POLYTECHNIC COLLEGE OF DAVAO DEL SUR, INC.

MacArthur Highway, Digos City

NURSING CARE PLAN

Name of Patient: ____________________________ Attending Physician: _________________________________

Age: _ __ Sex: _____ Civil Status: ____________________ Diagnosis: __ __ ___
Occupation: _______________ Religion: _____________________ Chief Complaint: __ ______________________
Address: _______________________________________________ Date of Admission: ___________________________________
Ward: _______ Room No.: ________ Bed No.: ________________
DATE/ CUES NEEDS NURSING SCIENTIFIC GOALS NURSING RATIONALE EVALUATION
TIME DIAGNOSIS BASIS OBJECTIVES INTERVENTIONS
CRITERIA
Subjective: Acute pain Normally, After 8 hours of 1. Monitor time, 1. To monitor the labor After 8 hours of
10-06-23 Pt. Verbalized “sakit related to uterine contractions of nursing frequency, intensity, progress and provide nursing intervention,
akong tiyan ug contraction and involuntary interventions, and duration of uterine information
bat’ang” with a cervical dilation muscles, such contractile pattern for the client. The client has a
Pain scale of 6/10 ● The client relaxed facial
as the heart,
2. Routinely 2. Provides information expression and is able
stomach, and will have a relaxed
Objective: assess pain noting to aid in determining choice to rest between
>G1P0 intestine, do not facial expression location, intensity or effectiveness of uterine contractions.
>AOG: 40 wks cause pain. This and be able to rest (scale of 0-10), and interventions.
>facial grimace concept makes between uterine duration. The patient was able
> restlessness uterine contractions. 3. A to demonstrate
>client periodically contractions 3. Provide a quiet non-distracting environment relaxation technique
caresses abdomen unique because ● The and comfortable provides optimal and deep breathing
when contractions they do cause patient will be able environment opportunities for relaxation exercises.
occur. pain. During to demonstrate (appropriate between contractions. The
> VS taken and temperature and environment of the labor The heart rate also
contractions, relaxation
recorded ventilation, clean and room can be controlled by decreased as aeb
blood vessels technique and well-maintained room). having the client listen to 84bpm.
Temperature: 36.8 constrict, deep breathing familiar music brought from The client verbalizes
PR: 82 reducing the exercises. 4. Provide a home, which can produce a perceived reduction of
RR: 23 blood supply to massage and calming effect. pain with a pain scale
BP: 110/80 uterine and ● The client counterpressure and of 3/10.
FHT: 140 cervical cells, will verbalize assist patient to find 4. Changing positions
resulting in perceived or actual position of maximum and using counterpressure GOAL MET
anoxia to comfort- standing, may help alleviate discomfort
reduction of pain
muscle fibers. sitting, squatting, caused by pressure of
as evidenced by a sidelying, hands and presenting parts on body
This anoxia can pain rate of 3/10 or knees as needed. structures, ligaments, or
cause pain in less. tissues. Massage helps
the same way 5. Initiate relieve muscle tension and
blockage of the teaching/ reinforcing provide a diversion to inhibit
cardiac arteries of nonpharmacologic pain sensations.
causes the pain comfort measures that
of a heart can be used during 5. To promote
attack. As labor labor if needed (e.g. relaxation and pain reduction
use of focal point,
progress and
visual imagery, 6. To avoid bladder
contractions breathing and distention and promote
become longer relaxation techniques). comfort
and more Assist with
intense, the implementation of 7. Early recognition of
ischemia to these measures as possible adverse effects
cells increases, needed. allows for prompt
the anoxia intervention.
increases, and 6. Encourage
the pain client to void every 1– 8. Enhances patient’s
2 hr comfort level
intensifies.
7. Instruct the 9. Provides emotional
patient to report any support, which reduces fear
feelings of dob or and anxiety levels, and help
chest pain, dizziness, minimize pain
nervousness, and
irregular heartbeat. Dependent:
10. Judicious use of a
8. Provide pharmacologic agent assists
comfort measures (ice the client in coping with
chips, petroleum jelly contractions and may
for dry lips, dry linens, facilitate labor.
etc.). Pharmacologic management
of pain during labor and birth
includes analgesia, which
9. Offer reduces or decreases
encouragement to the awareness of pain
patient by updating Evaluation
her regarding her labor
progress and provide
positive reinforcement. After 8 hours of nursing
intervention,
Dependent:
10.Administer pain The client has a relaxed
medications as ordered facial expression and is able
and assist with to rest between uterine
epidural placement. contractions.
 The patient was able to
demonstrate relaxation
technique and deep
breathing exercises.

The heart rate also

decreased as aeb 84bpm.
The client verbalizes
perceived reduction of pain
with a pain scale of 3/10.

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Name: Janeenne Fe Nicole B. Silvano Section & Year:____________________ Group No.: 12-B Rating: _______________
Reference___________________________________________________________________________________________
Criteria: Promptness (5%) _______ Objective Of Care (10%) ________
Format/Neatness (5%) _______ Nursing Actions (40%) ________
Assessment (15%) _______ Evaluation (10%) ________
Diagnosis (15%) _______ Clinical Instructor: