Case Scenario:

Cristina Yang, a 25 y/o working as a teacher and she is pregnant. 39 weeks AOG and arrives at the hospital
in Philippine General Hospital (PGH) at 8:00 am for labor pain. “ ang sakit na po at ako po ay natatakot, ito
po ay pinaka una kung baby at di ko po alam ang gagawin ko.” as verbalized by the patient. Upon
assessment, it is clear that she is uncomfortable,scowling face, irritable, and restless. While her vital signs
show the following: BP = 130/80 mmHG, PR = 86 beats per minute, temp = 36.5 C, FHT = 140 per minute,
pain scale = 9/10

Patient name: Cristina Yang Chief complain : Labor Pain, Back Pain, and delivery process
Age : 25 years old Nursing Diagnosis (Nanda Format) : Acute pain rt labor
Physician : Dr. Meredith Grey discomfort and back pain aeb restlessness, scowling, irritability and
teary eyed
ASSESSMENT DIAGNOSIS PLANNING IMPLEMENTATION RATIONALE EVAULATION
SUBJECTIVE: Acute pain Short Term: - Teach the - By giving - Goal attained
Mrs. Yang related to - after 30 patient about the the patient because after
complains that labor minutes of many pain knowledge 30 minutes of
she was in pain discomfort and nursing management helps them nursing
due to her first back pain as intervention methods to make intervention
pregnancy evidenced by the client available, educated the client
labor. restlessness, verbalized the including the decisions verbalized the
scowling, contributing benefits and about pain contributing
“ang sakit na po irritability and factors to drawbacks of management factors to
at ako po ay tearful patient. reduce or each. reduce or
natatakot, ito po prevent the - give soothing - Creating a prevent the
ay pinaka una pain by using noises, relaxing pain by using
kung baby at di analgesics environments, environment analgesic
ko po alam ang aids in the
medication. scents, and medication.
gagawin ko.” as relaxation of
lightings.
verbalized by - The Patient both mother - The patient
the patient. will be able to and child. was able to
make educated identify
OBJECTIVE: - proving massage - By giving
- uncomfortable decisions strategies to
- restless about the pain to the mother. massage it reduce
management help to discomfort and
- scowling face
methods she relieves felt more calm
- tearful
wants to muscular as a result.
- irritable
- nervous employ. tension and
- Vital signs such serves as a -The goal was
as: - The patient distraction met for the
- rated pain as will express from painful reason that
9/10 in a pain alleviation - Provide feelings. patient's
scale of 0-10 from labor and Hydrotherapy discomfort
- BP = 130/80 back pain as a - Warm was
mmHG result of the water controlled, and
- PR = 86 beats methods and immersion her blood
per minute comfort offers pressure was
- Temp = 36.5 C measures warmth, aids returned to
- FHT = 140 per acquired relaxation, normal.
minute - Perform the and is both
- The patient patient's safe and - The patient
will verbally inhalation and effective. looks to be
express exhalation -Using more relaxed
 alleviation exercises. breathing and
from pain as a exercises unconcerned
2/10 from 9/10 when about giving
for nursing laboring deliver.
interventions. provides
more oxygen - After a week
to reach your of being
Long term: muscles, released, the
After 24 hours, allowing client and
the patient will them to infant are both
go through a relax. healthy and in
normal good shape.
delivery with The objectives
no risk of have been
infection. The accomplished.
mother and
infant are safe
and after a
week they are
clear to
discharge.

NAME: DARWIN N. QUIRIMIT, SN

SECTION: C1-2BSN-19
CLASS INSTRUCTOR: MA’AM LOURDES SALVADOR