Assessment Nursing Inference Goal/Plan Intervention Rationale Evaluation

Diagnosis

Subjective: Acute pain Stretching of the After 30 minutes Assess pain, >Provides >After 30
“Sobrang sakit na po.” related to peritoneum of nursing noting location, information to minutes
physical agents overlying the interventions, intensity (scale aid in of nursing
Objective: such as uterus the of determining interventions,
 Facial grimace laboring. ↓ patient’s pain 0 – 10), choice or the
 Uncomfortable will be duration. effectiveness of patient’s pain
 Irritability Stretching of relieved or interventions. was
 restlesness cervix during controlled relieved and
 Vital Signs: dilatation Provide comfort >Promotes controlled.
BP= 130/80 ↓ measure like relaxation,
Pain Scale: 9 Stretching of the back rub, refocuses
ligaments helping position attention, and
↓ of comfort. may enhance
Suggest coping abilities.
Compression of use of relaxation
nerve ganglia in technique and
the cervix deep breathing
↓ exercises.

There is hypoxia
of contracted
myometrium
↓
Labor pain
 Assessment Nursing Inference Goal/Plan Intervention Rationale Evaluation
Diagnosis

Subjective: Hyperthermia Labouring

“Nanglalata ako at masakit r/t vigorous patient
din ulo ko, kanina pa ksi activity and ↓
ako umaga hindi dehydration. NPO for 12˚
kumakain, uhaw na uhaw ↓
na rin ako.” Dehydration

Objective:
 Restless
 Warmth to touch
 Flushed skin
 Vital Sign:
Temperature=
38.2˚C