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