EMILIO AGUINALDO COLLEGE
Gov. D. Mangubat St., Brgy. Burol Main, City of Dasmariñas, Cavite 4114, Philippines
Tel. Nos. (046) 416-4341-42www.eac.edu.ph
SCHOOL OF NURSING
ISO 9001:2015 CERTIFIED
QUALITY MANAGEMENT SYSTEMS
KNOWLEDGE DEFICIT TOWARDS BEARING DOWN
ASSESSMENT NURSING PLANNING INTERVENTION RATIONALE EVALUATION
DIAGNOSIS
Subjective: Knowledge deficit After 20 minutes 1. Determine 1. To promote After 20 minutes
“Nakalimutan ko related to lack of of nursing level of better of health teaching
na paano umire.” recall secondary intervention the knowledge, understanding the mother was
As verbalized by to lack of interest mother will be including able to
the patient in learning able to anticipatory 2. To perform demonstrate the
demonstrate the needs proper proper way of
proper way of pushing during pushing during
Objective: pushing during 2. Demonstrate contractions labor contraction.
- Cannot pay labor contraction. proper pushing
attention 3. To provide
- Inaccurate information on
follow-through of 3. Determine patient’s level
instruction patient’s ability of
to learn. understanding
4. Be alert to 4. To prevent
signs of from further
avoidance complication
5. Note personal 5. To use as
factors baseline data
26
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EMILIO AGUINALDO COLLEGE
Gov. D. Mangubat St., Brgy. Burol Main, City of Dasmariñas, Cavite 4114, Philippines
Tel. Nos. (046) 416-4341-42www.eac.edu.ph
SCHOOL OF NURSING
ISO 9001:2015 CERTIFIED
QUALITY MANAGEMENT SYSTEMS
ACUTE PAIN
ASSESSMENT NURSING PLANNING INTERVENTION RATIONALE EVALUATION
DIAGNOSIS
Subjective: Pain related to After rendering 1. Encourage 1. To promote Goal met as
“Sobrang sakit ng strong uterine nursing relaxation muscle evidenced by:
tyan at likod ko contractions intervention, the exercises such relaxation and
kapag humihilab.” secondary to patient’s pain will as deep help alleviate After rendering
As verbalized by the dilatation and alleviate from breathing the pain nursing
patient. compression of pain scored 9 to exercise intervention, the
pain scored 3 2. To anticipate patient’s pain was
nerves by
which is minimal 2. Observe untoward alleviated from
presenting part
pain. nonverbal cues complication of pain scored 9 to
Objective: of the baby. labor pain scored 3
- Pain scored 3. Assess which is minimal
9, severe pain patient’s 3. To determine pain.
using pain attitude toward the level of pain
scale 1-10 pain tolerance
- BP:
130/70mmHg 4. Determine pain 4. To determine if
- RR: 25 cpm characteristics the cervix is
- PR: 121 bpm using a pain fully dilated
- (+) facial scale.
grimace 5. To determine
- Narrowed 5. Monitor vital possible
focus signs complications
6. Encourage 6. To evaluate the
27
verbalization of feeling of
feelings about patient’s
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EMILIO AGUINALDO COLLEGE
Gov. D. Mangubat St., Brgy. Burol Main, City of Dasmariñas, Cavite 4114, Philippines
Tel. Nos. (046) 416-4341-42www.eac.edu.ph
SCHOOL OF NURSING
ISO 9001:2015 CERTIFIED
QUALITY MANAGEMENT SYSTEMS
the pain perception
towards pain
7. Provide quiet
and calm 7. To lessen the
environment feeling of
irritation of the
8. Provide patient
comfort
measures such 8. To help lessen
as backrub and the pain
change of
position 9. To monitor the
interval of
9. Note the onset contraction
of pain
28
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EMILIO AGUINALDO COLLEGE
Gov. D. Mangubat St., Brgy. Burol Main, City of Dasmariñas, Cavite 4114, Philippines
Tel. Nos. (046) 416-4341-42www.eac.edu.ph
SCHOOL OF NURSING
ISO 9001:2015 CERTIFIED
QUALITY MANAGEMENT SYSTEMS
HYPERTHERMIA
ASSESSMENT NURSING PLANNING INTERVENTION RATIONALE EVALUATION
DIAGNOSIS
Subjective: Hyperthermia After an hour of 1. Identify 1. To provide the Goal partially met
“Mainit ang related to nursing underlying proper as evidenced by:
pakiramdam ko” increased intervention, the cause underlying
As verbalized by After 3 hours and
metabolic rate patient’s cause
the patient 2. Note age of 30 minutes of
secondary to temperature will
patient 2. To provide nursing
normal able to maintain
specific intervention the
spontaneous within normal
Objective: 3. Monitor core nursing patient’s
delivery range from 36.2-
- Increased body temperature implementation temperature
temperature and 37.2 °C
became 37.0 °C
respiratory rate 4. Encourage 3. To measure
by 12:00 in the
8:30 AM patient to the
afternoon
Temp – 38.2 °C verbalize her effectiveness
RR – 25 cpm feelings toward of nursing
8:45 AM sudden intervention
Temp – 37.8 °C change of
RR – 25 cpm temperature 4. To express
9:00 AM patient’s
Temp – 38.8 °C 5. Note for the feelings toward
RR – 24 cpm presence of current
9:15 AM infection condition
Temp – 37.9 °C
RR – 23 cpm 6. Maintain 5. To prevent
9:30 AM bedrest from further
29
Temp – 38.0 °C complication
RR – 25 cpm
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EMILIO AGUINALDO COLLEGE
Gov. D. Mangubat St., Brgy. Burol Main, City of Dasmariñas, Cavite 4114, Philippines
Tel. Nos. (046) 416-4341-42www.eac.edu.ph
SCHOOL OF NURSING
ISO 9001:2015 CERTIFIED
QUALITY MANAGEMENT SYSTEMS
7. Discuss 6. To reduce
- Prolonged labor importance of metabolic
- (+) Flashed skin increased fluid demands
- (+) Warm to intake
touch 7. To prevent
dehydration
30
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EMILIO AGUINALDO COLLEGE
Gov. D. Mangubat St., Brgy. Burol Main, City of Dasmariñas, Cavite 4114, Philippines
Tel. Nos. (046) 416-4341-42www.eac.edu.ph
SCHOOL OF NURSING
ISO 9001:2015 CERTIFIED
QUALITY MANAGEMENT SYSTEMS
RISK FOR INFECTION
ASSESSMENT DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATION
Objective: Risk for infection After 30 minutes 1. Establish 1. To promote After 30 minutes
related to invasive of nursing rapport to the trust to the of nursing
BP: 130/70 mmHg procedure intervention and patient patient intervention and
RR: 25 cpm secondary to health teaching health teaching
PR: 121 bpm normal the mother will be 2. Explain the 2. To lessen the the mother was
spontaneous able to verbalize importance of risk of able to verbalize
Multiple vaginal her understanding perineal care infection
delivery her understanding
examination given on the
on the
to the patient interventions that 3. Discuss the 3. To prevent
will reduce the risk significance of interventions that
from having
of infection change of infection will reduce the risk
perineal pads if of infection
necessary 4. To know the
presence of
4. Discuss the infection
signs and
symptoms of 5. To prevent the
infection such spread of
as fever, pain, microorganis
redness, m
swelling, and
hot incision 6. To know if the
site. patient
understands
5. Demonstrate
31 techniques 7. To provide
how to perform immediate
• VIRTUE • EXCELLENCE • SERVICE
EMILIO AGUINALDO COLLEGE
Gov. D. Mangubat St., Brgy. Burol Main, City of Dasmariñas, Cavite 4114, Philippines
Tel. Nos. (046) 416-4341-42www.eac.edu.ph
SCHOOL OF NURSING
ISO 9001:2015 CERTIFIED
QUALITY MANAGEMENT SYSTEMS
proper perineal care
care by wiping
the area with
wet wipes
starting at the
front and
moving to the
back.
6. Encourage
patient restate
important
information
7. Discuss the
importance of
reporting for
any signs of
infection such
as redness on
the affected
site
32
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EMILIO AGUINALDO COLLEGE
Gov. D. Mangubat St., Brgy. Burol Main, City of Dasmariñas, Cavite 4114, Philippines
Tel. Nos. (046) 416-4341-42www.eac.edu.ph
SCHOOL OF NURSING
ISO 9001:2015 CERTIFIED
QUALITY MANAGEMENT SYSTEMS
RISK FOR FLUID VOLUME DEFICIT
ASSESSMENT DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATION
Objective: Fluid volume After 15 minutes 1. Assess the 1. To know the After 30 minutes
deficit, high risk of rendering patient level of patient’s level of of nursing
- Prolonged for excessive nursing understanding understanding intervention and
labor blood loss during intervention health teaching
2. Establish 2. To promote
delivery teaching the the mother
- Mild rapport to the trust
mother will be verbalized her
perspiration patient
able to maintain 3. To became understanding
fluid volume 3. Discuss the aware for and was able to
BP: 130/70 mmHg
RR: 25 cpm signs and untoward identify
PR: 121 bpm symptoms of complications interventions to
vaginal bleeding prevent of to
4. To prevent reduce the risk of
during delivery
from bleeding laceration
4. Discuss the
5. To replace the
importance of
fluid loss during
well-maintained
delivery
uterus contracted
after delivery 6. To monitor the
bleeding
5. Encourage
patient to intake 7. To promote
fluid after the easy
33 delivery comprehension
6. Encourage the
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EMILIO AGUINALDO COLLEGE
Gov. D. Mangubat St., Brgy. Burol Main, City of Dasmariñas, Cavite 4114, Philippines
Tel. Nos. (046) 416-4341-42www.eac.edu.ph
SCHOOL OF NURSING
ISO 9001:2015 CERTIFIED
QUALITY MANAGEMENT SYSTEMS
patient to report 8. To prevent
for the number of from any further
pad changes complications
7. Provide visual
aids during health
teaching
8. Provide
information of
safety measures
34
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