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Assessment Nursing Diagnosis Planning Intervention Rationale Evaluation

Provide comfort measures and teach relaxation techniques to help minimize pain and promote relaxation between contractions. Monitor labor progress and provide information to support informed decision making.

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BUNDA, GLYZE A.
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260 views3 pages

Assessment Nursing Diagnosis Planning Intervention Rationale Evaluation

Provide comfort measures and teach relaxation techniques to help minimize pain and promote relaxation between contractions. Monitor labor progress and provide information to support informed decision making.

Uploaded by

BUNDA, GLYZE A.
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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ASSESSMENT NURSING PLANNING INTERVENTION RATIONALE EVALUATION

DIAGNOSIS
Subjective: “Nagasakit Acute pain related to After nursing Independent GOAL MET. The client
ang akon balikawang” tissue dilation as intervention the client was able to minimize
evidenced by will be able to: discomfort and learned
Objective: verbalizations relaxing techniques between
1. Client will Assess nature and Cervical dilation should contractions.
Pain scale 8/10 identify/use amount of vaginal be approximately 1.2
Facial Grimace techniques to show, cervical cm/hr in the nullipara Pain scale 4/10
Restlessness control dilation, effacement, and 1.5 cm/hr in the
T: 36.5 fetal station, and fetal multipara; vaginal
pain/discomfort
BP: 120/80 descent. show increases with a
.
RR: 21 fetal descent. Choice
HR: 86 2. Client will and timing of
report medication is affected
discomfort is by the degree of
minimized. dilation and contractile
3. Client will pattern.
appear
relaxed/resting Time and record the Monitor the labor
between frequency, intensity, progress and provide
contractions and duration of information for the
uterine contractile client.
pattern per protocol.

Assist with comfort Promotes relaxation


measures (e.g., and hygiene; enhances
back/leg rubs, sacral feeling of well-being.
pressure, back rest, Note: Lateral
mouth care, recumbent position
repositioning, reduces uterine
shower/hot tub use, pressure on the vena
perineal care, and cava, but periodic
linen changes). repositioning prevents
tissue ischemia and/or
muscle stiffness, and
promotes comfort.

May block pain


Assist in use of impulses within the
appropriate breathing cerebral cortex through
and/or relaxation conditioned responses
techniques and in and cutaneous
abdominal effleurage. stimulation. Facilitates
progression of normal
Dependent labor

Administer
Nalbuphine +
Promethazine via IV
as ordered by the
physician

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