ACTUAL PROBLEM

DATA GOALS/ ACTION/ NURSING RATIONALE RESPONSE &

Expected outcomes INTERVENTIONS EVALUATION

Subjective findings:  -The patient STG: within 8 hour/s of NI Dxtc: After ___8___hr/s of NI, the 
Watcher verbalized “ Hindi niya patient was able to moderately
The patient will be able to at least -Assess the -To determine  possible show signs of relief as
maigalaw yung right half body nya”
open and close her fingers 5 times. patient’s activity manifested by : finally moving
level contributing  factors to the  patient’s
her hand upside down and can
Objective findings: -Monitor patient’s  vital signs pain.
open and close her fingers 10
BP: 120/80 mmHg times.
PR: 99 bpm LTG: after 7 /days of  NI STG: Fully met
RR: 18 cpm -The patient will be able  to maintain or
Txc:
Temperature: 38.8 C increase strength and function of After 30 days of NI, the patient was
affected and compensatory body part. -Administer medications as ordered. -This is to aid the  pain felt able to show signs of complete relief
SpO2: 94% the  patient as manifested by: performs physical
-impaired ability to turn side to side activity independently or with
-(+) general weakness -Encourage  comfortable assistive device as need.
-Reduce muscle tension and relieve
positioning. pressure. LTG: Fully met

Focus/ Nursing Dx:  (PE/S)

Impaired physical mobility related to Edx:
discomfort as manifested by
difficulty in flexing arm - Encouraged patient watcher to
always practice log rolling - To improve blood flow and to
prevent bed sore.

- Encouraged patient to do perineal

care at least once a day. - To be hygienic and to avoid
infection
POTENTIAL PROBLEM

DATA GOALS/ ACTION/ NURSING RATIONALE RESPONSE &

Expected outcomes INTERVENTIONS EVALUATION

Subjective findings:  -The patient STG: within 8 hour/s of NI Dxtc: -To determine After ___8___hr/s of NI, the 
patient was able to moderately
The patient will be able to rate pain -Assess the possible
Objective findings: show signs of relief as
as <6 in a scale  of 1-10, 10 as the patient’s activity contributing manifested by : rating the pain
highest  and 1 as the lowest. level as 4/10,
factors to the
-Monitor patient’s  vital signs winces and facial grimaces still
Focus/ Nursing Dx:  (PE/S) patient’s pain. occur, difficulty in walking still
Risk for occur.
Txc:
LTG: after 24 hrs/days of  NI STG: Fully met
-Administer -This is to aid the  pain felt y the
-The patient will be able  to express
relief over the  frontal lower part of patient
medications as After __8 or 24____hr/s of NI, the 
her  abdomen -Reduce muscle  tension and
ordered. patient was able to show signs of
relieve pressure. complete relief as manifested by a
-Encourage pain scale of 010, absence of
comfortable guarding, facial grimaces and can
now walk uprightLTG: Fully met
positioning. -Helps alleviate
any anxiety and  fears that may
exacerbate pain. (If partially/Unmet – write possible
Edx: reason why partially/unmet and add
what to do next/modification)
-Provide
information and -Providing
update towards the  client regarding information allows  the patient to
labor pain make informed
decisions
-Teach patient pain  control options regarding pain
available, giving control
the prons and cons  of each.