Patient: Freya Legend

Age: 31 Sex; F Civil status: M

ASSESSMENT NURSING SCIENTIFIC PLANNING INTERVENTION RATIONALE EVALUATION

DIAGNOSIS BACKGROUND
SUBJECTIVE: SHORT –TERM INDEPENDENT: GOAL
 “The pain Acute Pain Stretching of the GOALS: PARTIALLY
like the related to peritoneum  Obtain client’s MET:
cramps I feel progress of overlying the  After 30 assessment of Provides After 30 minutes
when I am labor as uterus. minutes to 1 pain to include information to aid to 1 hour of
on my evidence by hour of nursing location, in determining nursing
period but “The pain like intervention, characteristic, effectiveness and intervention,
more intense the cramps I patient will be onset, frequency, choice of patient report
and painful”, feel when I Stretching of the able to report quality, intensity, interventions. relieve of pain,
as verbalized am on my cervix during relieve of pain, and precipitating from 10, as the
by the period but dilation. from 10, as the factors. Re-assess highest to 6.
patient. more intense highest to 4. each time pain is
and painful”, reported
 “I had an as verbalized
Stretching of the
abortion on by the patient.
ligaments.  After 30  Assess degree of Attitudes and GOAL FULLY
my second “I had an minutes to 1 discomfort reactions to pain are MET:
pregnancy abortion on hour of nursing through verbal individual After 30 minutes
because I my second intervention, and nonverbal and based on past to 1 hour of
did not pregnancy patient will cues; note cultural experiences, nursing
Compression of
know that I because I did appear relaxed practices on pain understanding intervention,
nerve ganglia in
was not know that between response. of physiological patient appear
the cervix.
pregnant and I was contractions. changes, and relaxed between
at that time I pregnant and cultural contractions.
had a fever at that time I  After 2-3 hours expectations.
with cough had a fever of nursing After 2-3 hours
There is hypoxia
and colds with cough intervention of nursing
of contracted
and I did not and colds and myometrium. patient will not  Time and record Monitor the labor intervention
consult a I did not feel nausea, the frequency, progress and patient no longer
doctor and consult a with no blurry intensity, provide feel nausea, with
just took doctor and visions, and and duration of clear visions,
 over the just took over Labor pain. won’t get tired uterine contractile information for the and don’t get
counter the counter easily. pattern per client. tired easily.
drugs and I drugs and I protocol.
have been have been GOAL NOT
LONG-TERM
drinking drinking  Provide MET:
GOALS:
alcohol and alcohol and information about After series of
also has also has available health teachings
 After series of
family family analgesics, usual Allows client to patient can’t still
health teachings
problems”, problems”, as responses/side make informed identify/use
patient will
as verbalized verbalized by effects (client and choice about means techniques to
identify/use
by the the patient. fetal), and of pain control. control
techniques to
patient. Patient takes duration of pain/discomfort
control
medication analgesic effect in independently.
pain/discomfort.
 Patient feels: for her high light of current
Weak. blood situation.
Nauseated. pressure
Having blurry namely
vision. Methyldopa  Encourage client Keeps bladder free
Easily gets tired. 250 mg 2 x a to void every 1–2 of distension, which
day and she hr. can increase
 Patient takes gave her discomfort, result in
medication vitamins possible
for her high named OB trauma, interfere
blood Mom and Iron with fetal descent,
pressure supplement as and prolong labor.
namely indicated.
Methyldopa Patient feels:
250 mg 2 x a Weak.
day and she Nauseated.
gave her Having blurry
vitamins vision. Easily
named OB gets tired.
 Mom and Vital signs are Assist in the use of May block pain
Iron as follows: appropriate breathing impulses within the
supplement BP: 130/90 and/or cerebral cortex
as indicated. mmHg, PR: relaxation techniques through conditioned
69 bpm, RR: and in abdominal responses and
OBJECTIVE: 17cpm, T: effleurage. cutaneous
 Vital signs 37.4 C, FHT stimulation.
are as of 138 bpm. Facilitates
follows: Pain scale is progression of
BP: 130/90 10 (1 as the normal labor
mmHg PR:69 lowest, 10 as
bpm the highest).  Provide calming
RR: 17cpm Upon music and To redirect the
T:37.4 C physical imagery patient’s attention
FHT of 138 assessment techniques. from the pain.
bpm. patient’s feet
is edematous.
 Pain scale is Upon internal
10 (1 as the examination,  Monitor patient’s This serves as the
lowest, 10 as cervix is 4cm vital signs every baseline data. To
the highest) dilated. after 1 hour. determine the
Monitor FHT effectiveness of
 Upon every hour. interventions.
physical
assessment
patient’s feet  Record I and O Provides real-time
is every shift data that guides
edematous. daily care of the
patient.
 Upon
internal
examination,
cervix is  Monitor progress To check if
4cm dilated. of labor and infection is present
discharges. and how the labor is
going.

DEPENDENT:

 Insert IVs are given to

intravenous prevent dehydration
fluid PNSS 1L or having
to run for 10 insufficient fluids in
hours, as the body during
indicated. labor and birth.

 Give Used
Magnesium in pregnancy to
Sulfate 4 g IM prevent seizures
for 20-30 due to worsening
minutes (2 g preeclampsia, to
each buttocks) slow or stop
then preterm labor, and
Magnesium to prevent injuries
Sulfate drip 4 g to a preterm baby's
diluted in 250 brain.
ml D5 water to
run for
2g/hour, as
indicated.
  Start It has been the
Hydralazine recommended
5mg IV q15 x antihypertensive of
3 doses, as first choice for
indicated. severe hypertension
in pregnancy.

 Start HNBB 1 HNBB is effective

vial every 1 in significantly
hour for 4 reducing the
doses, as duration of the first
indicated. stage of labor.

COLLABORATIVE
 Diagnostic
and
Laboratory
examinations:

1. Blood typing It is used to

determine a
pregnant woman's
blood group, to
establish whether
she is A, B, AB, or
O, and whether she
is Rh-positive or
Rh-negative.
 To ensure that
2. HBsAg infants born to
HBsAg-positive
women receive
post-exposure
prophylaxis, which
is up to 95%
effective in
preventing perinatal
HBV infection.

Measures your
3. CTG baby's heart rate.

To monitor the
4. UTZ fetus' growth and
position (breech,
transverse,
cephalic, or
optimal) determine
the baby's sex.

Screens high levels

5. UA of sugars, proteins,
ketones, and
bacteria.

 NPO Diet To prevent

aspiration.