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Diana, 25 Y/O female patient who is present to the clinic today for her routine OB-GYNE Check up
1. Assessment
2. Diagnosis
3. Planning
4. Implementation
5. Evaluation
SUBJECTIVE DATA:
"I am feeling really tired and unproductive lately, I am always sleepy the entire day and can’t do anything productive. I do think that I am useless because of this pregnancy."
OB-GYNE History: G5P4 34 weeks AOG
(Problem-Focused Nursing Diagnosis)
Fatigue related to physiological condition as evidenced by blood pressure of 148/100, showing signs of fatigue and feeling useless and restless
Definition: An overwhelming sustained sense of exhaustion and decreased capacity for physical and mental work at the usual level. (NANDA-I, 2019)
After 3-4 hours of nursing intervention, the patient will have a lesser blood pressure state from 148/100 to 130/90
After 8 hours of nursing intervention, the patient will show less signs of fatigue and decrease the feeling of restlessness
Within 2-4 days of nursing intervention, the patient will report continuous sense of energy, normal count of blood pressure and regain herself from doing daily activities
Aid the patient with developing a schedule for daily activity and rest, emphasizing the importance of frequent rest periods.
Educate the patient as well as her family about task organization methods and time organization methods
Encourage the patient to increase fluid intake
Assist the patient in setting priorities for preferred activities and role responsibilities
Collaborative with occupational therapist as needed
A plan that balance periods of activity with periods of rest can aid the patient complete preferred activities without contributing to levels of fatigue.
Task organization and time management can assist the patient in saving energy and avoiding the signs of fatigue.
Balance intake of fats, minerals, carbohydrates, vitamins, and proteins for energy and nourishment consumption between herself and her baby.
For continuous hydration of the patient to recover from restlessness and fatigue
Attaining desired goals can develop the patient's sense of emotional health and be able to utilize available energy to complete important activities.
Offers the patient with assistive devices and educate the patient towards energy conservation methods
EVALUATION
After 3-4 hours, the patient was able to report reduction of high blood pressure count from 148/100 to 130/90.
After 8 whole hours of nursing intervention, the patient was able to show less signs of fatigue and decreased feeling of restlessness.
Within 2-4 days of nursing interventions, the patient was able to report a continuous sense of energy, and normal count of blood pressure and do usual daily activities.
BSN 1-Y1-11
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