NURSING CARE PLAN

ASSESSMENT NURSING SCIENTIFIC PLANNING NURSING RATIONALE EVALUATION

DIAGNOSIS EXPLANATION INTERVENTION
SUBJECTIVE The hypothalamus SHORT TERM: INDEPENDENT:
DATA: LABOR PAIN activates pituitary
“Ang sakit po ng RELATED TO gland to give 1. After 30 1. Encourage Encouraging the 1. After
tiyan ko at UTERINE signal to the minutes of mom to do mother to do performing
madalas na rin po CONTRACTION posterior pituitary teaching the breathing and breathing breathing
ang pag hilab ng AS EVIDENCED gland to secrete clients on relaxation techniques can techniques
tiyan ko” as BY PAIN RATE oxytocin that breathing techniques reduce pain the pain rate
verbalized by SCALE OF 8/10 causes widening, techniques the like purse lip while having scale was
patient/client shortening and patient will breathing contractions and reduced by
thinning of cervix able to reduce during labor also it promotes 2/10
OBJECTIVE during effacement the pain and delivery. relaxation
DATA: and dilatation. 2. After 30
 Numerical 2. After 30 2. Monitor the Monitoring for minutes of
rating pain minutes of time of contractions and teaching, the
scale – 8/10 Traction and teaching the contraction recording of the patient knew
 Grimace pressure of the patient will and labor and contraction about the
 Irritable adnexae and expect the record the patterns will be frequency,
 Excessive parietal frequency, duration, necessary for duration,
sweating peritoneum and duration, frequency, the nurses to intensity and
 Restlessness the structures lying intensity and intensity and note if there are interval of her
 BP-120/80 over the uterus interval of her interval of any uterine
mmHg uterine uterine accelerations or contraction
contraction contraction decelerations of
 PR – 87 bpm
Extending/Stretchi patterns. patterns. 3. After 2 hours
 RR – 19 bpm
ng of ligaments. 3. After 2 hours of teaching,
 Temp – 36.7 of teaching, 3. Reposition the mother
o
C the patient will mother into a Putting the performed
Causes know how to comfortable mother in properly the
Initial IE done at LABOR PAIN/ properly bear position comfortable bear down
6:45 AM resulting UTERINE down to position can help techniques
to 6 cm dilatation CONTRACTION shorten the to minimize the and she able
duration of 2nd pain and to shortened
The BOW stage labor. promote the length of
ruptured at 6:50 LONG TERM: relaxation her delivery.
AM
4. After the 4. Encourage 4. After the
The second IE delivery of the mother to Encouraging the delivery, The
done at 8:50 AM baby, The initiate mother to bond mother
resulting to 9 cm patient will nursing care with her baby developed a
dilatation initiate to to her baby will result to good
develop a after birth good attachment attachment or
The last IE done good and relationship bonding
at 9:00 AM attachment or with her baby relationship to
reaching a full bonding 5. Give health her baby
cervical dilatation relationship to teaching Giving health
– 10 cm her baby about teaching to the 5. After the
retrogressive mother about delivery, the
5. After the changes of retrogressive mother
delivery the her body changes will be noticed
patient will postpartum helpful for her to retrogressive
able to know period. know all that changes in
the happening in her her body and
retrogressive body are within she knew that
changes in her normal all are within
body during normal range.
her postpartum DEPENDENT:
period
6. Monitor vital
signs of Monitoring vital
mother and signs together
the fetal heart with colleague
rate and tone will be
every 15-30 necessary
minutes after because
giving narcotics can
medications have an effect
like to fetus when
administering administering it
oxytocin to during
stimulate
labor and
uterine
contraction

COLLABORATI
VE:

7. Administer
ordered
medications Giving
related to medication
labor pain related to labor
pain should be
done with the
guidance of the
physician to
validate and be
sure of the right
medication, right
route and right
time to
administer the
medication.
ASSESMENT NURSING SCIENTIFIC GOAL NURSING RATIONALE EVALUATION
DIAGNOSIS EXPLANATION INTERVENTION

Subjective: Pain related A second degree Short term: Independent:

“Ang sakit po ng to 2nd degree laceration is a After 1 hour of 1. The nurse will Clients who
sugat ko sa perineal common tear that can teaching the demonstrate the understand MET- after 1
perineal area laceration happen while having client, the use of peri- self-care hour of
kapag nakaupo secondary to a baby. When the client will bottle, witch methods teaching , The
at kapag umiihi normal baby is big and the demonstrate hazel pads, and experience client was
po ako” as spontaneous perineum is being understanding lidocaine spray decreased of able to
verbalized by the delivery over stretched. These of pericare for pericare anxiety and demonstrate
client. tears go through the methods that following an increase and verbalized
skin into the muscles can be used urination and of sense of the steps in
underneath the to help defecation. control. her pericare
-Client vagina. Second achieve her routine.
verbalized degree comfort
uncertainty lacerations sometime function goal 2. Teach proper Front to back
MET- after 1
related to pain s need sutures. The and avoid perineal care perineal care
day of delivery
management sutures will help to infection from front to will lessen
, the client
and perineal hold the edges of back the  risk ofreported that
care routine the tear together to Long term: introducing the pain
allow it to heal. germs from medication
Objective: After 1 day of the anal area
was effective
delivery, the into the
in reducing
Vital Signs: pain of the urethra, a
her pain and
mother will be primary achieving her
T: 36.7 reduced and source of
comfort as
PR: 87 bpm achieved her urinary tract
evidenced by
RR: 19 bpm comfort infeaction. absence of
BP: 120/80 because of facial grimace
mmHg the and a pain
Pain: 6/10 effectiveness 3. Instruct To promote scale of 3/10.
of pain patient to do sitz healing and
-Facial grimace medication bath promote
comfort due
to its muscle
relaxant
effect and
promote
good blood
flow supply
that will
promote
faster
healing

4. Nurse will Ensuring

Assessment Nursing Scientific Goal Nursing Rationale Evaluation
diagnosis explanation intervention

Subjective: “Ineffective Postpartum Short term: Independent: 1. Generates full- 1. GOAL MET-
“Hindi kasi yung role blues is 1. Withi 1. Establish participation of After 8
asawa ko nagdala sa performance defined as n 8 rapport the patient to hours, the
akin dito sa hospital, due to lack of low mood hours relationship. verbalize HER mother
kundi yung family and mild , the feelings managed to
kapitbahay namin. At support depressive patie (Sadness) and relieve her
wala rin kasi talaga secondary to symptoms nt will 2. Demonstrat concerns. stress and
plano etong pang- postpartum that are mana e breathing relax herself
anim na pagbubuntis blues.” transient ge to and 2. This will serve with regards
ko.” As verbalized by and self- reliev relaxation as her comfort to the
the patient limited and e her technique measure. absence of
are stress her spouse.
Objective: extremely and 3. Prepare 3. This will be 2. GOAL MET-
common in relax health their guide to The patient
Quiet the perinatal herse teaching manage the will use
Tearful eyes period. The lf with related to mother`s breathing
Labile mood factors that, regar postpartum postpartum technique
G6P6 when ds to blues blues. proficiently
present, do the especially to
not abse the patient 4. The family will
predispose nce and family. give comfort 3. GOAL MET-
a patient to of her measure and After 3 days,
the spous 4. Facilitating be the support the patient
developmen e. family system of the managed to
t of participation patient. overcome
postpartum 2. The in the her
blues: patie emotional 5. The significant postpartum
disappoinm nt will and physical others will blues.
ent to use care of improve their
family role, breat patient. roles and
low hing responsibilities
econonomic techni 5. Assisting a as a part of the
status, que patient, family.
ethnic, or profici significant
racial ently other, or 6. To easily
background, family to determine the
gravidity Long term: improve problem and
status After 3 days, relationship resolve it.
(primiparous the patient by clarifying
vs. will manage and
multiparous) to overcome supplementi
, planned her ng specific
vs.unplanne postpartum role
d blues. behaviors.
pregnancy,
spontaneou
s pregnancy
vs. IVF, type 6. Encourage
of delivery, family with
family conflict
history of resolution.
mood
disorders, or
history of
postpartum Collaborative:
depression.
7. Refer 7. To manage the
families to family with
human regards to
services relationship
and difficulties.
counselling
professional
s, as
needed.