assessment diagnosis planning intervention rationale evaluation

Subjective: ” masakit yun Pain in abdomen related to Independent:

tyan ko” post normal spontaneous Short term outcome: after 2 Establish rapport. Promotes cooperation from After 2 hours of nursing
vaginal delivery. hours of nursing intervention the client. intervention the client will
the client will state the able to gain knowledge in
relieve of pain. pain management and will
Objective: pain scale 10/6 Provide comfort measures It will calm and soothes the stated the relief of
Temp:36.5 such as deep breathing patient. discomfort, therefore goal is
Bp:90/60 pattern and rest to gain the met.
RR:20 cpm loss energy during labor.
PR: 85 bpm

Appearance: confuse Provide application of To relieve pain in the muscle

hot/cold compress. area.

Monitor vital signs. For comparison data.

Collaborative:

Administer mefenamic acid To comply with the physician’

and analgesic as ordered. order.