EXPLANATION OF

ASSESSMENT OUTCOMES INTERVENTIONS RATIONALE EVALUATION

THE PROBLEM

Subjective: Pain occur because Dx:Assess Emergency situations STO: (Goal Met)
of the stretching in STO: Within 30 psychological causes may
 “mansakit nan peritoneum over minutes – 1 hour of of pain and precipitate fear, anxiety  Within 30 minutes – 1
likod ko” as lying the uterus, effective nursing discomfort. which can raise hour of effective
verbalized by stretching of cervix interventions, the perception of pain and nursing interventions,
the patient. patient’s will be able discomfort. the patient was able to
during dilatation,
stretching of the to identify identify appropriate
Objective: appropriate methods methods to provide
ligaments,
compression of nerve to provide relief Tx: Provide comfort relief from pain.
 Facial grimace from pain. measures such as Ice compress
 Uncomfortable ganglia in the cervix, decreases edema and
there is hypoxia of application of ice
 Irritability minimizes hematoma
contracted pack into the
 Restlessness and pain sensation
myometrium, and all perineum, use of sitz LTO: (Goal Met)
 Vital signs: while heat promotes
of this is included to bath or heat lamp to
BP:110/70 vasodilation which
labor pain. episiotomy Within 24 – 48 hours
mmHg LTO: Within 24 – 48 facilitates resorption of effective nursing
extension.
Temp: 36.7 hours of effective of hematoma. interventions, the
PR: 102bpm nursing interventions, patient verbalized
RR: 19cpm the patient will relief from pain and
Source:
Pain: 9 https://www.scribd.co verbalize relief from discomfort.
m/doc/36343508/Ncp- pain and discomfort.
Provide touch therapy A soothing touch can
Labor-Pain reveal acceptance and
with permission. Give
patient a back massage empathy. Slow stroke
Nursing Diagnosis using slow, rhythmic back massage decreased
stroking with hands. heart rate, decreased
Use a rate of 60 systolic and diastolic
 Risk for pain
strokes a minute for 3 blood pressure, and
related to
 minutes on 2-inch increased skin
physical wide areas on both temperature at
agents such as sides of the spinous significant levels. The
laboring. process from the conclusion is that
crown to the sacral relaxation is induced by
area. slow stroke back
massage.

To assist the client in

exploring methods for
Edx: Encourage the the control of pain.
use of relaxation
techniques (e.g.,
deep breathing
exercise) and
diversional activities
(e.g., watching TV).