Assessment Subjective data: hindi pa po ako pamilyar sa proseso ng panganganak as verbalized by the patient

Diagnosis Anxiety related to lack of knowledge about labor experience

Planning After 30 minutes of giving nursing intervention the patient should:

Intervention Independent: 1. Assess level of anxiety through verbal and nonverbal cues. 2. Employ a calm, caring, confident, and nonjudgmental approach. 3. Allow client to express fears and feelings of anxiety appropriately. 4. Acknowledge normalcy of fear and provide opportunity for questions and answer honestly within clients level of understanding

Rationale Identify areas of concern that might interfere with the normal progress of labor. Enhances nurseclient relationship

Evaluation After 30 minutes of rendering nursing intervention the client was able to: Verbalized desire to participate actively as manifested by: Cooperation and following the instructions that we have given to her goals are partially met

Verbalize awareness of feelings of anxiety Verbalize willingness to cooperate and follow instructions carefully during the entire course of labor Manifest positive attitude towards healthcare personnel and support persons

Provides a healthy outlet of emotions and relieves anxiety Adequate explanation helps reduce anxiety, soothe fears, and provides assurance.

Objective: Facial tension and grimacing observed Impaired attention noted Appears preoccupied; decreased perceptual field.

Assessment Objective: Method of delivery: NSD 3rd degree perineal lacerations

Diagnosis Risk for infection r/t impaired skin integrity secondary to 3rd degree perineal lacerations

Planning After 1 hour of nursing intervention: Note for any signs and symptoms of infection such as fever and chilling Identify interventions to prevent/ reduce risk of infection

Intervention Independent: 1. Monitor vital signs especially temperature 2. Note signs/ symptoms of fever, pallor and chills 3. Perform surgical handwashing before and after doing perineal care on the site of episiotomy 4. Explain why and how infection is likely to happen 5. perineal care and teach the mother on the importance of proper perineal cleaning

Rationale

A slight elevation in temperature suggests fever. To assess if infection is occurring To prevent infection to the area and inhibit cross contamination Give the client the idea on the causative factors on infections formation Perineal area should be cleansed well to prevent the growth of microorganisms

evaluation After 1 hour of rendering nursing intervention Did not manifest the signs of infection (fever and chilling) T = 37.4C Listened upon explanation on the a factor ( impaired skin integrity ) of developing infection Was not able to verbalize an understanding of the risk factors Goals are partially met

Assessment Subjective: humihilab po ang tyan ko at ang sakit sakit as verbalized by the patient Objective: >Pain scale of 9/10 >facial grimacing noted >restlessness noted >sweating noted >difficulty to concentrate VS: T:36.5 PR:100 bpm RR: 25 cpm BP: 120/60

Diagnosis Acute pain related contractions of the uterine smooth muscles

Planning After 2 hours of nursing intervention the patient should participate in labor and cope with the pain as evidenced by: Verbalized pain within tolerable limits. Verbalized desire to continue with labor process. Demonstrate proper breathing techniques. Demonstrate use of relaxation and diversional activities

Intervention Independent: Assess degree of pain and characteristics. Employ calm, caring, confident and nonjudgemental approach. Support pt. paincoping activities: Offer support by staying with the patient, pating her arms, and brushing a whisp of hair off her forehead, and provide a cool cloth on her forehead as needed

Rationale

Evaluation After 2 hours of rendering nursing intervention the patient was able to: Claimed that she can deliver the baby Perceived labor experience in a positive manner Demonstrate proper breathing techniques Goals partially met

Provides baseline data for future intervention Gives patient sense of trust and improves nursepatient relationship Provides feeling or sense of security and trust between the nurse and the patient.

Instruct patient to do proper breathing technique (panting).

Proper breathing technique can prevent exhaustion, therefore preventing prolonged delivery of the fetus and prolonged pain