NAME: MAHA MATTI

AGE: 28 y/o SEX: FEMALE ADDRESS: San Clemente, Magsingal, Ilocos Sur.

ASSSESSMENT NURSING SCIENTIFIC NURSING NURSING RATIONALE EVALUATION

DIAGNOSIS BACKGROUND OBJECTIVES INTERVENTION
Abdominal and Pain during labor is Date: October 25 Independent: Date: October
Subjective: hip pain RT caused by 2021 25, 2021
labor and contractions of Establish rapport To easily gain
"sobrang sakit ng tyan at delivery of the muscles of the Shift: 7:00am- 3:00 cooperation form the Shift: 7:00am-
balakang ko" verbalized by baby AEB the uterus and by pm shift patient 3:00 pm shift
the patient cues presented. pressure on the
cervix. This pain can 1.Patient complain Goal met
Objective: be felt as strong about discomfort Monitor vital signs To have baseline data
Initial VS were taken as cramping in the should be minimize. and for comparison for 1. Patient
follows: abdomen, groin, and future data complain about
CR: 88 bpm back, as well as an 2.Decrease abdominal discomfort should
RR: 18 cpm achy feeling. Some and hip pain Client may experience is minimized.
T: 36.9°C women experience Get rid of possible stressors sudden pain brought by
BP:120/80 mmHg pain in their sides or 3.Appear or sources of discomfort of the surroundings and 2.Decrease
thighs as well. relaxed/resting the patient if possible. add anxiety stimuli to abdominal and hip
 Abdominal between contractions. the body. pain
discomfort and
hip pain Attitudes and reaction 3.Appear
 IE- Cervix 4 cm Assess the degree of to pain are individual are relaxed/resting
dilated discomfort through verbal based on past between
and non- verbal cues; note experiences, contractions.
cultural influences on pain understanding of
response. physiological changes,
and cultural
expectations.
 Assist with comfort
measures (e.g., back/leg
rubs, sacral pressure, back
rest, oral care,
repositioning,shower/hot
tub use, perineal care, and
linen changes).
Time and record frequency,
intensity, and duration of
uterine contractile pattern per
protocol.
Assess nature and amount of
vaginal show, cervical
dilation, effacement, fetal
station, and fetal descent.
Provide information about
available analgesics, usual
responses/side effects (client
and fetal)
Promotes relaxation
and hygiene; enhances
feeling of being well
Monitors labor
progress and provides
information for client.
Cervical dilation
should be approximately
1.2 cm/hr in the
multipara; vaginal show
increases with fetal
descent. Choice and
timing of medication is
affected by degree of
dilation and contractile
pattern.
Allow client to make
informed choice about
means of pain.
Provide safety measures;
eg., encourage client to
move slowly, keep siderails
up after drug administration,
and support legs with
position changes
Dependent:
Giving of medications
as prescribed.
o2 & Catheterize as indicated. desired rates.
Regional block
anesthesia produces
vasomotor paralysis, so
that sudden movement
may precipitate
hypotension.
Analgesic s alter
perception
, and client may fall
trying to get out of bed.
To deliver fluids
accurately and at