Nursing Care Plan

Assessment Subjective: y Nahihirapan akong huminga as verbalized by the client. Objective: y RR: 25 y Dyspnea y Use of accessory muscle to breath Nursing Diagnosis Ineffective Breathing Pattern related to Impingement of the diaphragm by enlarging uterus as evidenced by reports of shortness of breath, dyspnea, and changes in respiratory depth. Planning After 20 minutes of effective nursing intervention the client will establish a normal/effective respiratory pattern as evidence by absence of dyspnea and normal respiratory rate. Nursing Intervention y Stress importance of good posture. y Encourage adequate rest periods between activities. y Assist client in the use of relaxation techniques. y Elevate head on bed. y Encourage slower/deeper respirations. y Advised to limit congested places. Rationale Evaluation After 20 minutes of y To maximize respiratory effort. effective nursing intervention the client established a y To limit fatigue. normal/effective respiratory pattern as evidenced by absence of dyspnea and normal y To enhance respiratory rate. breathing pattern. y To promote proper breathing. y To promote proper breathing.

y To prevent suffocation.

Nursing Care Plan

Assessment Subjective: y dalawang beses lang ako kumakain sa isang araw as verbalized by the client. y Mahirap lang kami kaya hindi ko matustusan ang tamang pagkain para sa akin as verbalized by the client. Objective: y Weight : 53.5kg y Height: 5 2 (1.58m) y BMI: 21.48 y Pale conjunctiva Nursing Diagnosis Imbalanced Nutrition Less than Body Requirements related to insufficient intake of nutrients as evidenced by pale conjunctiva, inadequate financial resources and nutritional knowledge. Planning After 4 weeks of effective nursing intervention the client will demonstrate progressive weight gain and be free of signs of malnutrition as evidence by normal weight and lifestyle changes to maintain appropriate weight. Nursing Intervention y Evaluate total daily food intake, pattern and times of eating. y Emphasize importance of well-balanced, nutritious intake & educate the client about nutritional foods that are less expensive. y Assist the client to cook foods that are high in nutrients and essential vitamins. y Educate the client about the importance of eating fresh fruits and vegetables y Weight at regular intervals and document results. Collaborative mgt. y Consult dietitian/ nutritional team as indicated. Rationale y To reveal possible cause of malnutrition. y To gain knowledge about proper food selection and preparation Evaluation After 4 weeks of effective nursing intervention the client demonstrated progressive weight gain and is free of signs of malnutrition as evidenced by normal weight and lifestyle changes to y To monitor the effectiveness of plan. maintain appropriate weight. y To gain better understanding about the good benefits of eating fresh fruits and vegetables. y To monitor effectiveness of dietary plan. y To correct nutritional needs.

Drug Study
Name of Drug (Generic and Brand name) 1. Ferrous Sulfate Classification Dosage/ Frequency Route Mechanism of Action y Provides elemental iron, an essential component in the formation of hemoglobin. Indication Nursing Responsibility

Hematinic

Oral (PO)

y As a supplement during pregnancy

y Instruct the client to take tablet with juice (preferably orange juice) for better absorption. y Instruct the client not to take the medication with milk or any antacids as it may reduce the absorption. y Inform client to report constipation and change in stool color or consistency. y Inform client that oral iron may turn stools black.