ASSESSMENT

- Able to perform ADL's with assistance

- Dizziness noted
- With initial vital signs of

BP:130/80mmHg

PR: 86 bpm

RR: 36 bpm

Temp: 36.6 c

DIAGNOSIS
hypertension related to elevated blood pressure
as manifested by occipital headache

Planning

LTO: after 3 days of nursing interventions the

client will maintain normal and stable blood
pressure

STO: end After 8 hours of nursing intervention

the clients blood pressure will decreased to
acceptable limits
INTERVENTION
- Assess underlying conditions
- monitor blood pressure
- Observe skin colour temperature capillary
refills and diaphoresis

RATIONALE
- To determine what triggers the elevated BP
- Change in B.P may indicate change in patient
status required from medical attention.
- peripheral vasoconstriction may result in pale,
cool, clammy skin with prolonged capillary refill

Evaluation
STO:

After 8 hours of nursing intervention the client

has no elevation in his blood pressure
Goal was met

LTO: after 3 days of nursing intervention the

patient maintains a stable blood pressure
Goal was met
ASSESSMENT
S:
O:
- Facial grimaces
- uncomfortable
- Restlessness
- With initial vital signs of
BP:110/ 60mmHg
PR: 96 bpm
RR: 18
Temp: 36.6 c

DX: Acute labor pain r/t cervical dilatation

PLANNING:
SHORT TERM GOAL: After 8hrs of nursing
interventions the patient will be able to engage
in non pharmacologic measure to reduce
discomfort/pain

LONG TERM GOAL: After 24 nursing

interventions the patient will be able to report
pain management level

NURSING INTERVENTION
- Asses patient vital sign especially her blood
pressure.

- Provide/encourage use of comfort

measures, like repositioning.

- Teach patient to practice and emphasize

constant and proper hand hygiene.

- Relaxation is mostly taught in preparing for

childbirth classes

- Provide comfort.

RATIONALE

- To know any deviations from Normal range

- Position changes enhance circulation

reduce muscle tension.

- By teaching patients how to perform effective

hand hygiene techniques consistently, nurses
help reduce infection risk and promote better
overall health outcomes
- By learning relaxation techniques, mothers can
improve their coping skills and have a more
positive childbirth experience.

- it promotes a sense of well-being,

reduces anxiety, and enhances the overall
patient experience.
EVALUATION
SHORT TERM GOAL:
After 8hrs of nursing interventions the patient
was able to engage in non pharmacologic
pressure to reduce discomfort/pain

GOAL MET

LONG TERM GOAL:

After 24 of nursing interventions patient was be
able to report pain at management level. GOAL
MET