DATE/TI CUES N NURSING GOAL OF INTERVENTIONS IMPLEMENTATION

ME E DIAGNOSIS CARE
E
D
J SUBJECTIV Impaired comfort in Within our Frequent vaginal exams. 6
A E C relation to an care, the R: The cervix may open
N “Kadali lang, O increase in uterine client will be and thin without any
U naga M contraction. able to contractions leading to
A contract F manage preterm labor.
R siya.” O RATIONALE anxiety in
Y The client R During natural relation to Electronic fetal heart
verbalizes T labor, uterine pain with monitoring.
2 pain on the contractions positive R: This ensures normal
9 abdominal increase in intensity coping delivery of a healthy 7
area along and forces the fetus mechanisms baby.
2 with the into the birth canal. as evidenced
0 increasing The stretching of by: Regional anesthesia.
2 intensity it is the cervix to aid in R: Mechanism of action is
0 producing. the later expulsion a. to reduce pain.
of the fetus causes Verbalization
9:15 AM OBJECTIVE the release of of control of Bed rest in recumbent 9
Vital Signs oxytocin from the the situation. position.
within normal posterior pituitary R: It makes it easier to
range: gland therefore b. Express palpate the mother’s
T = 36.5 c increasing the confidence in abdomen in order to
BP = 100/70 strength of uterine herself and monitor contractions or
mmHg contractions in a the situation. perform vaginal 3
PR = 84 bpm positive feedback examinations.
CR = 87 cycle. Since the c. Acquires
RR = 21 cpm primary function of knowledge Monitor uterine
uterine contractions about the contractions interval,
is to expel the fetus
Rated 8 on a from the uterine preparation intensity, duration,
pain scale of cavity. It also plays for childbirth. frequency.
1 to 10, as an important role in R: Contractions
10 being the minimizing determine how safe the
most painful postpartum pregnant woman safely
and 1 being bleeding. delivers the fetus.
the least 4
painful. REFERENCE Handwashing before and
Carroll, R.G. (n.d.) after coming in contact
Evident facial Elsevier’s with the patient.
grimacing. Integrated R: To prevent any
Physiology. infection that may be
Intense Retrieved from transmitted to the client.
breathing. https://www.science
direct.com/topics/n Monitor vital signs.
Hyperextensi euroscience/uterine R: It allows early
on of the -contraction detection of any
neck in abnormalities that would 1
response to McEvoy, A. (2018). lead to complications to
pain. Physiology, the mother or the fetus.
Pregnancy
Guarding the Contractions. Assist in breathing
abdomen. Retrieved from exercises.
https://www.ncbi.nl R: To promote mind-body
m.nih.gov/books/N relaxation techniques for
BK532927/ pain to properly go
through the process of
labor. 2

Allow client to express

feelings of anxiety.
R: Promotes a healthy
state of mind for the client
and relieves anxiety.