7/29/2019 Case Pre Polyhydra Nsg Process
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ASSESSMENT NURSING
DIAGNOSIS
GOAL INTERVENTION/PLANNING IMPLEMENTATION RATIONAL
EVALUATION
SUBJECTIVE DATA-
Pt. having
backache
OBJECTIVE DATA-I
observe that pt.
having mild
backache
Subjective data-pt
.told me that she
having nausea and
vomiting
Objective data-I
observe that pt
looks lethargic and
weak due to
nausea and
vomotting
Subjective data-pt.
Told me that she
having weakness
Pain related to
increased
excessive
amount of
amniotic fluid
Risk for altered
fluid volume
deficient
related to less
intake
Nausea related
to physiological
changes during
pregnancy
Risk for infection
related to
hospitalization
To reduce the
intensity of
pain.
Pt will express
relief from pain
and comfort
fluid volume
level in the
body.will be
maintained
nausea will be
reduced
Pt. will be free
from infection
To Assess patient condition,
To assess vital signs.
To palpate the fundus for
height, location, and firmness.
To provide comfortable position
To provide relaxation therapy
To provide adequate amount of
fluid
Intake output should be
monitored.
To assess pt. For sign of infection
To maintained proper aseptic tech
Vital signs of the client is checked at
10:30am.
Up right position is given to pt.
Assess pt. Condition
Tab domped BD administored
Tab. Indomethacin 25 mg ,6 hourly is
administered to decrease amount of
amniotic fluid
Instruct patient to take adequate
amount of fluid like fruit juices
Moniter intake and output chart
Hand washing must be done before and
after procedure
TO find out
anywhether
deviation
from
normal
condition
To relieve
pain
To reduce
nausea
To
maintain
fluid and
electrolyte
balance
To reduce
chances of
infection
Pt express
relief from
pain and
comfort
Nausea
reduced
gradually
Pt was well
hydrated
Pt. Is free
from
infection
7/29/2019 Case Pre Polyhydra Nsg Process
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Objective data-i
observe that pt
looks lithargic
Subjective data-
Pt.told me that she
not take proper
diet
Objective data-i
observe that pt,
not take proper
diet due to nausea
Subjective data-
Pt.told me that she
having anxiety
Objective data-
I observe that pt
having anxiety due
to diseasecondition and pt.
Looks tense
Imbalanced
nutrition less
than body
requirement
related to poor
intake
Anxiety related
to disease
condition
Nutritional
status will be
maintained
Pt .will have less
anxiety
nique
To assess nutritional status of the
patient
To provide knowledge regarding
antenatal diet
To assess anxiety level of pt.
To provide information regarding
disease condition
To provide psychological support
In all procedure aseptic technique must
be maintained
Vital signs are monitored and
observed for any signs infection
assess nutritional status of the patient
health education given regarding
antenatal diet according to economical
status and pts like and dislike
include green leafy
vegetables,fruits,fruit juices,sprouted
seeds,dry fruits,plenty of water,rice dal
,chapaties ,milk,curd et
assess pt. Condition
provide information regarding disease
condition and treatment
provide psychological support to the
patient
To maintain
nutritional
status of
the patient
To reduce
anxiety
Pt take
proper diet
according
To my advice
Pt.having less
anxiety
