ASSESSMENT
DIAGNOSIS
Subjective: Acute pain related to labor
contractions.
“Masakit at humihilab ang
aking tiyan” as verbalized
by the patient.
Pain scale of 10/10
Objective:
Blood pressure is at
140/80 mmHg.
Fetal heart rate is 148
bpm.
Respiratory rate is 35.
Facial grimace with
accompanied hardening of
the abdomen due to
uterine contraction.
NURSING OBJECTIVES INTERVENTIONS
Short-term goal:
After 1 hour of nursing
intervention, the patient
will be able to demonstrate
relaxation techniques to
control pain during labor
contractions and minimize
discomfort as evidenced
by a pain scale rating of
4/10 or lower.
Long-term goals:
After 1 day of nursing
intervention, the patient
will be able to report a
relief of pain as evidenced
by a pain scale rating of
1/10 and will be able to
report a restored health
status as evidenced by
ability to perform normal
daily activities.
RATIONALE
CRITERIA
Independent:
Routinely obtain pain To monitor treatment
level by the patient. progress.
Provide back rubs to the
To promote relaxation and
patient as a comfort
enhance feeling of
measure.
well-being.
Teach the patient of the
breathing and relaxation To give patient means of
coping with and
techniques.
controlling the level of
discomfort.
Advise/recommend
position changes.
To enhance circulation and
reduce muscle tension.
EVALUATION
Short-term:
After 1 hour of nursing
intervention, the patient
was able to demonstrate
relaxation techniques such
as breathing exercises and
position changes to
control pain during labor
contractions. Discomfort
was minimized as
evidenced by a pain scale
rating of 5/10.
Long-term:
After 1 day of nursing
intervention, the patient
was able to report a relief
of pain as evidenced by a
pain scale rating of 1/10
and was able to report a
restored health status as
evidenced by ability to
perform normal daily
activities.