Name of Patient: Shiela Marie

Diagnosis or Clinical Impression: Full-term Pregnancy

Physiological Nursing Diagnosis #1 (PRE OP)

NSG.DX- Acute pain realted to uterine contarctions as evidence by pain scale of 9/10.

ASSESSMENT NURSING BACKGROUND PLANNING IMPLEMENTATION RATIONALE EVALUATION

DIAGNOSIS KNOWLEDGE
SUBJECTIVE: Acute pain Pain during labor is GOAL:  Assist the patient  Changing After the 4 hour shift
realted to uterine caused by After the 4 hour shift to her prefered positions of nursingintervention
“Sobrang sakit na po contarctions as contractions of the of nursing intervention postion that also throughout labor the patient was able to
ng tiyan ko” as the patient will be able helps facilitate can help to relieve verbalized comfort and
evidence by pain muscles of the
verbalized by the to verbalize comfort fetus' descent exhaustion, pain was at
scale of 9/10. uterus and by and painis at manageable level with
patient. into the birth improve comfort,
pressure on the manageable level canal. and promote a pain scale of 4/10.
cervix. This pain circulation.
can be felt as strong -The patient will be -The patient
OBJECTIVE: cramping in the able to demonstrate demonstrated non-
- Pain scale of 9/10 abdomen, groin, and non-pharmacological pharmacological
methods that reduces  Moving about
back. Upon methods that reduces
-Bending forward pain/ discomfort during labor is
due to pain admission, the  Encourage the pain/ discomfort
patient’s chief patient to move usually more
or walk on her comfortable than
-(+)Facial grimace complaint is
own pace. staying still and
-Guarding behavior excruciating can help labor
abdominal pain progress by the
-The patient winces since she is already simple effects of
when uterine on the active phase gravity and the
contractions occurs changing shape of
of labor
-Slowed movement the pelvis. It may
also relieve pain
-Contractions last for by shifting
60 seconds, 3 pressure and
minutes rest in allowing the baby
between. to move.

- Temp: 37.2 °C  A good and safe

Respiratory Rate: environemnt can
28 cycle per  Provide a quiet improve the
minute and well manegement of
Heart Rate: 102 ventilated pain, relaxation
beats per minutes environement by and reduce
Blood Pressure: SOURCE/S: anxiety.
controlling the
145/90 mmHg Nursing Care Plan room
Oxygen saturation: 9th Edition temperature and
95 % Guidelines for lights.
Individualizing care
Across the lifespan  Massage can
By Doenges, convey pain-
Moorhouse, Murr reducing
 Offer massage to messages.Massage
page 105-106
the patient or ask takes the form of
her who can do it light or firm
for her. It can stroking,
help to relieve kneading, deep
stress, divert the circular pressure,
laboring woman, and continual
and improve steady pressure.
comfort. Stroking or
rubbing the neck,
shoulders, back,
thighs, feet or
hands is an
effective pain-
reliever.

 Breathing
techniques
increases
relaxation and
 Teach the patient improves oxygen
for breathing supply.
techniques.
 Music creates a
pleasant and
relaxing
environment that
 Divert the reduces pain,
patient’s anxiety and fear.
attention from
the pain she is
experiencing by
suggesting to
play music she
likes.  Analgesics
provides pain
management
  Administer during labor by
analgesics as considerably
prescribed by the reducing the
physician. duration of the
active phase

Physiological Nursing Diagnosis #2(POST OP)

NSG.DX- Deficient Fluid Volume related to excessive blood loss after birth as evidenced by fatigue and increased heart rate

ASSESSMENT NURSING BACKGROUND PLANNING IMPLEMENTATION RATIONALE EVALUATION

DIAGNOSIS KNOWLEDGE
SUBJECTIVE: Deficient Fluid Deficient Fluid After 2 hrs hours of  Assess uterine  To note how much After 2 hours of
Volume related to Volume/Postpartum nursing intervention, contraction and lochia blood loss the client is nursing intervention,
Client verbalizes excessive blood Hemorrhage is the client will be able flow every two hours. experiencing and the client is now able
feelings of anxiety loss after birth as defined as any loss to: prompt immediate to:
and reports fatigue evidenced by of blood from the intervention
fatigue and uterus more than  Maintain fluid  Display pulse rate
OBJECTIVE: increased heart 500mL within a 24- volume at a  Facilitate health  Promote client’s at 86 bpm and
rate hour period. It may functional level, as teaching on causative awareness help blood pressure of
- Hemoglobin count be immediate or late evidenced by factors and purpose of problem, encourage 120/80 mmHg.
almost below occurring from the individually stable individual therapeutic cooperation, and be  Manifest moist
normal range first 24 hours of vital signs, moist interventions and knowledgeable about mucous membranes
- Heavy lochia flow delivery up to the mucous membranes, medications. the interventions and and good skin
- Soft uterus remaining days of and good skin turgor medications given. turgor.
- Blood Loss the 6-week
- Pallor or good capillary  Lochia flow slows
puerperium. refill ( Less than 2  Increased heart rate, to moderate amount
- Changes in mental  Monitor vital signs
state seconds) including systolic and low blood pressure, of flow with no
- Temp: 37.2 °C diastolic blood cyanosis, delayed large clots.
Respiratory Rate:  Verbalize capillary refill  Client verbalizes
pressure, pulse and
28 cycle per minute
understanding of heart rate. Check for indicates hypovolemia understanding of
Heart Rate: 102
beats per minutes causative factors and the capillary refill and and impending shock. causative factors
Blood Pressure: purpose of observe nail beds and Decrease fluid and purpose of
145/90 mmHg individual mucous membranes. volume of 30-50% interventions and
Oxygen saturation: therapeutic will reflect changes in medications.
95 % interventions and the blood pressure.
medications.
 Changes in blood
pressure and pulse
 Monitor laboratory
SOURCE/S: results may be used to
Nursing Care Plan roughly estimate for
9th Edition blood loss.
Guidelines for
Individualizing care  Activity may
Across the lifespan predispose to further
 Advise client to
By Doenges, bleeding
maintain bed rest and
Moorhouse, Murr
schedule activities to
page 105-106
provide undisturbed
rest patterns.

 Keep fluids within  To encourage fluid

reach of client intake

 Teach client perineal  To prevent

self-care development of
perineal infections

 Administer oxytocin as  It helps in the

prescribed by the contraction of the
physician. uterus
.
Physiological Nursing Diagnosis #3(POST OP)

NSG.DX- Pain related to uterine cramping (afterpains) and perineal trauma from childbirth

ASSESSMENT NURSING BACKGROUND PLANNING IMPLEMENTATION RATIONALE EVALUATION

DIAGNOSIS KNOWLEDGE
SUBJECTIVE: Pain related to Episiotomy is a surgical After 1 hour of nursing  Perform  Provides After 1 hour of nursing
uterine cramping incision of the perineum intervention, the client pain assessment by information to aid intervention, the client is
Client’s verbalization (afterpains) and made to prevent tearing will: identifying the type, in determining now able to:
of pain perineal trauma of the perineum and location, choice or
from childbirth release pressure on the - Report pain scale at 4 characteristic, effectiveness of - Reports pain scale of 4
OBJECTIVE: fetal head during out of 10 or lower. severity, and interventions out of 10
childbirth. There is a - No longer demonstrate duration of the pain. - Demonstrate two
- Presence of grimace upon movement relaxation techniques.
sensory and emotional Use a pain scale of
episiotomy - Demonstrate at least one - Verbalize sense of
experience that varies relaxation technique 0-10.
wound comfort and ease
from pleasant to - Display respiratory rate - Display respiratory
- Discomfort
- Irritability unpleasant, associated within normal range  Monitor Vital Signs  To obtain baseline rate at 18 cycles per
- Temp: 37.2 °C with labor and data and facilitate minute.
RR: 28 cpm childbirth. prompt treatment
HR: 102 bpm
BP: 145/90 (Varghese,Champaneria  At least three
mmHg  Promote perineal
, Kapoor,et al., 2016 times of perineal
SpO2: 95 % exercise and
exercise for 5
comfortable sitting
consecutive days
position
reduce discomfort
and improves
circulation in the
area
SOURCE/S:
Nursing Care Plan 9th  To establish the
 Inform client that the patient’s mind
Edition
pain rarely lasts frame about the
Guidelines for
longer than three pain and lessen
Individualizing care
days the perception of
Across the lifespan
By Doenges, pain and anxiety
Moorhouse, Murr page
209-210  To assist the
 Encourage the use of client in exploring
relaxation methods for the
techniques (e.g., control of pain
deep breathing
exercise) and
diversional activities
(e.g., watching TV).  Ice compress
decreases edema
and minimizes
 Provide comfort hematoma and
measures such as pain sensation
application of ice while heat
pack into the promotes
perineum, use of sitz vasodilation
bath or heat lamp to which facilitates
episiotomy resorption of
extension. hematoma.

 Decreases pain
and anxiety;
Helps promote
 Administer pain relaxation.
medication
(analgesic, narcotic
or sedative) as
prescribed.