Nursing Care Plan

Name of Patient: Quinsoy, Elaimie Gunibon Date of Admission: 10-03- 2019

Age: 20 Sex: Female Civil Status: Single Chief Complaint: Labor Pain

DATE NURSING
NURSING GOALS AND
AND CUES INTERVENTION RATIONALE EVALUATION
DIAGNOSIS OBJECTIVES
TIME S

SUBJECTIVE Anxiety related to Within the 2 hours Independent: After 2 hours of

DATA: lack of knowledge of nursing 1. Assess level of In order to Identify nursing intervention
Client verbalizes about labor intervention our anxiety through areas of concern the client was able to:
while crying, experience client will manage verbal and that might interfere Verbalized
“Ma’am ika usa anxiety with nonverbal cues. with the normal awareness of feelings
SCIENTIFIC BASIS
pa nako ma’am positive coping progress of labor. of anxiety
Vague uneasy
ug di ko kabalo feeling of mechanisms as “maam naglisod jud
discomfort or dread
unsaon pag evidenced by: 2. Employ a For it enhances ko, nahadlok ko kay
accompanied by an
utong ug tarong” autonomic Verbalize calm, caring, nurse client dibaya ko kabalo. First
response; a feeling
OBJECTIVE awareness of confident, and relationship for it time baya nako
of apprehension
DATA: caused by feelings of non-judgmental provides a healthy maam.”
anticipation of
anxiety. approach. outlet for emotions
danger. It is an
altering signal that
● Exhibitwarns of impending Verbalize and relieves anxiety Verbalized desire to
danger and enables
poor eye willingness to 3. Allow client to Provides a healthy participate actively
the individual to
contact take measures to cooperate and express fears outlet for emotions through effective
deal with threat.
● Facial follow instructions and feelings of and relieves anxiety pushing
tension Reference: Pilleteri carefully during anxiety “ sige maam, naka
(2019)) Maternal
and the entire course appropriately. sabot nako unsaon”
and Child health
grimacing nursing Vol 1. of labor OBJECTIVES
observed Manifest positive 4. Acknowledge Adequate PARTIALLY MET.
● Impaired attitude towards normalcy of fear explanation helps References:
Doenges M, Moohous
attention healthcare and provide an reduce anxiety,
M, Murr A. (2019)
noted personnel and opportunity for soothe fears, and Nurses’s Pocket
Guidelines Edition 14
● Appears support persons. questions and provides
preoccupi Acquires answer honestly assurance.
ed; knowledge about within client’s
decrease childbirth and is level of
d better prepared to understanding.
perceptua cope with future
l field. births. 5. Assist pt. In This position aids in
● Crying proper the easy expulsion
● Muscle positioning – of the fetus, thus
tension is Lithotomy reducing stress and
observed position. anxiety from
6. Promote prolonged labor.
effective second- For this position
stage pushing by aids in the easy
instructing client expulsion of the
to push with each fetus, thus reducing
contraction and stress and anxiety
rest between from prolonged
them. labor.
 Name of Patient: Quinsoy, Elaimie Gunibon Date of Admission: 10-03- 2019
Age: 20 Sex: Female Civil Status: Single Chief Complaint: Labor Pain

DATE NURSING
NURSING GOALS AND
AND CUES INTERVENTION RATIONALE EVALUATION
DIAGNOSIS OBJECTIVES
TIME S

SUBJECTIVE Altered comfort: Within our care, Independent Within our care, the
DATA: Pain related to our client shall 1. Monitor Vital -To obtain baseline client was able to:
“ Sakit na kaayo bearing down actively Signs data. This is to Maintained v/s within
maam, jusko efforts and participate in 2. Assess monitor the normal range:
tabangi ko”. distention of the labor and cope contraction progress of labor T: 37.4C
OBJECTIVE perineum. with the patterns, bloody and the condition of PR: 66bpm
DATA: SCIENTIFIC discomfort show and the both the mother RR: 16cpm
Rated pain: BASIS: effectively as degree of pain and the baby. BP: 110/70mmhg
10/10 Labor in NSD is a evidenced by: and its -Helps to identify Verbalize pain within
Facial grimace is physiologic process V/S is within the characteristics, areas of chief tolerable limits.
noticed during which the normal range location, severity, concern, providing Verbalize discomfort
Profuse products of T: 36.5-37.5 duration, and baseline for future Rated pain as 8 in a
sweating noted. conception (ie, the PR: 60-100 bpm frequency. interventions. scale of 1 – 10
fetus, membranes, RR: 12-20 cpm
Moaning and umbilical cord, and BP: 120/80- 140- 3. Provide - Left lateral Groaning, and facial
Crying placenta) are 90 mmHg comfort position increases grimacing, Profuse
Irritability expelled outside of Verbalize pain measures: venous return and sweating, Moaning ,
Muscle tension the uterus. Labor is within tolerable • Encourage enhances placental Crying
is observed. achieved with limits. comfortable circulation. Irritability, Muscle
Restlessness is changes in the Verbalize desire positioning. - Position changes tension is decreased
noted especially biochemical to continue with • Position the promote comfort, in tolerable level.
during connective tissue the labor process. client in a left reduce muscle Responded to
exacerbation of and with gradual Perceive labor side lying tension, relieve questions and
contractions. effacement and experience in a position. pressure and instructions
dilatation of the positive light and • Encourage promote fetal appropriately.
uterine cervix as a comply with the client to assume descent. OBJECTIVES IS
result of rhythmic instructions of the different MET.
uterine contractions physician positions and
of sufficient effectively. change them
frequency, intensity, Demonstrate use regularly.
and duration. of relaxation and 4. Teach proper -Proper breathing References:
Reference: Pilleteri diversional breathing technique can Doenges M, Moohous
(2019)) Maternal activities as technique. prevent exhaustion, M, Murr A. (2019)
and Child health indicated (Guided 5. Inspect the therefore Nurses’s Pocket
nursing Vol 1. - imagery, Deep client’s preventing Guidelines Edition 14
Breathing). suprapubic area prolonged delivery
Demonstrate and palpate for of the fetus and
proper breathing bladder prolonged pain.
techniques. distention.
Encourage the - A full bladder
client to void. contributes to
discomfort and
6. Provide impedes fetal
information and descent.
update client on - Helps alleviate
labor progress any anxiety and
Dependent fears that may
7. Administer exacerbate pain.
analgesia as - Mechanism of
ordered action is to reduce
Collaborative pain.
8. Refer to - To provide
physician any immediate medical
abnormalities intervention.
that may be
observed.
 D.) Nursing Care Plan
Name of Patient: Quinsoy, Elaimie Gunibon Date of Admission: 10-03- 2019
Age: 20 Sex: Female Civil Status: Single Chief Complaint: Labor Pain

DATE NURSING
NURSING GOALS AND
AND CUES INTERVENTION RATIONALE EVALUATION
DIAGNOSIS OBJECTIVES
TIME S

SUBJECTIVE Altered Comfort: Within 2 hours of Independent: Within our care, the
DATA: Pain related to nursing 1. Assess the -Assessing the pain client:
“ Sakit lagi tissue trauma intervention client level of pain level experienced Reported pain
habang gina secondary to will be able to: experience by by the client perception as having
tahi” medial Report pain the client and her determines her a numeric value of 3
episiorrhaphy reduction, from a ability to perform capability to comply out of 10.
OBJECTIVE Scientific basis scale of 2-4 pain normal task such with other Able to exhibit minimal
DATA: Pain is defined as scale. as eating, interventions. pain gramacing,
Rated pain as an unpleasant Demonstrate of breastfeeding muscle tension is
6/10. sensory and relaxation skills and dressing decreased, moaning
Facial tension emotional and diversional 2. Check vital -Serves as and crying is
and grimacing experience arising activities. signs comparison from eliminated.
observed from actual or previous
Weak and potential tissue Exhibit absence 3. Review client’s measurements thus
exhausted damage or of facial previous determine any
Muscle tension described in terms grimacing, muscle experiences with improvement or
is observed of such damage. tension, energy is pain and further deterioration
Moaning and Reference: Pilleteri regained, focus is methods found of the client’s
crying can be (2019)) Maternal also regained. helpful for pain condition.
heard from the and Child health Participate in control in the
patient but didn’t nursing Vol 1. demonstrating past
screamed or ways of cleaning 4. Provide -Identify possible
gave any Doenges M, the episiorraphy comfort ways on how to
verbalizations. Moohous M, Murr wound. measures handle the pain
Narrowed focus A. (2019) Nurses’s (backrub, experiences by the
is evident Pocket Guidelines therapeutic client pain
(reduced Edition 14 touch) management
interaction with 5. Encourage the -May help decrease
people) use of relaxation pain perception by
technique such interrupting the
as deep conduction of nerve
breathing and pain impulse
imagery