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Assessment Nursing Diagnosis Inference Goal/Plan Intervention Rationale Evaluation

Nursing assessed a patient experiencing acute pain related to labor with a reported pain scale of 9 out of 10. Based on the subjective and objective findings, the nurse inferred the pain was likely due to stretching of the peritoneum, cervix, ligaments, and compression of nerve ganglia during labor and delivery. The nurse's goal was to relieve the patient's pain within 30 minutes through interventions like back rubbing, repositioning, and relaxation techniques. The nurse evaluated the interventions as effective, as the patient's pain was relieved and controlled after 30 minutes.

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Tintin Tagupa
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3K views2 pages

Assessment Nursing Diagnosis Inference Goal/Plan Intervention Rationale Evaluation

Nursing assessed a patient experiencing acute pain related to labor with a reported pain scale of 9 out of 10. Based on the subjective and objective findings, the nurse inferred the pain was likely due to stretching of the peritoneum, cervix, ligaments, and compression of nerve ganglia during labor and delivery. The nurse's goal was to relieve the patient's pain within 30 minutes through interventions like back rubbing, repositioning, and relaxation techniques. The nurse evaluated the interventions as effective, as the patient's pain was relieved and controlled after 30 minutes.

Uploaded by

Tintin Tagupa
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
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Download as DOCX, PDF, TXT or read online on Scribd
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Nursing

Assessment Inference Goal/Plan Intervention Rationale Evaluation


Diagnosis

Subjective: Acute pain Stretching of After 30 Assess pain, >Provides >After 30


“Sobrang sakit na po.” related to the peritoneum minutes of noting location, information to minutes of
physical overlying the nursing intensity (scale aid in nursing
Objective: agents such uterus interventions, of 0-10), determining interventions,
 Facial grimace as laboring. the patient’s duration. choice or the patient’s
pain will be effectiveness of pain was
 Uncomfortable Stretching of relieved or Provide comfort interventions. relived and
cervix during controlled measure like controlled.
 Irritability dilatation back rub,
helping position >Promotes
 Restlessness of comfort. relaxation,
Stretching of refocuses
 Vital Signs: the ligaments Suggest use of attention, and
relaxation may enhance
BP= 130/80 technique and coping abilities.
Pain Scale: 9 Compression of deep breathing
nerve ganglia in exercises.
the cervix

There is
hypoxia of
contracted
myometrium

Labor pain

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