Nursing care plan of child with Endocrine Disorder.docx

Nursing care plan of child with Endocrine Disorder
Jalissa is an eight years old girl who has been admitted to
the ICU with head trauma after been involved in a vehicle
accident. She is unconscious and has conditions such as loss of
weight, decreased skin turgor, and has dry mucous membranes.
You did not copy and paste the entire case study.
Jalissa Twyman, 8 years old, was admitted to the pediatric
intensive care unit with a closed head trauma after being
involved in a bicycle/motor vehicle accident. Jalissa is
unconscious. The nurses caring for Jalissa document a weight
loss of 1.82 kg over a 24-hour period, decreased skin turgor,
and dry mucous membranes. Urine output for the same 24-hour
period is 3.5 L/m2.
Definition of the Medical Diagnosis
The endocrine mechanism is the network that consists of
secretes which releases and then produces hormones in use in
the controlling of many crucial functions in the person’s body,
including the body mechanism to change the calorie present in
the body into energy that yields power to organs together with
the cells (Whirter, 2016). The endocrine mechanism influences
individual heartbeats, the mode your tissues together with bones
develop, and also the ability to form a baby. It has an essential
function in determining if a person develops thyroid disorders,

diabetes, sexual dysfunctions, growth issues, or some hosts in
other hormonal diseases or not.
The endocrine disorders are in division into two groups,
namely the endocrine diseases, which result when there is more
or less production of endocrine hormones by the gland, and this
is called a hormonal imbalance. The second group is the
endocrine disease as a result of lesions development like the
tumors or nodules in an endocrine system that might affect the
levels of the hormone or not.
The feedback system in the endocrine aids in the control
process of hormonal balance in the bloodstream, if a person's
body has more or less of a given hormone, then the feedback
path will signal the appropriate glands to solve the problem.
Hormonal imbalances occur in instances when, first, the
feedback system experiences troubles on maintaining the proper
hormonal levels in a person's blood flow. Second is when bodies
do not remove the hormones out of the blood in an appropriate
way. High or low amounts of hormones in the endocrine might
be a result of some issues. The first issue is problems
encountered in the system entitled to the endocrine feedback.
The second issue is a disease. The third issue is gland failure in
the stimulation of another gland in the hormonal release; for
instance, problems concerning the hypothalamus may disrupt
the production of hormones in the pituitary gland. The fourth
issue is genetic disorders like the congenital hypothyroidism or
different endocrine neoplasia. The fifth concern, infections in a
person's body. The sixth concern, an endocrine gland injury
and, lastly, the endocrine gland tumor. Various endocrine
nodules and cysts do not result in cancer. They never spread to
the other organ parts. Bulges and tumors in the gland might
contradict hormonal release in the organs.
Signs and symptoms of an endocrine disorder and head trauma
There is a wide range of various categories of endocrine
diseases. Diabetes what kind of diabetes is she exhibiting?
happens to be a primary disorder of the endocrine that is in
diagnosis in the United States. The other types are as follows;

Adrenal insufficient,Does not apply to the topic. it is where the
adrenal gland produces a minimal hormone known as cortisol or
aldosterone. The symptoms may be stomach upset, fatigue,
changes in the skin, together with dehydration. Addison's
disorder happens to fall under the adrenal insufficiency.
Cushing disease, Does not apply to the topic.an overproduction
of the hormones in a pituitary gland that results in adrenal gland
overreacting. The same condition by the name Cushing
syndrome may happen in individuals and most infants who have
higher corticosteroid medications doses.
Does not apply to the topic.
Acromegaly or gigantism and some other growth
hormonal issues are there is more production of growth
hormones by the pituitary glands. A child's body parts or bones
might progressively grow abnormally. If there are lower levels
of growth hormone, then the child might stop becoming in terms
of height. Hyperthyroidism, in this condition, there is an excess
production of thyroid hormones by a thyroid, and this result to
sweating, an increase in the heart rate, weight loss, and a state
of nervousness. A cause of a thyroid that is overactive is a
disorder known as autoimmune, and the disease is known as
Graves.
Hypothyroidism,Does not apply to the topic. the gland on
thyroid, doesn't give adequate hormone of thyroid; this leads to
constipation, depression, and skin drying. The organ of
underactive may lead to slow growth in a child. Some of the
hypothyroidism is there during the birth of a child.
Hypopituitarism, little or no hormones, is released by the
pituitary gland. Several different diseases can cause it. Ladies
with the following situation can pause having a period.
Many endocrine neoplasiasDoes not apply to the topic.,
this is rare, a condition where genetics are decreased by society.
It may lead to tumors of the thyroid glands, adrenal, and
parathyroid, thus making the hormones being in overproduction.
Polycystic,Does not apply to the topic. having production on

androgens, may interfere with egg development and the release
from the ovaries of a female (Bajaj, Rajput & Jacob, 2013).
Polycystic ovary syndrome may lead to an individual being
unfertile. Precocious puberty, early abnormal puberty occurs
when the gland tells the body in life to produce the sex
hormones.
Potential Complications
While in most of the endocrine disorders are slow and
mild to the process, specific endocrine diseases may lead to
some of the complications over some time as signaling of
hormonal imbalance affects the regular operation of the body.
Complications of a particular disorder of endocrine include
heart disease, insomnia or anxiety, coma in hypothyroidism,
damage of the nerves, failure or loss of organs, reduced life
quality, and depression in many of the conditions.
Head to Toe Assessment
General: the patient has closed head trauma and unconscious
after been involved in an accident.
Vital signs: Temperature is 99.4°F; heart rate, 90 bpm, blood
pressure, 131/77 mm Hg; respiratory rate, 19 breaths/min
HEENT
Head: the hearing is ordinarily stiff and black. How is hearing
stiff or black.. and you state above unconscious
Eyes: the eyes lack discharge.
Pupil reactions.. imperative to assess in a TBI
Ears: the ears have regular physical appearances.
Nose: the nose does not have purulent discharge. Is there any
drainage?
Patency?
Mouth/Throat: the mouth has no sores, and the mouth is
moderately moist with healthy gum.
Respiratory: the patient has a clear breath through it is
prolonged. RR is documented as 19 breaths/min WNL
Cardiovascular:the patient does not have a history of murmur
nor palpitation. This is not objective documentation of her CV..

it is history
Gastrointestinal:the client was unconscious, but the guardian
admits that the client has been having nausea. Only the person
feeling it can give the symptom no nausea
abdominal contour.. marks. She was in a car accident so need
to assess for internal damage.
bowel sounds
Percussion
Palapation
Genitourinary: the client has no vaginal odor in her discharge
and has no swelling. She is achild.. not what you need to
assess
Did you read the case study .. there is critical data regarding
this system in the case study.
Skin: the skin is moderately tender with no scars or rashes.
Musculoskeletal: the guardian admits that the patient has been
having pain in her back but had not had any fractures.
pulses, capillary refill, ROM?
IV?
Neurologic: the patient has problems in her sleep patterns.
She is unconscious!
Diagnostic and Lab Studies Expected Outcomes
Closed head trauma, which is part of the endocrine disorder,
mostly occurs when one is involved in a physical accident that
tempers with one’s brain. Most patients might go on a comma
after experiencing trauma or brain injury. They are various tests
that can be used to examine the patient's brain status. The CT
scan is among the most common lab tests that are used to
explore the conditions of the brain. Blood and urine tests can
also be used in examining the patient's endocrine disorders as a
result of brain trauma.
All Jalissa Nursing Diagnosis
1. Decreased skin turgor
2. Weight loss

3. Dry mucus membrane
3 Jalissa Nursing Diagnosis, Goal Interventions, and Rationale
1. Weight loss is caused by a lack of eating during the time the
patient was diagnosed with trauma and went in a comma.
Desired Outcomes
· She is helping the client go back to her healthy life and start
eating as usual.
· The patient records an increase in weight though in the usual
way.
Interventions:
· Brings the patient back to healthy living.
· We are advising on healthy eating.
Rationale:
· Loss of weight is a highly associated failure to eat adequately.
· Eating adequately, a balanced diet helps one gain a healthy
weight.
0. Decreased skin turgor
Desired outcome:
· Ensure that the patient has normal skin turgor
Intervention:
· Guiding on proper feeding
Rationale:
· Decreased skin turgor is related to unfortunate feeding habits.
Evaluation
The patient states that she is capable of living a positive life
after trauma and is adapting to proper feeding and adequate
physical exercise. The patient is also able to increase weight in
inappropriate ways after modifying a good feeding program.

References
McWhirter, R. J. (2016). Adrenal cortex hormones—Advances
in research and application: ScholarlyBrief (13th ed.).
ScholarlyEditions.
Bajaj, S., Rajput, R., & Jacob, J. J. (2013). Endocrine disorders
during pregnancy. JP Medical.
McDermott, M. T. (2019). Management of patients with pseudo-
endocrine disorders: A case-based pocket guide. Springer
Nature.
Armed conflicts in Afghanistan
Student’s Name
Professor’s Name
Date
Introduction
For many decades Afghanistan has remained mired in conflicts.
Though the support of the US government Afghanistan is
fighting various rebel groups and movement like
Taliban
Islamic state
Islamic radicalism
Parchamis
Shi’ite Resistance Groups

Some of the factors that make people fight in Afghanistan
include false religious teaching that make Muslims more of
radicals. There are multiple resistance groups that fight against
the state government such as Taliban, Islamic radicalisms and
Islamic state as they all seek diverse goals such as overthrowing
the government and making Afghanistan a pure Islamic state.
2
Reasons for armed wars in Afghanistan
There are multiple resistant movements in Afghanistan's which
tend to force the ruling government to hear their voices. Some
of the demands of these movement include;
Resistance against US invasion
Fight for the natural resources
Struggle for leadership positions
Repressions by the military regimes
Poor political environment
Fight to support the communist government as seen in soviet
army invasion
Most youths regard US invasion as a form or neo-colonialism
propelling their rebellion against its support to the government.
Natural resources and leadership positions are scare coupled
with poor government polices which make people fight for these
few leadership post and scare resources.
3
Impacts of Afghanistan wars on the youths

Dreadful impact of Afghanistan wars on youths
Lack of employment
Poverty among youths
Deaths
School dropouts
Depressions and anxieties
Rapes and early unwanted pregnancies among ladies (Peter W.
Singer, 2016)
Deaths and rapes are obvious outcomes of battles which lead to
stress and anxieties on youth and family member who loose
their loved ones. School dropout contribute to early pregnancies
and high levels of poverty. Leading to depressions and
desperations among youths.
4
Afghanistan youth involvement in armed fights
Practice of young soldiers is widely practiced in Afghanistan
for various reasons
They are poor
As a sign of faith in their religion
Force recruitment into agencies like Taliban
Low level or education(Peter W. Singer, 2016)
To perpetuate atrocities which adults shy away from
In most case youth are kidnapped and forced to join army or
resistant movements. They are forced into acts of terror attacks,
mass killing and evils that adults would not imagine themselves

doing. A sign of loyalty to falsified Islamic religious teaching
the youth are lured to join the resistance movements. Low levels
of education among youth deny them ability to make insightful
decisions.
5
Creating a brighter future fir youths in Afghanistan
To create a better future for youths in Afghanistan several
measures need to be taken
Recognizing that youths have skill, zeal and potential to be
productive("Poverty Reduction Policy and Youth
Unemployment in Afghanistan," 2017)
Creating right infrastructure to utilize their talents
Creation of more economic opportunities
Sharing their knowledge and experiences
Revolutionizing radical Islamic beliefs
Youth should be used in productive ventures. The youths should
be regarded as an asset and be involved in right education while
government should create employment orpptunities to alienate
cases of poverty among youths as it is the main reason that lure
them to join resistance movements.
6
conclusion
It is critical for the youth to be used in the right way as they are
main turning points of government and economies. World states
should take the challenges facing Afghanistan youths as their
own burden and make contributions towards ceasing their
involvement in wars and effects of such wars of the youths.
References

Peter W. Singer. (2016, July 28). Young Soldiers Used in
Conflicts Around the World. Retrieved from
https://www.brookings.edu/on-the-record/young-soldiers-used-
in-conflicts-around-the-world/
Poverty Reduction Policy and Youth Unemployment in
Afghanistan. (2017, August 9). Retrieved from
https://www.researchgate.net/publication/319006791_Poverty_R
eduction_Policy_and_Youth_Unemployment_in_Afghanistan
Nursing Care of the Child with a Neuromuscular Disorder
Cerebral Palsy
Chapter 44: Nursing Care of the Child with a Neuromuscular
Disorder
Pamela is a six-year-old who was born with cerebral palsy. She
has some health conditions related to cerebral palsy, which
include mental impairment, hearing, and vision impairment, as
well as spasticity. She is in the hospital for the diagnosis of her
condition. NO she is ot.. you did not copy the case study as it is
written.
Pamela Souza, 6 years old, was born with cerebral palsy.
Pamela suffers from general spasticity, mental impairment,
impaired vision and hearing, and hydrocephalus. She has been
admitted to the pediatric unit for evaluation of intrathecal
spasticity control. This is the focus of the case study and what
you should have developed.
Cerebral palsy (CP) is among the groups of health disorders that
have significant effects on the movement and coordination of
body muscles (Ornoy, 2018). There other main areas that are
affected by CP are the vison, sensation as well as hearing.
However, the phrase cerebral is used to mean the brain. The

word palsy is used to mean weakness or incapability of the body
parts to move effectively. Through a lot of researches that has
been done, it has been realized that CP is among the most
common causes of childhood's motor inabilities and disabilities.
Across the world, about five children in 1000 are affected by
cerebral palsy.
Signs and symptoms of CP
The signs of any symptoms of CP are different from one person
to another and might range from minor or mild signs to acute
and severe signs. Some patients might have challenges in
walking while others might have problems sitting. On the other
hand, some people who are affected by CP can have difficulties
in grasping objects. Over time, the signs can worsen or become
less severe, depending on the brain areas they have changed.
The most common signs are:
· Variations and differences in the muscle tone which include
becoming very floppy or stiff.
· I was taking long to adapt some motor skill milestones, which
include rolling over, crawling as well as sitting up.
· Difficulties in walking
· Delays in developing speech capabilities
· Stiffness of muscles or excessive flexibilities
· Tremors
· Problems during the process of swallowing
· Blindness and intellectual disabilities (Miller, 2018).
Some children are born with cerebral palsy, but the signs and
symptoms do not present themselves until the children reach
some months or even years. In most cases, the flags can present
themselves at the age of three to four months.
Causes of cerebral palsy
The most common cause of CP is the abnormalities in the
development of brain or brain injuries. These damages affect
the brain part that is used in controlling the movement of the
body parts, their coordination, and posture. The cost on the
brains most often happens before a child is born, but in other
instances, it can occur during birth or in the first ten months

after birth (Ornoy, 2018). There are other causes of CP, which
include:
· Lack of adequate oxygen during the process of child delivery
· Gene mutations that can read to the development of the brain
in an abnormal way
· Maternal infections which include herpes simplex
· Infections in the mind which might consist of meningitis
· Bleeding in the brain
· Head injuries can be caused by accidents, falls, or physical
abuse.
The people who are at risk for cerebral palsy
Various factors put the children at high risk for CP. These
factors include:
· Low birth weight
· Twins or triplet
· Premature birth
· Breech birth
· Rh incompatibility
· Maternal exposure to poisonous or poisonous substances
during the pregnancy period
Various complications are caused by cerebral palsy, which
include spasticity as well as contractures. Other complications
include difficulties in feeding, fractures, challenges in
communication, vomiting, osteopenia, constipation as well as
bowel obstruction.
General: difficulties in vision and communication due to brain
damage.
Vital signs: Body temperature 86.5°F WHAT?
; heart rate, 98 bpm, blood pressure, 110/73 mm Hg; respiratory
rate, 21 breaths/min
HEENT
Head: the hair is black with no abnormalities
Eyes: Eye pain Why?

and difficulties in seeing correctly,
has some discharge in the eyes. Why?
Pupil reactions?
Ears: Normal physical appearance of the ears.
Gross hearing?
Nose: Has a dry nose with no growth or physical abnormalities.
Mouth/Throat: the lips are moist, and the mouth has no lesions
or sores. The throat has no wounds, and the gums are strong and
healthy.
Respiratory: her breath is clear with no difficulties and has no
coughs or rhonchi.
Cardiovascular:the patient has no history of cyanosis, syncope,
or palpitations.
heart sounds and rhythm?
Gastrointestinal: the patients admit having constipation
occasionally. Parents are reporting and this is not part of you
head to toe assessment
abdominal contour
Bowel sounds
bowel movements
Percussion
Palpation
Appetite
Genitourinary: the client has no odor in her vagina She is 6
year old!
and no swelling nor virginal redness.
Urine output
Urine color
Continence
Skin: the skin is smooth with no scars, rashes, nor lesions.
Abdominal circumference: the abdominal girth has average
liquor WHAT?
volume. Wrong order
Musculoskeletal: the patients complain of back pain and have a
history of fractures.

This is her problem area.. this is a very incomplete
assessment
ROM
Spasticity
gait
joints
pulses
Neurologic: the patients have depression, which is making it
difficult for her to sleep well.
What tests would be done at the present time in the present
situation.. she is pre-operative.
She has been admitted to the pediatric unit for evaluation of
intrathecal spasticity control. This is the focus of the case study
and what you should have developed.
Cerebral palsy can affect any child either during birth or before
the child is born. It can be seen as a natural health condition,
and some people might also take it as part of life by accepting
it. However, some advances have been made in the current
diagnosis of CP. The electroencephalogram can be used in the
evaluation of the electrical activity of the patient's brain
(Miller, 2017). This method can be used to evaluate the
condition of Pamela. The CT scan can also be used in creating
clear and cross-sectional images of the patient’s brain.
All Pamela Nursing Diagnosis
These are NOT NANDA nursing diagnosis.. You should know
this by now.
1. Impaired vision and hearing related to brain damage
2. Mental impairment which makes the patient unable to make
quick decisions.
3. Hydrocephalus

4. Spasticity
5. Difficulties in movement
6. Inability to speak
7. Constipation due to difficulties proper digestion.
3 Pamela Nursing Diagnosis, Goal Interventions, and Rationale
This pt is pre-operative
1. Constipation which is caused by gastrointestinal muscles
relation, which makes it difficult for the food to be properly
digested.
Desired Outcomes
· To minimize and entirely do away with constipation
· Help the patient adapt to healthy eating
Interventions:
· Assessing the nature as well as the degree of constipation.
· I am advising the patient and the guardian on the proper ways
of eating a healthy diet.
Rationale:
· Constipation is caused by the inability of the body to digest
food properly.
· A lack of proper physical exercise might cause constipation.
0. Impaired vision and hearing related to brain damage
Desired outcome:
· Ensure that the client gets back her vision and hearing ability.
· Help the patient adapt to impaired vision and hearing.
Intervention:
· I was counseling the patient on how to positively adapt to the
conditions related to impairment in vision and hearing.
Rationale:
· Counseling helps the patient and the guardians to live
positively even when in impairment of vision and hearing.
Evaluation
The patient states that she can adapt to their condition and raise
her self-esteem after the counseling section. Taking the
medication and exercising has been received positively by the
patient and her family.

References
Miller, F. (2017). Early-onset scoliosis in cerebral
palsy. Cerebral Palsy, 1-14. https://doi.org/10.1007/978-3-319-
50592-3_117-1
Miller, F. (2018). Knee flexion deformity in cerebral
palsy. Cerebral Palsy, 1-22. https://doi.org/10.1007/978-3-319-
50592-3_136-1
Ornoy, A. (2018). Animal models of cerebral palsy: What can
we learn about cerebral palsy in humans. Cerebral Palsy, 1-
12. https://doi.org/10.1007/978-3-319-50592-3_218-1
Running head: NURSING MANAGEMENT DURING
PREGNANCY
NURSING MANAGEMENT DURING PREGNANCY 9
NAME: Adebola Amoo Ross
Beth (age 18) is experiencing her first pregnancy and is now 24
weeks gestation. She tells you that she is “amazed by the

changes that have happened to my body already.” Beth wants to
understand what additional changes are going to occur to her
“besides just getting a really huge belly.” Additionally, Beth
relates to you that she is in her senior year of high school, is no
longer involved with the baby’s father, and lives at home with
her mother and 12-year-old brother. (Learning Objectives 3 and
5).
Definition of the Medical Diagnosis
Pregnancy is a psychosocial phenomenon that is usually
characterized by the changes in biological as well as
psychosocial adaptations which evolve generally in a healthy
manner (Susan, Terri & Susan, 2009). However, some pregnant
women may experience some problems or complications due to
specific factors or characteristics. These can classify their
conditions as high-risk and may negatively affect the
mother/child evolution. The detection of this risk calls for the
provision of appropriate and quality care by the nurses as well
as the healthcare team. The gravid-puerperal period requires a
multidisciplinary care because the women require minimal
interventions. However, emergencies or life-threatening
complications in some situations may occur and thus there is
need to identify them effectively. A multi-disciplinary approach
consisting of health professionals as well as local administrators
is required to ensure that effective actions are performed to
ensure that there is a risk-free and quality mother and child
assistance (Gaucha, 2016).
The maternal as well as the neonatal morbidity data have been
used to improve the technical as well as the scientific
knowledge of the nursing practitioners who usually have direct
participation during this period and thus ability to create quality
strategies. Monitoring pregnant women during prenatal care, or
during labor, delivery, or offering assistance to high-risk
pregnant women in maternal ICUs are the role of nursing
practitioners in obstetrics. This calls for a clinical preparation
on the side of nursing practitioners so as to identify the real as
well as the potential problems, manage the diagnoses correctly

and plan and implement the care (Dennis & Hardy, 2016).
Common Signs and Symptoms
The common signs and symptoms of pregnancy are both
physiological as well as psychosocial. Some of the
physiological changes are increase in the size of breasts,
increased blood circulation in the genitalia area, stretchmarks in
the abdomen, absence of menstruation, pelvic pain/discomfort,
intermittent nausea, swollen feet and ankles, vomiting,
tiredness, weight gain, increased frequency of urination, and
possible heartburn/indigestion. The psychosocial changes may
include changes in her social life, dramatic body alterations,
fear of raising the child alone without a father, and fear of
giving birth or fear of pain during delivery (WHO, 2015).
Pregnancy is a normal process in which the pregnant woman
would be able to manage the problems and issues with the
support of healthcare providers. However, there are some
complications that might arise during pregnancy. Some of these
complications include high blood pressure, preterm labor,
gestational diabetes, preeclampsia, or a loss of
pregnancy/miscarriage (ACOG, 2014).
General: Steady movement, normal belly size at 24 weeks of
pregnancy, impaired verbal communication due to anxiety.
Vital signs: Temperature, 98.6°F; heart rate, 99 bpm, blood
pressure, 122/75 mm Hg; respiratory rate, 22 breaths/min
HEENT
Head: Excess dryness in hair.
Eyes: No eye pain, discharge or itchiness.
Ears: Normal external appearance.
Nose: Dry nasal mucosa with no purulent discharge.
Mouth/Throat: Dry oral mucosa without lesions, no sores or
exudate. Healthy gums.
Breast changes: Normal breast changes. Colostrum can be
expressed.

Respiratory: Clear to auscultation together with no coughs,
rales, or rhonchi.
Cardiovascular:No history of syncope, murmur, palpitations or
cyanosis.
Gastrointestinal:The client admits experiencing nausea and
some instances.
Genitourinary: No vaginal odor, no swelling or redness
observed.
Skin: No visible scars, lesions or rashes.
Abdominal: Fetal movements can be observed. No presence of
scars, lesions or rashes.
Fundal height: Present at the upper margin of the umbicus and
about three hand breadths from the symphysis pubis.
Abdominal girth: normal increase in abdominal girth. Normal
liquor volume.
Musculoskeletal: The client reports instances of back pain. No
history of fractures reported.
Neurologic: Client is a bit disoriented. Disturbed sleep patterns.
There are a number of physiological adaptations that develop
throughout normal pregnancy. Some of these changes are
confirmed through laboratory tests. However, some of the
symptoms and tests may be easily be misinterpreted by some
healthcare professional, especially those who are not experts or
specialized in pregnancy related problems. The hs-cT nI
concentration is one of the factors that is used to test pregnancy
complications. For instance, higher values of hs-cT nI is an
indicative factor of preeclampsia (ACOG, 2014). Furthermore,
hyponatremia can occur in preeclampsia which is indicated by
low levels of sodium and potassium. Cardiac evaluation to
evaluate history of hypertension or cardiac diseases are also
done. 3-hr glucose test is also done to screen for diabetes
(Cervellin, Comelli , Bonfanti, Numeroso , & Lippi, 2019).
All NANDA Nursing Diagnosis
1. Nausea
2. Disturbed sleep pattern related to physical and emotional

alterations
3. Anxiety related to labor
4. Imbalanced nutrition
5. Risk of altered breathing related to anxiety
6. Constipation related to pregnancy
7. Impaired urinary elimination related to urinary infection
8. Impaired skin integrity due to edema
3 NANDA Nursing Diagnosis, Goal Interventions and Rationale
1. Nausea is caused by changes in the gastrointestinal and
stomach muscles relaxing as well as the pressure on the stomach
as a result of the growing weight of the baby in the uterus. This
can result from some foods becoming difficult to digest.
Desired Outcomes
· Experience minimal or no nausea
· Reports satisfaction with care
Interventions:
· Assess the nature, frequency and nature of nausea
· Advise on dietary instructions
Rationale:
· Nausea may be caused by visual stimuli and odors thus need to
assess on the nature.
· Foods rich in oils and fats as well as some beverages trigger
nausea during pregnancy.
2. Disturbed sleep patterns related to physical or emotional
alterations
Desired outcome:
· Ensure there is normal sleep patterns
Intervention:
· Counselling on positive self-image
· Advise on dietary observations.
Rationale:
· Counselling helps in ensuring that there is positive self-image
to physical and emotional alterations.
· Beverages such as caffeine have an ability to disturb sleep
patterns.
3. Imbalanced nutrition caused by insufficient intake of

nutrients to meet metabolic demands
Desired outcome:
· Patient able to verbalize the understanding of dietary needs.
· Patient to develop a proper dietary plan within financial
resources.
· Patient should display appropriate weight gain.
Interventions:
· Determine the patient’s nutritional status, condition of the hair
as well as any instances of weight gain.
· Provide information about the patient’s normal weight gains in
the course of the pregnancy which are modified to meet the
patient’s needs.
· Provide information about the effect of reduced activity as
well as bedrest on protein requirements
· Collaborate with a dietician
Rationale:
· Establishing the patient’s nutritional status helps in
establishing the guidelines that are essential in determining
dietary needs as well as educating the patients.
· The provision of information regarding normal weight gains
are essential in determining whether underweight patients need
a diet higher in calories. This is due to the fact that the fetus
risks ketosis resulting from dieting that leads to obesity.
· The provision of information regarding to bedrest and reduced
activity help in determine the protein needs which are reduced
due to decreased metabolic activities.
· Collaborating with a dietitian helps in incorporating specific
needs and restrictions to the patient.
Evaluation
The patient reports that she is able to have a positive image
about pregnancy and towards oneself after counselling.
Furthermore, dietary advices resulted to better sleep patterns
and balanced nutrition.

References
American College of Obstetricians and Gynecologists (ACOG).
(2014). Preeclampsia and high blood pressure during pregnancy.
FAQ034. Retrieved May 31, 2016,
from http://www.acog.org/~/media/For%20Patients/faq034.pdf?
dmc=1&ts=20120730T1500377195
Cervellin G., Comelli I., Bonfanti L., Numeroso F., & Lippi G.
(2019). Emergency diagnostic testing in pregnancy. Journal of
laboratory and precision medicine: 5(2). doi:
10.21037/jlpm.2019.10.04
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