RENEA JOY M.

ARRUEJO
BSN II-D
Name of patient: Mrs. Jennifer Domenden
Age: 34 y/o

ASSESMENT DIAGNOSIS PLANNING INTERVENTIO RATIONALE EVALUATION

N
Subjective data: Independent:

“nagsakit Ma’am”. As
verbalized by the patient.
Objective data:
Continued uterine
contraction
Uncomfortable
Facial grimace
V/S taken as follows:
T: 37.5°c
PR: 89 bpm
RR: 23 cpm
BP: 140/110 mmHg
Pain scale: 8
Acute pain related to The patient will be Evaluate pain promotes Goal partially met,
uterine contractions and able to relief her regularly noting relaxation patients is able to
stretching of cervix and pain. characteristics, report slight relief
birth canal. intensity, duration, to promote of pain as
frequency, and, wellness evidenced by pain
interval. scale of 6 out of 10
to gain
Encouraged patient cooperation with
to do the deep the patient and
breathing exercise. significant others
advised patient to evaluate
do the side lying patient’s response
position to pain

monitor patient’s to assist patient

vital signs closely, to explore
every 2 hours methods for
alleviation of pain
Dependent:
to give
provide additional appropriate
comfort measures like intervention
back rub
 RENEA JOY M. ARRUEJO
BSN II-D
Name of patient: Mrs. Jennifer Domenden
Age: 34 y/o