Pamatmat, Faye L.

BSN126/ Group 104

Patient’s name: Mhelky Jamora
Diagnosis: G2P1 (1011) Pregnancy Uterine 40-41 weeks cephalic in labor
Nursing Diagnosis Analysis Goal and Interventions Rationale Evaluation
Objectives
Acute Pain R/T tissue Immediate cause: Goal: After an 8 The client’s pain
trauma Acute Pain hour shift of nursing was relieved and
interventions, the controlled.
Subjective: Intermediate cause: client’s pain is
• Pain Scale: 6 tissue trauma relieved and
out of 10 (10 controlled.
being the Root Cause:
highest, 1 Normal Objectives:
being the Spontaneous After nursing
lowest) Delivery interventions,:
1. the client will be
Objective: Scientific able to report the 1. Obtain client’s 1. To rule out
• Guarding Implication: characteristic of assessment of pain worsening of
behavior Labor in NSD is a pain. to include location, underlying
• Positioning to physiologic process characteristic, condition/
avoid pain during which the onset, frequency, development of
• Facial grimace products of quality, intensity, complications.
• Expressive conception (ie, the and precipitating (NANDA 11th ed., p.
behavior fetus, membranes, factors. Reassess 500)
(irritability) umbilical cord, and each time pain is
placenta) are reported.
• Slowed
expelled outside of 2. Observe 2. Observations
movement
the uterus. Labor is nonverbal cues/ may or may not be
• VS as follows: achieved with pain behaviors. congruent with
T= 36.5 changes in the verbal reports or
PR= 86 biochemical may be only
RR= 24 connective tissue indicator present
BP=100/70 and with gradual when client is
effacement and unable to verbalize.
dilatation of the (NANDA 11th ed., p.
uterine cervix as a 500
result of rhythmic 3. Monitor skin and 3. These are
uterine contractions color temperature usually altered in
of sufficient and vital signs. acute pain (NANDA
frequency, 2. the client will be 11th ed., p. 501)
intensity, and able to perform 4. Demonstrate and 4.To promote
duration. pain management. encourage deep nonpharmacological
breathing pain management.
exercises. (NANDA 11th ed.,
p.501)
5. Provide comfort 5. To promote
measure (touch, nonpharmacological
repositioning every pain management.
2 hours), quiet (NANDA 11th ed.,
environment, and p.501)
calm activities.
6. Encourage use 6. To distract
of relaxation attention and
techniques such as reduce tension.
focused breathing, (NANDA 11th ed., p.
CDs/tapes. 501)
7. Encourage 7. To distract
diversional attention and
activities (TV, reduce tension.
radio) (NANDA 11th ed., p.
501)
3. the client will be 8. Encourage 8. To prevent
able to rest and adequate rest fatigue. (NANDA
sleep continuously. periods. 11th ed., p. 502)