ASIA PACIFIC COLLEGE OF ADVANCED STUDIES

A.H. Banzon St., Ibayo, Balanga City, Bataan

COLLEGE OF NURSING AND ALLIED HEALTH SCIENCES
 ASIA PACIFIC COLLEGE OF ADVANCED STUDIES
A.H. Banzon St., Ibayo, Balanga City, Bataan
COLLEGE OF NURSING AND ALLIED HEALTH SCIENCES

NURSING CARE PLAN

Assessment Nursing Analysis Planning Interventions Rationale Evaluation
Diagnosis

Acute pain related Contractions of the GOAL MET

Subjective Short Term Independent:
to increasing -Establish rapport
Cues: muscles of the Goal:
uterine -Gain the client’s After vaginal
uterus and by
contraction trust and will be delivery, the client
“Sobrang sakit na po secondary to labor pressure on the ableto perform will feel relieved
cervix -After 1 hour of
talaga ng tiyan at and delivery intervention
balakang ko. Hindi ko (active phase) as ↓ vaginal delivery, from discomfort
with ease and the pain will
na po kaya, grabe po evidenced by pain Cervix dilate and the client will feel
‘yung hilab at para po scale 8/10, relieved from disappear
soften as well as -Monitor the client’s -Establishing and
akong natatae.” As restlessness and shorten discomfort vital sign especially maintaining
verbalized by the discomfort ↓ level of pain normal range of
client. vital signs, to
Pain impulse
travels up the spinal know how pain
Objective affects the client
cord to the cortex of
Cues: the brain. Long Term
↓ Goal: -Provide use of
Restlessness -Promotes
Contraction comfort measure relaxation and
becomes consistent -After `vaginal (back rubs, back rest, hygiene. Position
Facial Grimace and severe mouth care, perineal changes can also
delivery, the care, hot compress,
↓ enhance
Irritability client labor pain repositioning) circulation and
Labor pain will disappear. reduce muscle
Discomfort tension

Pain Scale 8/10

 ASIA PACIFIC COLLEGE OF ADVANCED STUDIES
A.H. Banzon St., Ibayo, Balanga City, Bataan
COLLEGE OF NURSING AND ALLIED HEALTH SCIENCES

-Provide the patient

Vital Signs: to find position of
maximum comfort -To reduce
BP: 110/70 like standing or muscle tension
RR: 20 sitting as needed
PR: 92
02SAT: 94
-Teach the client
some relaxation
breathing exercises -Promotes
relaxation and
improve coping
mechanisms
when it comes
Dependent: to pain

-Prepare analgesic
administration
prescribed by
physician

-To alleviate
pain,
Collaborative:
pharmacologic
medications can
None
be used.
 ASIA PACIFIC COLLEGE OF ADVANCED STUDIES
A.H. Banzon St., Ibayo, Balanga City, Bataan
COLLEGE OF NURSING AND ALLIED HEALTH SCIENCES

NURSING CARE PLAN

Assessment Nursing Analysis Planning Interventions Rationale Evaluation
Diagnosis
Subjective Cues: Acute pain related Contraction of the Short Term Independent: GOAL MET
to postpartum muscle of uterus Goal: -Establishing -Gain the client’s
“masakit po ang contraction as ↓ Rapport trust and will be After the series
aking ari o vagina evidenced by After 5 hours of able to perform nursing care
dahil sa aking cramping Vaginal Delivery nursing care intervention with intervention, the
panganganak” as (afterpain) (childbirth) intervention, the ease client will feel
verbalized by the client will feel relieved the
↓
patient relieved from the -Assess the -Establishing and afterpain of
afterpain of client’s vital sign maintaining a postpartum
Separation of
Objective Cues: postpartum while in recovery normal range of delivery
placenta delivery room vital signs
Facial Grimace ↓
Long Term Goal:
Irritability Uterus shrink back -Assess for the -To know how
to its normal size After 1 week of pain, intensity pain affects the
Discomfort ↓ nursing care (scale 1-10) client
intervention the
Pain Scale 7/10 Postpartum pain of the client -Provide optimum -To provide
contraction will disappear comfort like hot comfort to the
Vital signs: (afterpain) water bottle or client’s pain
heating pad
T: 36.5
-Teach the client -To decrease the
PR: 90
some perineal risk of postpartum
RR:22 care intervention
BP: 110/70 complications
including wound
 ASIA PACIFIC COLLEGE OF ADVANCED STUDIES
A.H. Banzon St., Ibayo, Balanga City, Bataan
COLLEGE OF NURSING AND ALLIED HEALTH SCIENCES

separation and
infection

Dependent: -
Administer -To alleviate pain,
acetaminophen as pharmacologic
prescribed by the medications can
physician be used.
 ASIA PACIFIC COLLEGE OF ADVANCED STUDIES
A.H. Banzon St., Ibayo, Balanga City, Bataan
COLLEGE OF NURSING AND ALLIED HEALTH SCIENCES

NURSING CARE PLAN

Assessment Nursing Analysis Planning Interventions Rationale Evaluation
Diagnosis

Readiness for Express GOAL MET

Subjective Short Term Independent:
enhanced family
Cues: willingness to Goal:
coping related to -Establishing -Gain the client’s After the series of
acquire new
patient's Rapport trust and will be nursing care
information
“Ano-ano po ba ang willingness to and learnings After 30 minutes able to exchange intervention, the
mga dapat kong improve of nursing care information client’s will be able to
↓
kailangan gawin o personal Gaining intervention, the verbalize desire to
matutunan” as relations with client will be undertake task
information to -Discuss the
verbalized by the family members improve actions able to verbalize importance of -To enhance leading to change
patient as evidenced by: desire to relationship and used it
and behavior open
support seeking undertake task among family
↓ communication
leading to members
Will be able to and of not
Objective change
improve having secrets
Cues: relationship to
others Long Term
-Express willingness ↓
Goal: -Determine
to acknowledge -To help the family
Readiness for individual
new information to adapt, grow,
enhanced After 1 hours situation and
and desire to and thrive when
family coping stage of growth
enhance connection of nursing care family is faced with these
to the family intervention, experiencing or transitional event
patient will be demonstrating
Vital signs: able to
T: 36.5 -To growth
verbalize desire process is
 ASIA PACIFIC COLLEGE OF ADVANCED STUDIES
A.H. Banzon St., Ibayo, Balanga City, Bataan
COLLEGE OF NURSING AND ALLIED HEALTH SCIENCES

PR: 90 to undertake -Assist the family essential to reach

RR:22 task leading to member to learn goal of enhancing
BP: 110/70 change and new, effective the family
ways of dealing relationship
used it with feelings and
reaction -
-To promote
individual well
being and
-Encourage the strengthen
family member to
coping abilities
pursue personal
interest, hobbies,
and leisure
activities

Dependent:

None

Collaborative:

None