NURSING CARE PLAN (NCP) 1

ASSESSMENT NURSING SCIENTIFIC GOALS AND NURSING RATIONALE EVALUATION

DIAGNOSI ANALYSIS OUTCOMES INTERVENTIONS
S
Subjective: Acute p Labor pain Short-term INDEPENDENT INDEPENDENT Short-term
“Sakit najud Labor pain refers to an After 8hrs of 1.Asses patient vital 1.To know any After 8hrs of
kaayo, dili na r/t cervical emotional nursing sign especially her deviations nursing
makaya ang dilation experience interventions blood pressure. from Normal interventions
kasakit" as and involves the patient will range the patient was
verbalized by both be able to 2.Provide/encourag able to engage
the patient. physiological engage in non e use of comfort 2.Position in non
and pharmacologic measures, like changes pharmacologic
Objective: psychological measure to repositioning. enhance pressure to
•Facial grimace mechanisms. reduce circulation reduce
•Uncomfortabl Which it has discomfort/pai 3.Assess client reduce muscle discomfort/pain
e two n desire for physical tension. .
•Irritability components: touch during GOAL MET
•Restlesness During the contractions. 3.Touch may
•Vital sign: first stage, a Long-term serve as a
BP – 90/60 visceral pain After 3 days of 4.Offer distraction, Long-term
HR – 96 results from nursing encouragement provide After 3 days of
RR – 18 cervical interventions provide information supportive nursing
T – 36.7 dilatation and the patient will about labor reassurance interventions
O2 SAT – 98% distension of be able to progress and and patient was be
the lower report pain provide positive encouragemen able to report
uterine management reinforcement for t and may aid pain at
segment with level clients/couple’s in maintaining management
contractions. efforts. sense of level.
control and GOAL MET
Cervical 5.Teach patient on reducing pain.
dilation ( or how to do a proper
cervical hygiene in self 4. Provide
dilitation) is examining her emotional
the opening vagina support ,
of the cervix, which can
the entrance 6.Teach patient to reduce fear,
to the uterus practice and lower anxiety
during emphasize constant levels and help
childbirth, and proper hand minimize pain.
miscarriage, hygiene.
induced 5.Patient will
abortion or 7.Relaxation is know to how
gynecological mostly taught in self examine
surgery preparing for herself and the
cervical childbirth classes procedure
dilation may needed to
occur 8.Provide comfort perform the
naturally, or measure like bag examination.
maybe rub, helping
induced position of comfort 6.Handwashing
surgically or suggests use of seves as first
medically. relaxation line defense
techniques and against any
deep breathing infection.
exercises.
7.Relaxation
REFERENCE/S DEPENDENT: keeps the
: 1.Administer abdominal wall
Www.sc analgesic such as from becoming
ienceditect. butorphanol tartare tense and
com (stadol) or allows the
Www. meperidine hydro uterus to rise
ncbi.nml.nih . chloride (bemerol) during
goc/ by IV during contractions
pmc/articles/ contractions or without
PMC4589939 deep intramuscular pressing
/ (IM) IF indicated against the
during active phase abdominal
of stage labor. wall.

8. Promote
relaxation
refocuses
attention and
may enhance
coping
abilities.

DEPENDENT:
1.IV route
provides more
rapid and
equal
absorption of
analgesic and
IM route may
require up to
45 mins to
reach
adequate
plasma levels.
Administering
IV during
uterine
contraction
decreases
amount of
medication
that
immediate
reaches fetus.
 NURSING CARE PLAN (NCP) 2

ASSESSMENT NURSING SCIENTIFIC GOALS AND NURSING RATIONALE EVALUATION

DIAGNOSIS ANALYSIS OUTCOMES INTERVENTION
S
Subjective: Fear related Fear is one’s Short-term INDEPENDENT: INDEPENDENT: Short-Term:
“Pagkakita nako to innate response to After 8hrs of 1.Measures vital 1.Fear and - After 8 hours
sa dugout, Dali- response to perceived nursing signs and acute anxiety of nursing
Dali dayon me stimuli threat that is interventions physiological can both interventions
og anhi kay consciously patient will be responses to the involve pt will be
nahadlok recognized as a able to situation. sympathetic able to
naman ko basin danger. verbalize arousal. verbalize
unsa nani" as accurate 2. Acknowledge accurate
verbalized by A stimulusis a knowledge normalcy of 2. This knowledge of
the patient. detectable and sense of fear, promotes an and sense of
changes in the safety related pain, and attitude of safety related
Objective: physical or to current despair, and caring and to current
•Facial grimace chemical situation. give opens the door situation.
•Uncomfortabl structure of an “permission” to for discussion *GOAL MET
e organism express feelings about feelings
•Irritability internal or Long-term appropriately and/or
•Restlessness external After 3 days of and freely. addressing Long-Term:
•Vital sign: environment. nursing reality of - After 3 days
BP – 90/60 The ability of interventions 3. Discuss the situation. of nursing
HR – 96 an organism or patient will be client’s interventions
RR – 18 organ t detect able to perceptions and 3. This pt will be
T – 36.7 external demonstrate fearful feelings. promotes an able to
O2 SAT – 98% stimuli, so that through use of atmosphere demonstrate
an appropriate effective 4.Monitor of caring and understanding
reaction can be coping maternal vital permits through use
made is called behaviors and signs after explanation or of effective
sensitivity. resources. DRUG correction of coping
administration. misperceptions. behaviors (e.g.,
problem-
REFERENCE/s 5.Assess pain as 4.Monitoring solving) and
Doenges, verbalize by maternal vital resources.
M.et.al.(2016). patient and sign will help in *GOAL MET
Nurse’s Pocket continue to maintaining the
Guides (14th administer ideal maternal
ed.,p 316) medication as blood pressure,
prescribe by respiratory rate
physician. and blood
saturation.
6.Provide
comfort 5.When the
measures , quiet patient knows
environment about her
and calm current
activities. situation and
7.Familiarize the know that it is
patient with a part of the
surrounding as pregnancy
necessary. progress, there
is a feeling or
8.Teach patient relief and
pain control reduction of
options anxiety.
available giving
the pros and 6.To promote
cons of each pharmacologica
l pain
management.
DEPENDENT:
1. Review the 7. Familiarity
use of with the setting
antianxiety promotes
medications and comfort and a
reinforce decrease in
use as fear.
prescribed.
8.Providing
information
allows the
patient to more
informed
decisions
regarding pain
control.

DEPENDENT:
1.To lessen the
anxiety and fear
of the patient.