NURSING DIAGNOSIS NURSING GOALS NURSING OUTCOME

Assessment Diagnosis Mutual Planning Interventions Actual Evaluation

(Goal attainable within the shift) (with Rationale & Source)
Subjective: Fatigue related to psychological Short Term Goal: PRIMARY INTERVENTIONS Subjective:
Patient stated that she feels tired and physiological stressors, heat After 8 hours of nursing Promotive:
all the time, “kapoy jud ako pamati intolerance and poor nutrition as interventions, the patient will be I: Promote sufficient nutritional intake.
ug wala sad lain na makaatiman evidenced by patient’s verbal able to: R: The patient will need properly balanced intake of
sa akong mga anak sa balay,” statement of “kapoy jud ako  Rate the level of fatigue she fats, carbohydrates, proteins, vitamins, and minerals
patient mentioned it is hard for pamati ug wala sad lain na maka is experiencing (0-10) to provide energy resources.
them to meet their financial atiman sa akong mga anak sa  Identify the basis of fatigue S: Wayne, G. (2020).
responsibilities, she also balay,” difficulty in meeting their and individual areas of
verbalized that they do not eat financial responsibilities, and food control I: Aid the patient develop habits to promote effective Objective:
well as she knows they should, intake.  Discuss what she thinks rest/sleep patterns.
patient also reported heat worsens her fatigue R: Promoting relaxation before sleep and providing for
intolerance.  Name appropriate food that several hours of uninterrupted sleep can contribute to
can meet the nutritional energy restoration.
requirements needed by the S: Wayne, G. (2020).
Objective: Theoretical basis: mother
T: 36.5℃ PR: 70 bpm RR:16 cpm In the third trimester, the baby is Preventive:
BP: 100/70 mmHg putting more physical demands I: Aid the patient with developing a schedule for daily
Height: 5’3” (160cm) Weight: 50kg on the mother’s body. It is also in Long Term Goal: activity and rest. Emphasize the importance of
this trimester that the baby would After 32 hours of nursing frequent rest periods.
grow bigger and gain more interventions, the patient will be R: A plan that balances periods of activity with periods
weight. This results to the able to: of rest can aid the patient complete preferred
mother’s weight gain of 0.5kg per  Report improved sense of activities without contributing to levels of fatigue.
week until her full term. Another energy S: Wayne, G. (2020).
reason for fatigue on the third  Develop habits to promote
trimester of the pregnancy is the effective rest/sleep patterns I: Encourage the patient to maintain a 24-hour activity
lack of sleep. It may be hard for  Identify appropriate coping log for at least 1 week.
the mother to find a comfortable behaviors in dealing with R: Recognizing relationships between specific
sleeping position. Other fatigue activities and levels of fatigue can aid the patient
physiological symptoms in the  Perform an exercise recognize unnecessary energy outflow. The log may
third trimester of pregnancy such conditioning program that indicate times of day when the person feels the least
as leg cramps, backache, and improves her condition fatigued. This information can help the patient make
heartburn can cause fatigue and choices about setting his or her activities to take
stress onto the mother’s body. advantage of episodes of high energy levels.
Another factor that causes fatigue S: Wayne, G. (2020).
is the mother’s responsibility in
taking care of her other children
as well as her job (De Bellefonds, SECONDARY INTERVENTIONS
2019). An unbalanced diet means Curative
that the body is unable to extract I: Encourage the use of assistive devices (e.g.,
the full range of nutrients it needs wheeled walker, handicap parking spot, elevator,
from the food one partakes in. It backpack for carrying objects)
may also mean that some of the R: to extend active time/conserve energy for
food one consumes contains other tasks
ingredients harmful to health S: Doenges, M.E., Moorhouse M.F., & Murr, A.C.
(Rosser, n.d.). An imbalanced diet (2016).
with too much fat and refined
sugars can lead to physical and I: Avoid or limit exposure to temperature and humidity
mental tiredness. Food that helps extremes
balance the body provide stable R: It can negatively impact energy level.
energy, help fight tiredness and S: Doenges, M.E., Moorhouse M.F., & Murr, A.C.
keep the nervous system up and (2016).
running (Step to Health, 2018). A
balanced diet supplies the I: Assist the client to identify appropriate coping
nutrients your body needs to work behaviors.
effectively. Without balanced R: This promotes a sense of control and improves
nutrition, your body is more prone self-esteem.
to disease, infection, fatigue, and S: Doenges, M.E., Moorhouse M.F., & Murr, A.C.
low performance (Kans, 2020). (2016).
Having heat intolerance means
that your body is not regulating its TERTIARY INTERVENTIONS
temperature properly.The body Rehabilitative
regulates its temperature by
maintaining the delicate balance I: Encourage an exercise conditioning program as
between hot and cold (Wint, appropriate.
2019). The core body temperature R: Fatigue caused by deconditioning and prolonged
is already higher than normal bed rest can be reduced through improved functional
when one is pregnant. As the capacity using aerobic exercise.
baby grows, the body uses more S: Wayne, G. (2020).
energy to carry him around which
can boost the mother’s chances
of getting overheated. When
temperature starts to rise, the
body utilizes more energy to cool
itself down and cool down the
baby’s body. (Health Status, n.d.)
Bibliography:
De Bellefonds, C. (2019). Fatigue During Pregnancy. Retrieved on November 17, 2020 from https://www.whattoexpect.com/pregnancy/symptoms-and-solutions/pregnancy-fatigue.aspx
Doenges E.M., Moorhouse M.F., & Murr. A.C. (2016). Fatigue. Nurses’ Pocket Guide pp.310-316. Philadelphia, PA: F.A. Davis Company
Health Status. (n.d.) Overheating During Pregnancy: Why It Happens and How to Avoid It  Retrieved on November 17, 2020 from https://www.healthstatus.com/health_blog/pregnancy/overheating-
pregnancy-happens-avoid/#ixzz6e4HJscoA
Kans, B. (2020). Balanced diet. Retrieved on November 17, 2020 from https://www.healthline.com/health/balanced-diet
Rosser, J. (n.d.). What is an unbalanced diet? Retrieved on November 17, 2020 from https://www.success-stream.co.uk/what-is-an-unbalanced-diet/
Steptohealth. (2018).Consequences of an Imbalanced Diet: Foods that Lead to Tiredness . Retrieved on November 17, 2020 from https://steptohealth.com/consequences-of-an-imbalanced-diet-
foods-that-lead-to-tiredness/
Wayne, G. (2020). Fatigue. Retrieved on November 17, 2020 from https://nurseslabs.com/fatigue/
Wint, C. (2019). What is Heat Intolerance? Retrieved on November 17, 2020 from https://www.healthline.com/health/heat-intolerance