CUES NURSING DIAGNOSIS

RATIONALE OBJECTIVES INTERVENTION RATIONALE EVALUATION

Subjective:

“Sayang talaga itong bata na ito, lalaki pa naman sana, tama n asana para hindi na kami magdagdag ng anak kasi may panganay na kaming babae”.

Objectives: Looks sadAbdominal painPhobia to get pregnantNeeds attendedNeeds counselingLow- self esteemRestlessnessNeeds emotional supportPresence of anxietyNeeds sympathy

Risk for loneliness related to IUFD.

“Sayang talaga itong bata na ito, lalaki pa naman sana, tama n asana para hindi na kami magdagdag ng anak kasi may panganay na kaming babae”.

Know that her baby was dead in her womb.

Unable to accept what was happen to her baby.

Doesn’t feel the moving of the baby

Doesn’t hear the FHT of the baby

Risk for loneliness related to IUFD

At the end of 20-30 mins. Of nursing intervention the client will be able to:

Enumerate ways to lessen low- self esteem such as:

a. Counselingb. Express her

feelingsc. Reading the bible.

The client or the family will help to strengthen her self- esteem.

Be motivated to participate and cooperate during health teaching.

Discuss the importance of counseling to increase his self-esteem.

Tell to the client or family to read bible to increase her self-esteem.

Acknowledge the mother or family’s performance toward each health teaching.

For the client to obtain knowledge about the importance of counseling to increase self-esteem.

To ensure that the bible helps to strengthen his self- esteem.

To maintain positive output towards health.

To maintain nurse-client relationship for effective therapeutic.

Gained knowledge as evidenced by:

a. Client was able to enumerate the ways to lessen low self- esteem.

b. Answered questions correctly.

Reading some pocket books and bible.

a. The client and family listen attentively.

b. The patient was able to participate and cooperate during health teaching.

CUES NURSING DIAGNOSIS

RATIONALE OBJECTIVES Outcome Criteria INTERVENTION RATIONALE EVALUATION

Subjective:

“ Nahihirapan ako matulog dahil sa sobrang sakit ng tiyan ko” as verbalized by the patient.

Objective:

RestlessnessYawning

Disturbed sleep pattern related to abdominal pain secondary to IUFD. Identify individually

appropriate interventions to promote sleep.

Perform proper technique of relaxation.

Maintain positive outlook towards health and health care.

Verbalizes understanding of sleep disturbance.

Reports improvement in sleep/rest pattern.

Identify circumstances that interrupt sleep and frequency.

Listen to subjective reports of sleep pattern disturbance that are associated with specific underlying illness.(e.g. IUFD, abdominal pain)

Provide quiet environment

Encourage participation in regular exercise program during day.

To determine usual sleep pattern provide comparative baseline.

To aid stress control/ release of energy.Exercise at bedtime may stimulate rather than relax client and actually interfere to sleep.

Teach patient proper deep breathing technique.

Encourage patient to limit fluid intake in evening if nocturia is a problem.

Recommend limiting intake of chocolate and caffeine/ alcoholic beverages, especially prior to bedtime.

Establish rapport.

To divert attention from abdominal pain.

To reduce need for nighttime elimination.

To build trust.