Singco, Ma. Clarabella L.

Assessment Data Nursing Diagnosis Planning Intervention Rationale Evaluation

Subjective: “Nasakit Alteration in After 4 hours of 1. Monitor 1. For patient After 4 hours of
po ang tyan ko rito” comfort related to nursing intervention appropriately to avoid nursing
as verbalized by the abdominal pain due the patient will be and assess more interventions:
patient. to contractions able to: urine specific complex  Client has
gravity to procedures the ability to
Objective: -feel an detect fluid 2. For patient understand
 Facial uncontrollable urge retention, if to know the precise
Grimaces to push firm there is a proper process
 Unexpected contractions distended positions and during labor
movement bladder, techniques  Client has a
VS: -know proper perform for labor and good
BP: 180/90 effective pushing for catheterization. delivery of tolerable
RR: 41 easier delivery 2. Perform health the baby level of pain
Temp: 37.0 teaching while 3. Breathing  Client should
patient is in properly exhibit no
labor helps reduce signs of
3. Doctor and stress and bladder
nurse should tension, distention
perform IE to lower blood and have the
monitor pressure, ability to
cervical and even void every 2
dilatation reduces pain hours
4. Monitor and  The pain felt
breathing discomfort will lessen
exercises 4. To promote after delivery
5. Advice patient a more of the fetus.
not to make engaged
unnecessary fetus with a
movements dilatation of
8-10 cm