ASSESSMENT SUBJECTIVE DATAPt. having backache OBJECTIVE DATA-I observe that pt.

having mild backache

NURSING DIAGNOSIS Pain related to increased excessive amount of amniotic fluid

GOAL To reduce the intensity of pain. Pt will express relief from pain and comfort

INTERVENTION/PLANNING 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

IMPLEMENTATION Vital signs of the client is checked at 10:30am. Up right position is given to pt.

RATIONAL TO find out anywhether deviation from normal condition To relieve pain

EVALUATION

Pt express relief from pain and comfort

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

Risk for altered fluid volume deficient related to less intake Nausea related to physiological changes during pregnancy

fluid volume level in the body.will be maintained nausea will be reduced

To provide adequate amount of fluid Intake output should be monitored.

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

To reduce nausea To maintain fluid and electrolyte balance

Nausea reduced gradually Pt was well hydrated

Subjective data-pt. Told me that she having weakness

Risk for infection Pt. will be free related to from infection hospitalization

To assess pt. For sign of infection To maintained proper aseptic tech

Hand washing must be done before and after procedure

To reduce chances of infection

Pt. Is free from infection

nique Objective data-i observe that pt looks lithargic

In all procedure aseptic technique must be maintained Vital signs are monitored and observed for any signs infection

Subjective dataPt.told me that she not take proper diet Objective data-i observe that pt, not take proper diet due to nausea

Imbalanced nutrition less than body requirement related to poor intake

Nutritional status will be maintained

To assess nutritional status of the patient To provide knowledge regarding antenatal diet

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

To maintain nutritional status of the patient

Pt take proper diet according To my advice

Subjective dataPt.told me that she having anxiety Objective dataI observe that pt having anxiety due to disease condition and pt. Looks tense

Anxiety related to disease condition

Pt .will have less anxiety

To assess anxiety level of pt. To provide information regarding disease condition To provide psychological support

assess pt. Condition provide information regarding disease condition and treatment provide psychological support to the patient

To reduce anxiety

Pt.having less anxiety