CUES NURSING GOAL & NURSING RATIONALE EVALUATION

DIAGNOSIS OBJECTIVES INTERVENTION

Subjective: Risk Within our 8-hour shift, Independent: At the end of the shift, the
“Kapoy na kayo for Maternal Exhaustio the patient in labor will patient:
ko, gusto nako n (Powerlessness) be able to:  Acknowledge  Discomfort and
mahuman nani, related to inappropriate reality of pain may be Goal Met
mura nakog bearing down  verbalize patient’s misunderstood  verbalized
makuyapan,” as techniques. understanding reports of in the presence understanding of pro
verbalized by the of proper way of pain/discomfor of lack of way of bearing down
SCIENTIFIC BASIS
patient. bearing down. t, progression Partially Met
The high abdominal
note evidence that is not  used effective
pressure accompanied
Objective:  identify/use of frustration. recognized as and appropriate
by descent of the
 pallor was effective and a dysfunctional bearing down
organs causes
observed appropriate problem. techniques.
pressure on the
bearing down  Providing Feeling
perineum which, in
 vital signs techniques. relaxation listened to and  Demonstrated effect
response to the
results: steps and supported can breathing pattern
myotatic reflex, bulges
 demonstrate encouraging help patient
and contracts. Even
 BP:13 and maintain an ambulation as relax, reducing
more powerful
0/90 effective necessary for discomfort and
expulsive efforts are
 PR: breathing patient enhancing
then required to expel
105 pattern. repositioning. ability to cope
the descending fetus,
 RR: 24 with situation.
thereby stretching the
 Encourage
lower birth canal. After
 cervical sustained
forced inspiration, the
dilation deep breaths  Reduces
reduction in the
by: anxiety,
 7cm maternal blood promotes
pressure may lead to a o Demon relaxation and
reduction in placental stration: sense
perfusion and therefore highligh of control,
also in fetal ting assisting client
oxygenation that could slow to cope
lead to fetal distress. inhalati positively with
on, the situation.
holding
a few
second
s of
end-
inspirati
on and
passive
exhalati
on