Assessment Nursing Inference Planning Nursing Rationale Evaluation

diagnosis intervention
Subjective According to NANDA, Short Term Short Term
Cues Acute pain acute pain is the state in Objective Monitor vital signs To provide Objective
related to which an individual and mental status. baseline from
“Sobrang altered experiences and reports After 30 which to After 30
hirap at ang characteristics the presence of severe minutes of compare minutes of
sakit na ng of stimulated discomfort or an intervention, abnormal intervention,
tyan ko. contractions uncomfortable sensation the client will: findings. the client:
Feeling ko and/or lasting from 1 second to
hihimatayin augmented less than 6 months. verbalize Discuss anticipated Helps prepare verbalized
ako sa labor understanding changes /difference client because understanding
pagl- References: of the said in labor pattern and induction of the said
labor.” As condition. contractions. procedures and condition.
verbalized Nurseslabs. (01 June use of oxytocin
by the 2019). 36 Labor stages, report pain is can result in reported pain
patient. induced and augmented reduced or rapid onset of is reduced or
labor nursing care manageable. strong, frequent manageable.
plans. Retrieved from contractions,
Objective https://nurseslabs.com/l appear relaxed which often aappeared
Cues abor-stages- between interfere relaxed
inducednursing-care- contractions. negatively with between
Vital Signs plan/6/#f1 the client’s contractions.
BP: 120/80 ability to use
PR: 85 RegisteredNurseRN. learned coping
RR: 20 (n.d.). Nursing care techniques,
Temp: plan and diagnosis for which a slower
35°C acute pain. Retrieved buildup in the
from contractile
Pain scale: https://www.registeredn pattern would
7 (1 lowest, ursern.com/nursingcare- allow.
10 highest) plan-anddiagnosis-for-
acutepain/ Answers to
questions can
G2 T2 P0 Establish a rapport alleviate fear
A0 L2 that enables client/ and promote
partner to feel understanding.
Fundic comfortable asking
height: 41 questions. Encourages
cm relaxation and
Review/provide gives client a
First instruction in means of coping
assessment simple breathing with, and
of cervix techniques. controlling the
dilation: 3 level of,
cm discomfort.

After 4 hrs: Enhances

3 cm client’s control
Review analgesics of situation and
Another 4 that are available provides
hrs: 7 and appropriate for information
cm client, and explain necessary for
their time factors making an
Another 4 and restrictions. informed
hrs: 10 choice.
cm
Prevents/limits
muscle fatigue;
Encourage and enhances
assist client with circulation.
change of position,
and readjust EFM.
Relaxation can
aid in reducing
Encourage client to tension and fear,
use relaxation which magnify
techniques. Provide
instruction as pain and hamper
necessary. labor progress.

Give Reassures
encouragement; client/couple.
keep client Provides
informed of positive
progress. reinforcement
for
Efforts and
promotes focus
on the future.

Provide comfort Promotes

measures (e.g., relaxation,
effleurage, back reduces tension
rub, propping with and anxiety and
pillows, applying enhances
cool washcloths, client’s coping
offering ice and sense of
chips/lip balm). control.
Assessment Nursing Inference Planning Nursing Rationale Evaluation
diagnosis intervention
Subjective Risk for Labor is considered normal when uterine Withim 10 Independent: Detects The Mother
cues Fetal contractions result in progressive hrs of abnormal Patient
injury dilation and effacement (stretching and nursing Assess FHR response participated
“Napapagod related to thinning) of the cervix. Normal labor interventio electronically. which may in the
na ako, hindi prolonge progresses slowly through the initial n to Note indicate interventions
ko alam d labor (latent) phase and then, when the cervix improve the variability, hypoxia or to improve
hanggang is dilated more than four centimeters, the labor of the periodic distress. labor and the
kailan pa more rapid, active phase of labor begins. mother so changes, and baby as
ako iire.”As During active labor, the cervix should that the baselines rate. Lack of successfully
verbalized progressively dilate at a rate of no less baby is Descent in delivered 6
by the than 1.2 cm per hour (during a woman’s delivered the birth hours after
patient. first pregnancy) or 1.5 cm per hour (for safe, it will Monitoring canal may mother was
subsequent pregnancies) (1). If labor be: fetal descent in indicated fully dilated
progresses more slowly than this, a birth canal malposition. and effaced
Labor woman may be experiencing arrested or Fetal relation to fetal patient
prolonged to prolonged labor. patient will ischial spines. maintained a
over 12 display a In order to normal range
hours; Prolongation and arrest of labor are fetal heart determine of heart and
mother primarily due to conditions that cause rate within Assess for potential showed no
getting tired mechanical impediments or inadequate normal malposition dysfunctiona decelerations
and as such contractions, both of which are discussed limits using l labor, it is or distress
is pushing in this section. Leopold’s necessary to throughout
ineffectively Fetal malpresentation: If the baby is No late Maneuvers and determine the labor
. Fetus has not in the cephalic (vertex) position (in lacerations findings on the fetus’s lie process.
not which the head is at the lower part of the internal and position
descended abdomen) before birth, issues with labor No distress examination. within the
into birth progression can occur. for the birth canal.
canal duration on
Cephalopelvic disproportion (CPD): labor
Vital Signs: CPD occurs when there is disproportion After the 2
between the size of the fetus and the size hours of
-BP 90/60 of the maternal pelvis. This size nursing
mm of Hg mismatch can cause labor to slow or stop Collaborative This can rule interventions
-PR 78 bpm completely. : out. , the patient
-RR 16 cpm will be able
-Temp 36.6 Problems with uterine contractions: Note odor and to:
-Weight Inadequate uterine activity occurs when color of
57kg contractions are either not sufficiently amniotic fluid Manifest
- Height strong or not appropriately coordinated once. reduction of
150cm enough to dilate the cervix and push the core
baby out. Issues with uterine activity can temperature
arise due to a pregnancy with multiples, from 38.9 to
excessive use of painkillers or a normal
anesthesia, or a variety of other factors range of
. 36.5C - 37.5
Maternal obesity: Higher maternal BMI C
(body mass index) is correlated with a
longer first stage of labor, as well as a
variety of other pregnancy
complications.

Source:
https://www.abclawcenters.com/practice
-areas/prenatal-birth-injuries/traumatic-
birth-injuries/prolonged-and-arrested-
labor/
Assessment Nursing Inference Planning Nursing Rationale Evaluation
diagnosis intervention
Subjective Altered Episiotomy is an incision made in Within 2 Monitor -to obtain At the end of
Cues comfort: the perineum the tissue between the days of patient’s vital baseline care all
acute pain vaginal opening and the anus during nursing sign data objectives
“Ang sakit ng related to childbirth. care the were partially
aking tahi at surgical patient will met as
parang incision be able to: Accepts -pain is evidenced by:
mawawarak”, secondary patient’s subjective
verbalized by the to -observed perception experience
patient episiotomy evidence about pain. and cannot The patient
wound of pain Acknowledge be felt by was able to
the pain others observed
-patient experience evidence of
Reference: report of and convey pain
https://www.mayoclinic.org/healthy- less pain acceptance of -to
lifestyle/labor-and-delivery/in- clients determine
depth/episiotomy/art-20047282 -verbalized response of deviations The patent
feeling of pain from reports less
comfort normal and pain
Objective obtain especially
Cues -on the Assess subjective when she
given, patients cues takes her
VITAL SIGNS
administer general health medication
Temp-36.5 C
pain condition
RR-17 cpm
reliever to
PR-75 bpm -promotes
the client
BP-120/85 feeling of The patient
mmHg Provide rested, verbalized the
adequate rest comfort feeling of
Client rate the and also comfort
pain 5 (1 lowest avoid
10 highest) Perform fatigue
cleansing
LABORATORY bedbath to the The patient
RESULTS patient able to
Urinalysis -to cleanse verbalize
Color: Yellow the body feeling of
Transparency: and feeling relief from
Provide of relief
slight hazy optimal pain cleansing
Glucose: also to bedbath
relief with reduce the
negative doctor’s risk of
Protein: negative prescribed
ph: 6.5 infection
analgesics The client was
able to
verbalize
-Each understanding
client has a about the
right to procedure
expect
maximum
pain relief.