SANAANI, NUR-FATIMA, M.

BSN-2H

Ateneo De Zamboanga University

College Of Nursing
RLE
Level 2-H

CLIENT: MRS, ANA DUTERTE

 AGE: 30 Y.O
 OCCUPATION:PUBLIC TEACHER
 GRAVIDA: 3
 PARA: 2
 TRIMESTER: 3RD, 39 WEEK PREGNANT
DATE INITIATE: 8:00 AM, 7/20/19

ASSESSMENT DIAGNOSIS OUTCOME INTERVENTION RATIONALE EVALUATIO

N
 SUBJECTIVE Nursing diagnosis:  At the end  Monitor vital Patients vital
DATA: Acute pain related to of the signs and Monitoring vital signs had
o chief effects of labor and session perform signs, To know already
complaints of delivery patient, will preliminary the measurable normalized
back pain on learn how assessment pain ,to be able
and off “hndi to cope  Initiate to collaborate
ko na po kaya with pain teaching/reinforc any sign of labor Patient initiate
ma’am, ang control, ement of non- progression that the pain
sakit na ng option and pharmacologic had subside
likod ma’am” what she comfort from the
as being would like measurement that laboring
verbalized to use can be initiate Allowing nurse
 Patient will during the labor to initiate Patient
experience progression individual experience
relief from  Provide teaching plan relief from the
 OBJECTIVE DATA: obtaining techniques in for Patient laboring
o Uncomfortabl from labor relieving pain,
 SANAANI, NUR-FATIMA, M.
BSN-2H

e by the use massage, and Provide

o Cervix is of counter pressure, necessary Patients
dilated at 3 cm childbirth assisting in information for experience
on admission. techniques repositioning to nurse can relief/relaxes
o Pain scale:8 learning/ minimized pain reinforce, with with an
o Fetal heart rate comfort uncomfortability medication if expression of
o ( FHT ) 140/  PT. will  Assessing for the OB, doctor relief ,after
min have dilation and prescribed, or laboring
o Patient vital relief/relax Effacement of the non-
expression cervix of pharmacologic
signs:
and will be patient(cervix will comfort
o BP- 120/80 begin to dilate at
mmHg, able to measurement
8cm ) that can help
o Pulse between
uterine  IV line started initiate in labor
-88/min, with D5LR 1
o RR- 22/min, contraction
s Liter at 25
o Temp- 37*C gtts/min

 Post -op
Medicati
on:

o Ceftriaxon
e I gram
once a day
x 3 days
o Tramadol
100 mg
IV every 8
hour PRN
for pain