ASSESSMENT DIAGNOSIS PLANNING INTERVENTIONS RATIONALE EVALUATION
Subjective data: Acute pain related SHORT TERM: [Link] the patient’s [Link] is always SHORT TERM:
“sumasakit ang tiyan ko” as to abdominal After 12 hours of level of pain using subjective, finding After 12 hours of nursing
verbalized by the patient contractions as nursing intervention the numeric pain out how much pain intervention the patient
evidenced by the patient will be scale. the patient is will be able to;
OBJECTIVE DATA: tachypnea, able to; experiencing is
(+)Tachypnea tachycardia, facial important to drive [Link] a decrease of
(+)Restlessness grimace, and [Link] a decrease further interventions. pain.
(+)Body weakness restlessness. of pain.
(+)Tachycardia 2. Screen pain along 2. Pain is often [Link] signs of being at
(+)moaning/crying [Link] signs of being with assessing vital considered the fifth ease and comfort, as
(+)facial grimace at ease and comfort, as signs. vital signs. In evidenced by resting and
evidenced by resting addition to this, blood breathing even and
and breathing even pressure, pulse, and unbothered.
and unbothered. respiratory rates can
VITAL SIGNS: elevate when
BP:130/90 experiencing pain. LONG TERM:
RR:27 LONG TERM: After 1 day of nursing
PR:98 After 1 day of interventions the patient
TEMP:37.1 nursing [Link] 3. An epidural can be will be able to;
PAIN SCALE: 8/10 interventions the analgesics if ordered. placed to block pain
patient will be able below the waist. The [Link] and utilize
to; nurse assists the practices that will help
anesthesiologist with reduce the pain such as
[Link] and positioning and relaxation and breathing
utilize practices that preparing the site for techniques and changes in
will help reduce the epidural insertion in the body positioning.
pain such as relaxation the lower back.
and breathing
techniques and
changes in the body [Link] comfort by [Link] the
positioning. adjusting the position body’s positioning [Link] sense of control
of the patient to will help limit fatigue of response to acute situation
lessen the pain. and enhance and positive outlook for the
circulation. Allow the future
mother to decide
[Link] sense of which positions
control of response to relieve pain. VITAL SIGNS:
acute situation and BP:100/60
positive outlook for [Link] aware of client’s RR:25
the future “Right to Treatment” [Link] includes PR:77
with regards to pain prevention of or TEMP:37.1
management. adequate relief from PAIN SCALE: 8/10
VITAL SIGNS: pain. Failure to meet
BP:100/60 the standard of GOAL MET
RR:25 assessing pain can be
PR:77 legally interpreted as
TEMP:37.1 nursing negligience.
PAIN SCALE: 8/10
CHARITY MYLES T. DELA CRUZ BSN2 C NCP
CHARITY MYLES T. DELA CRUZ BSN2C NCP
ASSESSMENT DIAGNOSIS PLANNING INTERVENTIONS RATIONALE EVALUATION
Subjective data: Risk for decreased SHORT TERM: [Link] the patient’s [Link] pressure SHORT TERM:
“Sumusuka ako ng dugo” as cardiac output After 12 hours of vital signs regularly naturally increases After 12 hours of
verbalized by the patient related to nursing intervention and in between during the intrapartum nursing intervention the
complications from the patient will be contractions. phase. Cardiac output patient will be able to;
OBJECTIVE DATA: labor and delivery. able to; will negatively affected
(+)Tachypnea when venous return is [Link] will remain free
(+)Responsive [Link] will remain reduced due to uterine from any signs of
(+)Conscoius free from any signs of pressure on the inferior decreased cardiac output,
(+)weight loss decreased cardiac vena cava, dehydration like arrhythmias,
(+)appetite loss output, like caused by decreased shortness of breath, and
(+)nausea arrhythmias, shortness circulating blood alterations in vital signs.
of breath, and volume, or bleeding.
alterations in vital [Link] fetal heart rate will
signs. [Link] fetal heart [Link] fetal status will be remain within normal
VITAL SIGNS: rate during labor and affected if the patient limits.
BP:100/60 [Link] fetal heart rate delivery develops decreased
RR:25 will remain within cardiac output, causing LONG TERM:
PR:77 normal limits. uteroplacental After 1 day of nursing
TEMP:37.1 insufficiency and interventions the patient
PAIN SCALE: 8/10 LONG TERM: reduced oxygen delivery will be able to;
After 1 day of to the fetus.
nursing [Link] understanding
interventions the [Link] [Link] may be of treatment regimen
patient will be able supplemental compromised in patients
to; oxygenation as who are in labor. [Link] behaviors
needed Providing supplemental and lifestyle changes to
[Link] oxygenation can help maintain or maximize
understanding of ensure adequate circulation.
treatment regimen circulating oxygen and
uteroplacental perfusion.
[Link] VITAL SIGNS:
behaviors and lifestyle BP:100/60
changes to maintain or RR:25
maximize circulation. 4. Pregnant women are PR:77
[Link] for any prone to bleeding TEMP:37.1
signs of bleeding during labor and PAIN SCALE: 8/10
VITAL SIGNS: delivery. Heavy vaginal
BP:100/60 bleeding and a GOAL MET
RR:25 significant decreased in
PR:77 blood pressure must be
TEMP:37.1 monitored during labor
PAIN SCALE: 8/10 and delivery, as this can
further complicate
cardiac output.
