Assessment Diagnosis Planning Implementation Rationale Evaluation

Short term Independent:

Subjective cues: Acute pain related After 5 hours of The patient managed To avoid any Goal met
“hindi ko to labor nursing to hold the pain until abnormalities during her
masasabing labor na contraction intervention the the baby was labor. The patient was fully
kase hindi siya ganun secondary to patient normally delivered. recovered and ready to
kasakit, nung magfo- episiotomy due to delivered her baby. take care of her newborn.
four pa lang facilitating fetal Dependent:
humihilab lang, nung passageway Long term: The patient followed To have a good quality of
4 na masakit na After a week of all the advices of her parenting to her newborn.
masakit na talaga As manifested by: nursing midwife for caring a
siya” as verbalized by -increased pain intervention newborn.
the patient scale 9 the patient was
-(+)facial grimace totally recovered Collaborative:
Objective cues: The patient regularly To verify the condition of
-(+)moaning and she can able to
-Pain scale at 6 came to laboratories. herself and her baby.
-increased range carry her baby.
-(+)facial grimace of motion
-Increased range of -(+)irritability
motion -(+)DOB
-(+) Moaning
-(+)irritability
-(+)DOB