventions, the measures helpful in aggravate the question
weakness stress birth patient will be increasing energy fatigue, asked and
noted during labor approaches, a able to tolerate level of the patient including sleep identified
-with the and birth. woman is activities within to tolerate activities deprivation, factors
following generally tired level of own within level of own emotional aggravating
vital signs: from the ability. ability. distress, side fatigue.
burden of effects of
T-36.5 0C carrying so medication,
P-75bpm much extra The patient will Nursing Orders: and
R-20cpm weight with be able to: progression of
BP-110/70 her. In 1. Assess sleep disease
mmHg addition, most a. Identify patterns and process.
women do not negative note changes in (Doenges;2002
:
sleep well factors thought process. 87)
during the last affecting
month of performance. This aids in
pregnancy. defining what
Near the b. Adapt lifestyle the patient is
pregnancy, to increase capable of,
she probably energy level. which is
was unable to necessary
find c. Verbalize before settling
comfortable understanding realistic goal.
position in bed of potential (Gulanick;2007
because of the loss of ability :8)
fetus’ activity in relation to
or the existing Difficulties
presence of condition. 2. Assess the sleeping need
back or leg patient’s level of to be
pain. All d. Develop an mobility. addressed
during labor, activity and before activity
she has eaten rest pattern progression
very little, if that promotes can be
anything, and optimal achieved.
has worked independence (Gulanick;2007
very hard with and minimizes :8)
little or no fatigue.
sleep. Provides for Patient can sit
(Pillitteri;2007: 3. Monitor patient’s sense of and can do
510) sleep pattern control and tooth
and amount of feeling of brushing by
sleep achieved accomplish- herself.
over the past ment.
few days. (Doenges;2002
:
83)

Shorter activity Patient

periods moves slowly
performed and rest more
4. Encourage more slowly often.
patient to do and more
whatever frequent rest
possible like periods
self-care and sit promote
in chair. optimal
performance
and
achievement
5. Suggest that the levels.
client perform (Doenges;2002
 :
activities more 87)
slowly and for
shorter times, Necessary to Patient eats
resting more meet energy the right kind
often, and using needs for and nutritious
more assistance activity. foods.
as required. (Doenges;2002
:
83)

Appropriate Patient
assistance verbalizes
ensures what are her
safety. concerns on
(Kozier;2002: her condition
6. Encourage 908) to the nurse.
proper nutritional
intake.

7. Plan time to be
with the patient,
and listen
actively to the
client’s concern.