NURSING CARE PLAN
CUES NURSING SCIENTIFIC BASIS GOALS AND NURSING RATIONALE EVALUATION
DIAGNOSIS OUTCOME ACTIONS AND OF NURSING
CRITERIA NURSING ORDERS
ORDERS
Subjective Alteration in An occurrence of pain After 8 hours of NURSING ACTION: After 8 hours of
cues: comfort in the uterine fundus rendering Perform nursing care rendering
“Sakit pa related to pain lasting for a few nursing and procedures to nursing
lage ako secondary to minutes is aggravated Interventions alleviate pain. interventions
tyan dae labor by movements and is client will be client will be
oi” contraction. relieved by able to relieve NURSING able the client
comfortably lying from pain. ORDERS: will be able to
Objective down. Normally Independent: verbalie a relief
cues: contractions of OUTCOME: 1. Assess pain noting of pain with a
1. Rates involuntary muscles location, pain scale 0/10
pain with such as the heart, characteristics, where 0 is to o
an stomach, and intestine intensity from 0-10 1Helps evaluate pain and 10 is to
intensity does not cause pain. 1. Patient will scale. degree of worst possible
of 8/10 on This concept makes verbalize that discomfort and pain.
a pain uterine contractions pain is relieved effectiveness of
scale, 0 is unique because they do or contolled. analgesia or may
no pain cause it. Several 2. Monitor vital reveal developing
and 10 is explanations exist for signs. complications.
the worst why this 2. Vital signs are
pain. happen.During alterd during
2. contractions blood acute pain or
Guarding vessels 2.Patient will discomfort..
behavior constrict,reducing the diplay relief of 3. Encourage use of
noted by blood supply to uterine pain and able to relaxation
placing and cervical cells, sleep or rest techniquese.g.,guided 3. Helps patient
her hand resulting in anoxia to appropriately. imagery,visualization rest more
in the muscle fibers. This and provide effectively and
fundal anoxia can cause pain 3. Patient will diversional activities. refocuses
ares every in the same way that demonstrate the attention, thereby
time lockage of cardiac use of 4. Provide comfort during pain or
shemoves arteries causes the pain relaxation skills measures,e.g.,mouth discomfort.
or get up. of a heart and general care, back rub
3.Noted a attack.Aslabor comfot repositioning(use
facial progresses and measures as proper measures as
grimaced contractions become indicated for needed).Assure 4.Prevents drying
when the longer and harder to individual patient that position mucosa and
time she ischemia t cell situation. change will not injure associated
changes increases, and the pain stoma. discomfort.
her intensifies. Pain also Reduce muscle
position probably results from Dependent: tension,promotes
such as stretching of the cervix 5.Administer relaxation, and
from lying and the perineum.This medication may enhance
or sitting. phenomenon is the (Mefenamic acid.)as coping abilities.
4.Intake of same as that causing prescribed by the
pain intestinal pain when physician.
reliever accumulating gas
(mefenami stretches the intestines.
c acid)
5.Vital (Pilliteri,2007:544)
signs: 5.Precribed to
Temperatu stop synthesis of
re:36.8 prostaglandins.
Pulse
rate:70cp
m
Respirator
y rate:
15bpm
Blood
pressure:1
30/90mm
Hg
