Name of Patient: Dimaguiba, Addelaine Chantal Date of Admission: August 15, 2022 Room: 457 Age: 25 y/o Sex: F Civil Status: Married Chief Complaint: GI Distress and Abdominal Pain Religion: ____________________Attending Physician: Dr. Chua PROBLEM SCIENTIFIC BASIS GOALS/OBJECTIVES NURSING RATIONALE EVALUATION CRITERIA INTERVENTIONS
Subjective: Nursing Diagnosis: The patient will be able 1. Engage the client 1. Systemic toxic The patient was able to ● Vomiting Acute pain related to to identify and use in conversation to reactions with identify and used ● GI distress increasing uterine methods to alleviate the test their sensory compromised methods to alleviate the ● Abdominal pain contractions secondary pain and discomfort that perceptions, and sensory abilities pain and discomfort that to labor and delivery come with the active for one to two take place if the come with the active Objective: stage of labor. hours, take substance is stage of labor. ● T- 36.3 Uterine muscular 15-minute absorbed into the ● BP- 120/80 contractions and intervals to check bloodstream. ● RR- 20 pressure on the cervix their respiration Hypoxia may be ● PR- 81 during labor are the two and pulse. preceded by poor ● SPO2- 98% main causes of pain. The 2. Encourage the sensorium, baby's pressure on the patient to urinate whereas severe bladder and bowels, as every 1-2 hours analgesia well as the stretching of and palpate the paralyzes the the birth canal and suprapubic region diaphragm and vagina as the baby to check for impairs breathing. passes through it, can all bladder 2. This avoids cause discomfort. Your distension. bladder lower abdomen and back 3. During labor, distension, which may feel achy or provide the can prolong labor uncomfortable during patient with the and create labor contractions, and necessary discomfort, your pelvis may feel comforts. potential trauma, compressed. 4. Demonstrate the problems carrying correct breathing, the fetus, and relaxation, and difficulty with belly lifting descent. A full techniques while bladder may providing support. cause delivery 5. if recommended issues like by the doctor, postpartum administer hemorrhage and analgesics delayed delivery. intravenously (IV) 3. One of the most when the patient effective is having non-pharmacologi contractions. cal pain treatment methods is massage. Tiny nerve fibers make the opposite of pain impulses stronger and faster in the presence of stimulation, such as vibrations, stroking, or massage. 4. Relaxation techniques and breathing exercises may speed up normal labor while reducing pain signals. Contrarily, abdominal lifting is a method of reducing labor pain that entails stroking the top of the stomach without pressing inside. 5. The amount of medication that immediately reaches the fetus is decreased when medications are administered by IV during uterine contractions.
-NurseStusy.Net (n.d.). Labor and Delivery Nursing Diagnosis and Nursing Care Plan. https://nursestudy.net/l abor-and-delivery-nursi ng-diagnosis/?fbclid=Iw AR0RiYNHEjU9LxR8VTL EY9ZnwcH2D2Xywfpbsv Bh2QrOVX5bEl0BteAOY bg#:~:text=Nursing%20 Diagnosis%3A%20Acute %20Pain%20related,inc reasing%20pressure%2 0on%20the%20back BBN/DTS/2020 Denniella Marie B. Carreon NAME OF STUDENT
