ASSESSMENT DIAGNOSIS PLANNING INTERVENTIONS RATIONALE EVALUATION

Impaired Physical Pt. will report pain is INDEPENDENT

Mobility r/t relieved or controlled -Assessed pain level every - To provide effective pain Goal partially met, the the
 Limited ROM Decreased Muscle by the end of 8 hours, hour management. patient still reports of pain
Strength as evidenced by; ,patient demonstrated
 Inability to - Assisted patient to try - To provide comfortable relaxation skills and
perform action - demonstrate use of different positions. position and to ease pain. diversional activities, the
as instructed relaxation skills and patient verbalize
diversional activities. reduction/relief of pain.
 LFacial - Keep informed about the - To inform the mother.
grimace - verbalize progress of labor and
reduction/relief of Baby’s condition.
pain
- Monitored skin color and - Which usually altered in
temperature and vital signs. acute pain.

- Provided comfort - To promote

measures by providing nonpharmacological pain
pillow. management.

- Encouraged - Only the client can judge

verbalization of feelings the level and distress of pain;
about the pain. pain management should be a
team approach that includes
the client.

- Encouraged and assist - It contributes to pain relief

patient to do deep breathing and reduction by reducing
exercises. muscle tension and anxiety.
- Encouraged adequate rest - To prevent fatigue
periods that can impair ability
to manage or copewith
pain.

- Instructed the patient to - Unrelieved pain can create

report any improvement in other problems.
pain.

- Observed nonverbal cues - Observations may not be

and pain behaviors congruent with verbal reports
or may be indicator present
when client is unable to
verbalize.

- Encouraged diversional - To distract attention and

activities such as watching reduce tension.
TV.

DEPENDENT:
- Opioid Analgesic; treats
- Administered Nalbuphine and prevents moderate to
as doctor’s order. severe pain during childbirth.
ASSESSMENT DIAGNOSIS PLANNING INTERVENTIONS RATIONALE EVALUATION

Subjective: INDEPENDENT
Disturbed sleep Pt. will report of - Determined client’s usual - To identify appropriate
“ Nagigising ako every pattern related to improved sleep by the sleep habits and changes. interventions. Goal not met, the patient still
2 hours tuwing gabi frequent urination next 24 hours, as does not report of improved
kasi ihi ako ng ihi, kaya evidenced by; - Listened to reports of sleep - Helps clarify client’s sleep, the patient still reported
gusto nalang sana quality. perception of sleep quantity. of interrupted sleep, the
magpa catheter eh” as - continuous patient verbalize slight
verbalized by the uninterrupted sleep improvement quality of sleep,
patient. - Performed monitoring and - Allows for longer periods the patient stated not well
- Pt. will verbalize care activities without of uninterrupted sleep, rested, the patient
“ mga 4-5 hours lang improved quality of waking client whenever especially during night. demonstrates frequent
ang tulog ko each night sleep possible. yawning, the patient wakes up
e” As verbalized by the frequently during night.
patient. - Statement of feeling
well rested - Promoted use of bedtime - Promotes relaxation and
“ Dahil sa sobrang rituals such as drinking a readiness for sleep.
sakit ng contraction ko - Absence of frequent glass of milk before
nagigising ako, hindi yawning sleeping.
ko tuloy maituloy tuloy
maideretso tulog ko”, - Reports of waking
as verbalized by the up less frequently - Provided warm bath and - Increases the effect of
patient. during the night massage. relaxation.

Objective:
- Improved environment by - Provide a situation
- with 4-5 times reducing noise and conducive to sleep.
frequent urination dimming the lights.
every shift; amounting
50-100 ml each
urination; with Intake
of 600 ml and output - Provided bedtime care - to promote physical
of 500 ml of urine. such as back massage. comfort.

- With light yellow

urine. - Taught client to elevate - It promotes lung expansion
head by using more pillows
- With frequent during sleep
yawning
- Encouraged the mother to - Voiding before bedtime
void before sleeping. may limit the sleep
disturbance.
ASSESSMENT DIAGNOSIS PLANNING INTERVENTIONS RATIONALE EVALUATION

Subjective ACUTE PAIN AFTER 2 HOURS INDEPENDENT . the goal was partially
“masakit parati yung RELATED TO RENDERING  monitored skin and • These are usually met
pag ihi ko” as INFLAMATION OF NURSING color temperature altered in acute pain pain was relleif and
verbalized by the THE URETHER INTERVENTION: and vital signs every rated as 2/10 from 6/10.
patient SECONDARY TO Short term 2 hours
U.T.I. GOAL:  demonstrated and • to promote
Objecctive  the patient will encourage deep nonpharmacological pain
P- the pain started verbalize breathing exercises management
everytime the patient gradual relief of  encouraged the
needs to urinate pain patient to do • to distract attention
Q- burning sensation  decrease the diversional activities and reduce tension
R- urethra pain scale of 6-1 such as listening to
S- pain scale of 6/10 as evidence by music and watching
moderate pain stable vital signs tv ect..
T- It started  the patient will
December 8 2016 be able to
everytime she urinates perform pain
management
VS:
BP:90/60
RR:20
PR:86
T:36.6
ASSESSMENT DIAGNOSIS PLANNING INTERVENTIONS RATIONALE EVALUATION

SUBJECTIVE: DISTURBED FOLLOWING 1 DAY OF INDEPENDENT GOAL MET

“Paputol putol ang SLEEPING NURSING  Observed and  To determine  the patient
tulog ko dahil sa PATTERN INTERVERTION THE obtain usual sleeping verbalized:
frequency ng pag ihi RELATED TO PATIENT WILL feedbacks pattern and to “nakatulog na ako
ko halos every 2 FREQUENT ACHIEVE OPTIMAL regarding on the compare if there nang mabuti at naka
hours akong NIGHTTIME AMOUNT OF SLEEP AS usual sleeping are any pagpahinga na ako
bumabangon para URINATION EVIDENCED BY: pattern, bed improvements on ng maayos kumpara
umihi” SECONDRY TO Short term goal time routine and the sleeping dati”
BLADDER OBJECTIVE: usual number of pattern of the  the patient does not
OBJECTIVE: COMPRESSION  Decreased hours of sleep patient. look weak and
 fatigue appearance of eye and rest. restlessness
 eyebags bags.  Did as much  To avoid compare to pass
 frequent  Verbalized of feeling care as possible disturbances  the presence of
yawning rested. without waking during sleep, and eyebags have been
GOAL: up the client and also to maximize minimized
 Improvement of did as much care the sleep and rest decreased of the usual
sleeping pattern as possible of the client. yawning.
 Absence of while the client
restlessness is still awake.
 Advised the  Drinking lots of
patient to drink fluid during the
lots of fluids day, especially
during the day, water, makes sure
especially she received her
water, but cut adequate supply of
down on the fluids she is
amount you required during the
drink in the day and cutting
 hours before down the amount
bedtime. during the
patient’s bedtime
reduces the filling
of the bladder.

 Advised patient  This position takes

when sleeping, the pressure off the
to lie on your lower back, and
left side with her provides good
knees and hips flow of blood
bent, place nutrients to your
pillows between fetus.
your knees,
under abdomen,
and behind the
back.  This will be less
 Put a nightlight arousing and help
in the bathroom the patient return
instead of to sleep more
turning on the quickly
light to use the
bathroom
ASSESSMENT DIAGNOSIS PLANNING INTERVENTIONS RATIONALE EVALUATION

Acute pain related to SHORT-TERM GOAL

Subjective surgical incision due to After 1-2 hours of rendering INDEPENDENT -to have good nurse-client GOAL PARTIALY MET
“masakit yung tahi ng cesarean birth nursing interventions the -Established rapport. relationship -the patient verbalized pain
cs ko” patient’s pain scale will decreased from scale of
decrease from 6/10 to 0/10 -Monitored vital signs -to establish baseline data 6/10 to 2/10 as evidenced
OBJECTIVE q2 hours by
(+)Facial grimace (-)facial grimace
(+)Guarding -Assessed quality, -for comparison in making (-)guarding
characteristics, severity evaluation and assess for
Objective of pain. possible internal bleeding.
P- the pain is
aggravated -Provided comfortable -Calm environment helps
by environment- changed to decrease the anxiety of
movement
bed linens and turned the patient and promote
Q-sharp
on the fan. likelihood of decreasing
stabbing
pain pain.
R-lower
abdomen -encouraged the patient -to distract attention and
S-pain scale to do diversional reduce tension
of 6/10 activities such as
moderate listening to music and
pain watching tv ect..
T-It started
December
10, 2016 COLABORATIVE
after the
anesthesia -Administered -to be relieved of pain
were off
analgesic
VS:
BP:100/70
ASSESSMENT DIAGNOSIS PLANNING INTERVENTIONS RATIONALE EVALUATION
Impaired SHORT-TERM
SUBJECTIVE skin/tissue After 20-30 minutes INDEPENDENT SHORT TERM
“mediyo malakiang integrity related of rendering nursing  Established rapport  to gain trust with the GOAL MET
hiwa na ginawa si tiyan to surgical wound intervention the client  Understand the
ko, baka matatagalan incision patient will be able to:  Inspected the importance of caring
ang paghilom ng sugat secondary to  Understand incision  frequent assessment the incision site as she
ko” verbalized by the cesarian section the REEDA( redness, can detect early signs verbalized” mas mag
patient after the day of importance of and symptoms of preprecaution na ako
edema,ecchy,
the surgery. caring the infection ngayon habang hindi
mosis, discharge
incision site. pa nag hehealang
and approximation)
OBJECTIVE  Demonstrate wound ko “
Surgical dressing on proper way of  to enhance patient’s  Demonstrate proper
the lower abdomen just  Performed bedside way of wound care and
wound care self- esteem and to
above the symphysis care proper dressing
and proper provide comfort to
pubis. dressing the patient Partially met
Redness on the skin LONG-TERM  The wound shows
surrounding the After 7 days of  Kept the area clean  moisture harbors signs of
incision sight(8cm nursing intervention and dry bacteria and healing(dryness and
bikini cut) the patient will be pathogen intact wound)
able to:
 Main the  Carefully dressed  to prevent infection
wound intact wounds
Show signs of
healing(dry and intact  Informed patient of  to increase
wound) the purpose of self- compliance
care practices

 Used appropriate  to protect wound and

barrier dressings, or the surrounding
wound coverings area
drainage appliance
 and skin protective
agents for open
wounds

 Encouraged early  to promote

ambulation circulation and
reduces risks
associate with
immobility

DEPENDENT
 Administered
prophylactic
antibiotics as
indicated.
ASSESSMENT DIAGNOSIS PLANNING INTERVENTIONS RATIONALE EVALUATION

SUBJECTIVE: Fear related to Patient will identify -explore client’s perception -it is important to understand - Goal partially met, the
pregnancy and verbalize fear, of threat to physical or the client’s perception of the patient identified, verbalized
“ Noong unang outcome. and demonstrate threat to self-concept. phobic object or situation in but did not demonstrate
pregnancy ko kasi coping behaviors that order to assist with the coping behaviors.
umabot hanggang reduce own fear by desensitization process
term yung baby ko the end of 2 hours as
pero ngayon kasi evidenced by; - reassured client of her - panic level anxiety client
natatakot ako baka safety and security may fear for own life
hindi umabot ng term”, and also for the life of
as verbalized by the her baby
patient.
- include client in making -allowing the client choices
decisions related to provides a measure of control
OBJECTIVE: selection of alternative and serves to increase
coping strategies. feelings of self-worth.
- Restlessness
-verbalization of feelings in a
- Diaphoresis -encouraged client to nonthreatening environment
explore underlying feelings may help client come to
VS:
that may be contributing to terms with unresolved issues.
BP:90/60
irrational fears.
RR:20
-provides the client with
PR:86
-explore things that may sense of ontrol over the fear.
T:36.6
lower fear level and keep it Distracts the client so that
manageable(singing while fear is not totally focused on
dressing, practicing positive and allowed to escalate.
self-talk while in a fearful
situation).