LORMA COLLEGES CON TEMPLATE

PATIENT HISTORY
RELATED LEARNING EXPERIENCE

AREA: Labor Room and Delivery

th
STUDENT NAME: Safran, Jayrelle Aldrin Shayne D. ROTATION: 7 Rotation Room
DATES: DECEMBER CLINICAL INSTRUCTOR: ROWENA
YR LEVEL AND SEC: BSN II – Nightingale 9,10,11,16,17,18, 2021 HENSON

PROBLEM: Acute Pain DIAGNOSIS: Pregnancy Uterine; 38 weeks AOG; Gravida 3; Para 2
PRIORITIZATION: 1st DATE: December 15, 2021

ASSESSMENT NURSING PLANNING IMPLEMENTATION RATIONALE EVALUATION

DIAGNOSIS
SUBJECTIVE: Acute pain LTO: Diagnostic: Diagnostic: Goal Partially
Mrs. Mac Beth related to After 3 days of 1. Assess vital 1. Changes in these Met
is conversant surgical nursing signs, noting vital signs often After 3 days of
but claimed to incision intervention the tachycardia, indicate acute pain nursing
feel slightly secondary to patient will be able hypertension, and and discomfort. intervention, the
tired and dizzy. episiotomy. to: increased Note: Some patients objectives were
respiration, even if may have a slightly partially met as
Mrs. Mac Beth  Have vital patient denies lowered BP, which evidenced by:
verbalizes that signs within pain. returns to normal
she has pain on the normal range after pain Vital Signs:
her episiotomy range: 2. Evaluate pain relief is achieved. T= 37.2 C
site, “I can’t sit T= 36.5- regularly (every 2 P= 73 bpm
properly 37.5 C; P= hrs noting 2. Provides R= 18 cpm
because I have 60-100 characteristics, information about BP = 120/80
pain in there”, bpm; location, and need for or mmHg
she verbalizes R=15-20 intensity (0–10 effectiveness of
pointing on her cpm; scale). Emphasize interventions and to Pain scale of at
perineum. BP= 110- patient’s identify worsening of 4/10 at still
OBJECTIVE: 140/60-90 responsibility for underlying couldn’t sit
Age: 25 y/o mmHg reporting pain/ condition/developing properly due to
Vital signs:  Pain scale relief of pain complications. Note: the presence of
BP120/80mmH of at 2-3/10 completely. It may not always be pain on the
g PR 82bpm  Sit properly possible to eliminate episiotomy site.
RR 18 STO: 3. Note location of pain; however,
breaths/min After 8 hours of surgical incisions. analgesics should The client didn’t
Temperature nursing reduce pain to a manifest facial
36.5. intervention, the Therapeutic: tolerable level. grimace upon
Patient is patient experience 1. Place the moving, non-
irritable and lesser pain and patient in a 3. This can influence irritable and
with guarding above a tolerable comfortable side- the amount of stayed calm and
behavior and level as manifested lying position postoperative pain cooperative, and
facial grimace by: experienced; for the minimal
upon  pain scale 2. Administer example, vertical or redness on the
movement. of at least Mefenamic acid diagonal incisions site subsided.
Numeric pain 5/10 (Ponstan) are more painful
scale of 8/10 as  no facial 500mg/cap 1 cap than transverse or S-
claimed by the grimace TID PRN once on shaped.
patient. upon diet as ordered.
Her episiotomy movement Therapeutic:
site was  non- Educative: 1. To relieve the
repaired irritable 1. Discuss with pressure on the
through and most SO(s) ways in episiotomy site.
episiorrhaphy. of the time which they can
Site was noted is calm and assist client with 2. To maintain
to have minimal cooperative pain management. acceptable level of
redness, but  removed pain. Notify
neither redness 2. Encourage physician if regimen
hematoma nor from the adequate rest is inadequate to
ecchymosis site. periods. meet pain control
noted. No other goal.
lacerations on
the perineal Educative:
area noted. 1. Family
Hemorrhoids members/SOs may
are not evident. provide assistance by
transporting client to
Medication: prevent walking long
Mefenamic acid distances, or by
(Ponstan) taking on client’s
500mg/cap 1 strenuous chores,
cap TID PRN supporting timely
once on diet. pain control,
encouraging eating
nutritious meals to
enhance wellness,
and providing gentle
massage to reduce
muscle tension.
2. To prevent fatigue
that can impair
ability to manage or
cope with pain.
 LORMA COLLEGES CON TEMPLATE
PATIENT HISTORY
RELATED LEARNING EXPERIENCE

AREA: Labor Room and Delivery

STUDENT NAME: Safran, Jayrelle Aldrin Shayne D. ROTATION: 7th Rotation Room
DATES: DECEMBER CLINICAL INSTRUCTOR: ROWENA
YR LEVEL AND SEC: BSN II – Nightingale 9,10,11,16,17,18, 2021 HENSON

PROBLEM: Risk for Infection DIAGNOSIS: Pregnancy Uterine; 38 weeks AOG; Gravida 3; Para 2
PRIORITIZATION: 2nd DATE: December 15, 2021

ASSESSMENT NURSING PLANNING IMPLEMENTATION RATIONALE EVALUATION

DIAGNOSIS
SUBJECTIVE: Risk for LTO: Diagnostic: Diagnostic: Goal Met
No infection After 3 days of 1. Assess 1. Increase in After 3 days of
verbalization related to nursing intervention, temperature and temperature and nursing
OBJECTIVE: mediolateral the patient will pulse. maternal intervention, the
Age: 25 y/o episiotomy. remain free of 2. Assess client’s tachycardia may objectives were
Vital signs: BP infection, as perineum. indicate infection. met as evidenced
120/80mmHg evidenced by normal by the following:
PR 82bpm RR vital signs and Therapeutic: 2. Assessing the
18 absence of signs and 1. Change perineal client’s perineum Vital Signs:
breaths/min symptoms of pads frequently. will help identify the T= 37.2 C
O2SAT 98% infection. presence of P= 73 bpm
Temperature 2. Perform infections. R= 18 cpm
36.5. STO: perineal care and BP = 120/80
Her episiotomy After 8 hours of discuss its Therapeutic: mmHg
site was nursing intervention, importance. 1. To prevent
repaired the patient will be vaginal The patient
through able to: contamination or remained free of
episiorrhaphy.  maintain Educative: infection infection and is
Site was noted temperature 1. Encourage able to verbalize
to have and pulse patient to wash 2. To promote the importance of
minimal rate within her hands after cleanliness to the perineal care,
redness, but the normal handling pads and perineal area demonstrate and
neither range. use only her apply proper
hematoma nor  absence of personal handwashing
ecchymosis abnormal equipment. after going to the
noted. No discharges Educative: comfort room
other at 2. Demonstrate 1. These actions and handling
lacerations on episiotomy the proper way of prevent the patient unsterilized
the perineal line handwashing. from contracting or objects.
area noted.  verbalize the spreading infection.
Hemorrhoids importance 3. Encourage the
are not of the patient to change 2. Handwashing is
evident. performance her perineal pads the first-line defense
of proper as frequently as from acquiring
Medication: perineal possible. infections.
Amoxicillin care in
(Himox) preventing 4. Teach the 3. Lochia is an
500mg/cap 1 perineal patient the criteria excellent medium
cap BID for infections. for judging the for bacterial growth
7days  wash hands amount and type that could spread
after going of normal lochia. through the vagina
to the and the uterus. The
comfort presence of wet
room and pads against the
handling episiotomy suture
unsterilized line slows healing.
objects such 4. Excessive
as amounts of Lochia
cellphone, indicates that the
money and patient is losing
perineal more than the
pads. average amount of
blood. Clots may
indicate that a
portion of the
placenta has been
retained. A red flow
after a pink or white
flow may indicate
that a new bleeding
is beginning. An
offensive lochia odor
usually indicates
that the uterus has
become infected.
Absence of lochia
during the first three
weeks may indicate
postpartal infection.
 LORMA COLLEGES CON TEMPLATE
PATIENT HISTORY
RELATED LEARNING EXPERIENCE

AREA: Labor Room and Delivery

STUDENT NAME: Safran, Jayrelle Aldrin Shayne D. ROTATION: 7th Rotation Room
DATES: DECEMBER CLINICAL INSTRUCTOR: ROWENA
YR LEVEL AND SEC: BSN II – Nightingale 9,10,11,16,17,18, 2021 HENSON

PROBLEM: Ineffective breastfeeding DIAGNOSIS: Pregnancy Uterine; 38 weeks AOG; Gravida 3; Para 2
PRIORITIZATION: 2nd DATE: December 15, 2021

ASSESSMENT NURSING PLANNING IMPLEMENTATION RATIONALE EVALUATION

DIAGNOSIS
SUBJECTIVE: Ineffective LTO: Diagnostic: Diagnostic: Goal Met
“Nakapag- breastfeeding After 3 days of 1. Assess breast 1. Normal nipple After 3 days of
breastfeed na related to nursing intervention, and nipple structure. and breast nursing
ako pero di ko inability to the patient will be structure or early intervention, the
pa alam kung latch on able to: 2. Evaluate and detection and objectives were
pano yung secondary to  Express record the mother's treatment of met as
tamang knowledge physical and ability to position, abnormalities with evidenced by
paraan. deficit psychological give cues, and help continuing support the following:
Pangatlong comfort in the infant latch on. are important for
anak ko na ito breastfeeding successful The mother was
pero practice and 3. Evaluate and breastfeeding able to properly
nahihirapan techniques. record the infant's breastfeed her
parin ako sa  State at least ability to properly 2. Correct baby as
pagpwesto ng one resource grasp and compress positioning and evidenced by
aking anak for the areola with lips, getting the infant proper
kapag breastfeeding tongue, and jaw. to latch on is positioning and
magpapadede. support. critical for getting proper
At di ko alam Therapeutic: breastfeeding off attachment of
kung may STO: 1. Provide and to a good start and the infant.
sapat ba akong After 8 hours of encourage support contributes to
gatas para sa nursing intervention, by actively helping breastfeeding Mother was able
aking anak.” as the patient will be the mother to success to verbalize
verbalized by able to: correctly position physical and
Mrs. Mac Beth  breastfeed the baby to attain a 3. The infant must psychological
her baby as good latch on the have a "competent comfort in
Insufficient manifested nipple and suck" in order to breastfeeding
emptying of by proper encouraging her to achieve successful practice and
breast continue trying. breastfeeding. The techniques and
 attachment. jaws must was able to find
Perceived  hold her baby 2. Assist the mother compress the milk a resource for
inadequate properly as by helping the infant sinuses beneath breastfeeding
milk supply evidenced by grasp the nipple the areola and support. Infant
OBJECTIVE: proper correctly and advise must be well back was able to
Age: 25 y/o positioning. the mother to on the areola with manifests signs
achieve mutually expose the nipple to the tongue over of adequate
G3P2 satisfactory air between the lower gum, intake at the
breastfeeding feedings. forming a trough breast
Doesn’t know regimen with infant around the breast,
how to content after Educative: and the lips must
breastfeed feedings and output 1. Teach the mother be flanged and
completely. within normal range. to massage breast or sealed around the
Observable burp infant and breast
signs of switch to other
inadequate breast when infant's Therapeutic:
infant intake swallowing slows 1. Many problems
(decrease in down. that can lead to
number of wet discontinuing
diapers, 2. breastfeeding can
inappropriate Discuss/demonstrate be prevented by
weight loss/or breastfeeding aids giving a high level
inadequate such as infant sling, of practical and
gain) nursing pillows, or emotional support
footstool. to the mother
Infant arcs and
cries when at 3. Provided health 2. To promote
the breast teachings about proper attachment
breastfeeding and prevent the
Infant unable - Proper positioning nipples of the
to latch onto (Hold baby – tummy mother to become
maternal to tummy, baby’s sore.
breast nose and chin should
correctly be placed against Educative:
the breast) 1. The perception
- Breastfeed every 2- of inadequate milk
3 hours, 8-10 times supply can lead to
daily early weaning.
-How to get good Infants should
attachment (Make breastfeed from
sure baby sucks the both breasts at
areola, not just the each feeding.
nipple. Baby's top Breast massage
and bottom lip can enhance the
should be turned flow of milk and
out. Baby's chin stimulate
should be pressed production
into the breast)
2. To promote let-
down reflex

3. For effective
breastfeeding and
for the safety of
the baby.