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Date/Time Focus DAR

Imbalanced nutrition, less than body Diagnosis:


requirements, related to nausea and
vomiting during pregnancy. Subjective:
“I am vomiting in the morning and late
afternoon and have experiences mild head
ache.”
LMP: Sept. 20, 2020.

Objective:
V/S taken as follows:
T: 36.8 P: 65BPM R: 20 BPM Bp: 120/80
Height: 5’3”
Weight: 130 pounds.
Pregnancy test result: Positive.

Action:
• Obtain weight and compare to baseline to
determine effects of nausea and vomiting on
nutritional intake.
• Review client’s typical dietary intake over
24 hours to determine nutritional intake and
patterns so that suggestions can be
individualized.
• Encourage client to eat five or six small
frequent meals throughout the day to
prevent her stomach from becoming empty.
• Suggest that she munch on dry crackers,
toast, cereal, or cheese or drink a small
amount of lemonade before arising to
minimize nausea.
• Encourage client to arise slowly from bed in
the morning and avoid sudden movements
to reduce stimulation of the vomiting center.
• Advise client to drink fluids between meals
rather than with meals to avoid over
distention of the abdomen and subsequent
increase in abdominal pressure.
• Encourage her to increase her intake of
foods high in vitamin B6 such as meat,
poultry, bananas, fish, green leafy
vegetables, peanuts, raisins, walnuts, and
whole grains, as tolerated, to ensure
adequate nutrient intake.
• Advise the client to avoid greasy, fried, or
highly spiced foods and to avoid strong
odors, including foods such as cabbage, to
minimize gastrointestinal upset.
• Encourage the client to avoid wearing tight
or restricting clothes to minimize pressure on
the expanding abdomen.
• Arrange for consultation with nutritionist
as necessary to assist with diet planning.

Response:
Date/Time Focus DAR
Frequent urinary elimination related to Diagnosis:
physiologic changes of pregnancy.
Subjective:
“I am experiencing frequent urination.”
LMP: Sept. 20, 2020.

Objective:
V/S taken as follows:
T: 36.8 P: 65BPM R: 20 BPM Bp: 120/80
Pregnancy test result: Positive.

Action:
• Assess client’s usual bladder elimination
patterns to establish a baseline for
comparison.
• Review with client the physiologic basis for
the increased frequency during pregnancy;
inform client that frequency should abate
during the second trimester and that it most
likely will return during her third trimester.
This will promote understanding of the
problem.
• Encourage the client to empty her bladder
when first feeling a sensation of fullness to
minimize risk of urinary retention.
• Suggest client avoid caffeinated drinks,
which can stimulate the need to void.
• Have client reduce her fluid intake for 2 to
3 hours before bedtime to reduce nighttime
urination.
• Urge client to keep perineal area clean and
dry to prevent irritation and excoriation from
any leakage.
• Instruct client in Kegel exercises to increase
perineal muscle tone and control over
leakage.
• Teach client about the signs and symptoms
of urinary tract infection and urge her to
report them should they occur to ensure
early detection and prompt intervention.

Response:

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