ASSESSMENT DIAGNOSIS PLANNING IMPLEMENTATION RATIONALE EVALUATION

Subjective:
- Umenting amniotic Short term: Independent:
The patient stated fluid leakage from the This is to monitor the progress After 30 minutes of effective and
that “May cervical os with After 30 minutes of Monitor Vital signs every 15 of labor and the condition of efficient nursing care
naramdaman visualization of effective and efficient minutes for 2hrs and 30 mins both the mother and the baby. intervention, all goals were met
akong lumabas pooling in the nursing care intervention until stable. Helps to identify areas of chief as evidence by the patient:
na may amoy posterior vaginal patient will: concern providing baseline for Verbalized that pain was reduced
tapos fornix. And painful Monitored V/S: future for future interventions. from a scale of 9/10 to 3/10
nararamdaman ko uterine contractions. -Verbalize pain is reduce BP: 120/80mmHg Left lateral position increases Had vital signs in normal ranges:
na sumasakit na scale from 7/10 to 3-5/10 RR: 18 bpm venous return and enhances BP:120/80 mmHg
yung tyan ko” PR: 80 cpm placenta circulation. Position PR: 80 bpm
-Vital sign results normal T: 36.7°C changes promote comfort, RR: 18 cpm
P - The patient felt ranges: reduce muscle tension relieve T: 36.7
the pain when she BP:90/60 - 120/80 mmHg pressure and promote fetal
sat for a long time PR: 70-120 cpm -Provide comfort measured: descent
and relieve the RR: 16-22 bpm Encourage comfort position proper breathing technique can
pain when she T: 36-37.4°C /axilla by positioning the client in the left prevent exhaustion therefore Stated discomfort as controlled
walks. side lying position. preventing prolonged delivery of with non-pharmacologic methods
Encourage client to assume the fetus and prolonged pain.
Q- Dull in pain different positions and change helps evaluate any anxiety and
them regularly. tears that may exacerbate pain.
R- Ache the back Proper was observed to be restless
and lower when contractions.
abdomen. Dependent:

S- 7/10 -Provide information and update

on the client labor progress.
T- The pain starts
early in the - Teach proper breathing
morning around technique.
5:00 am and has
an interval
contraction of 5 to
15 minutes.

Objective:

-Monitored V/S:
BP: 120/80mmHg
RR: 18 bpm
PR: 80 cpm
T: 36.7°C
ASSESSMENT DIAGNOSIS PLANNING IMPLEMENTATION RATIONALE EVALUATION

Subjective: “Impaired physical Short term: Independent:

“Medyo mobility related to
nahihirapan ako pain and discomfort” -After 30 minutes of
na gumalaw dahil nursing the intervention,
masakit pa yung the client demonstrates
tahi ko sa pwerta.” techniques/behavior that
As verbalized by enable resumption of
the patient. simple activities.
- Maintain optimal mobility
Objective: and function.
-Display increased
-Difficulty of strength and be free of
turning associated complications
-Slow movement -contractures and
- Controlling decubitus ulcers.
behavior
- Limited range of Long term:
motion
After 4 hours of nursing
intervention, the patient
increase strength and
enable to move do other
activities.
-Vital sign results normal ranges:
BP:90/70 - 120/80 mmHg
PR: 70-120 cpm
RR: 16-22 bpm
T: 36-37.4°C /axilla
-Encourage frequent change of
position when on bedrest or
chair rest; support affected body
parts and joints with
pillows, rolls, sheepskin, and
elbow and heel pads, as
indicated.
- Encourage deep breathing and
coughing. Elevate head of bed,
as appropriate
-Suggest and provide diversion
as appropriate to client’s
condition—visitors, Take time to
interact with client, showing
interest in client’s life.
- Instruct in and assist with active
and passive range-of-motion
(ROM) exercises.
-Institute a planned activity or
exercise program as appropriate,
with client’s input
- Provide foam, water, or air
- Decreases discomfort,
maintains muscle strength and
joint
mobility, enhances circulation,
and prevents skin breakdown.
- Mobilizes secretions, improves
lung expansion, and reduces
risk of respiratory complications,
such as atelectasis or
pneumonia.
- Decreases boredom;
promotes relaxation
- Maintains joint flexibility,
prevents contractures, and aids
in
reducing muscle tension.
- Increases client’s energy and
sense of well-being. Studies
have shown that regular
exercise programs have
benefited
clients with ESRD, both
physically and emotionally.
Stable
clients have not been shown to
have adverse effects
- Reduces tissue pressure and
may enhance circulation,
thereby
 flotation mattress or soft chair reducing risk of dermal
cushion. ischemia and breakdown

Dependent:
ASSESMENT DIAGNOSIS PLANNING IMPLEMENTATION RATIONALE EVALUATION

Subjective:
“The patient Acute pain related to After effective and efficient Provide such comfort measures Promotes relaxation, reduces After effective and efficient
stated that she an increased nursing care intervention as back rub and restful muscle tension, and enhances nursing care intervention all
has a contraction frequency and force patient will: environment. coping. goals are met as evidence by the
with an interval of of ureteral Report pain is relieved, Assist with and encourage use of Redirects attention and aids in patient:
5 to 15 minutes” contractions as with spasms controlled. focused breathing, guided muscle relaxation. Report pain is relieved, with
evidence by the Appear relaxed and be imagery, and diversional spasms controlled.
Objective: patient that changing able to sleep and rest activities. Appear relaxed and be able to
The patient keeps her position and keep appropriately. Explain cause of pain and sleep and rest appropriately.
on moving and on making face importance of notifying Provides opportunity for timely
changing her grimace caregivers administration of analgesia and
position just to of changes in pain occurrence or alerts caregivers to possibility of
relieve the pain characteristics. passing of stone or developing
she also keeps on complications. Sudden
making face cessation of pain usually
grimace and indicates stone passage.
making unusual
sound when labor
contractions
occur.