PATIENT PROFILE

Client Initials: CJG

Age: 18 years old

Sex: Female

Chief Complaint: Labor pain

Admitting Diagnosis: Gravida 1 Para 0 (1000) with 40 weeks and 2 days of gestation, Cephalic in labor

Type of Delivery: Primary Low Transverse Ceasarian Section

Discharge Diagnosis: Gravida 1 Para 1 (1001) Pregnancy uterine delivered term cephalic livebirth

CLIENT HISTORY AND ASSESSMENT

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PLAN OF CARE

 Subjective Data

“Madalas pong sumasakit yung tahi ko kahit tatlong araw na nakakalipas.”

Pain scale of 7/10 as told by the patient.

 Objective Data

(+) facial grimace (+) Blanch test >3 secs

(+) lethargic BP – 130/70mmHg

(+) guarding of the abdomen RR – 24 cycles/min

(+) dark under eyes (+) fast, shallow breathing

 Assessment

Impaired skin integrity r/t pain secondary t caesarian section

 Plan

At the end of the 8-hr shift, patient will:

- manifest alleviation of pain from 7/10 to 5/10

- identify at least 5 non-pharmacologic ways to help alleviate pain.

- demonstrate proper wound cleaning in 10 mins in front of the student nurse.

- obtain BP of 120/80; RR of within 12-20 cycles per minute; and have blanch test < 3 secs.
  Intervention

Independent:

- monitor vital signs every 4 hours.

- perform health teaching regarding non-pharmacological techniques in pain alleviation and proper
wound cleaning.

- establish rapport with the patient so that she will be honest enough when asked regarding the pain
scale.

Dependent:

- refer the patient to the doctor if Temperature increased beyond the upper limit.

- administer pain medications ordered by the doctor correctly.

 Evaluation

After effective nursing intervention within the shift,

- The patient’s pain has minimized from 7/10 to 5/10.

- The patient was able to enumerate techniques in pain alleviation and proper wound cleaning.

- The patient was able to demonstrate proper wound cleaning.

- The patient was able to obtain BP of 120/80; RR in between 12-20 cycles per minute; and a blanch test
of < 3 secs.