ASSESSMENT

SUBJECTIVE: Medyo sumasakit na ang tiyan ko as verbalized by the patient. OBJECTIVE: > P abdominal contraction Q pricking sensation R lower back radiating to the abdomen S 6/10 T 9am onwards; contraction frequency for every 2 mins. Lasting for 60 secs. or more > facial grimace > irritable

DIAGNOSIS
Acute Pain related to abdominal contractions as possibly evidenced by 6/10 of pain scale and facial grimace.

PLANNING
SHORT TERM GOAL: After 6 hours of nursing intervention the patients pain scale will decrease from 6/10 to 4/10. LONG TERM GOAL: After discharge the patient will be able to report improvement about her condition.

INTERVENTION
INDEPENDENT: > monitor Vital Sign > monitor the frequency and duration of her contraction > provide peaceful and warm-ventilated environment > health teachings about her condition > instruct deep breathing exercises > promote rest > labor watch and assisting in labor delivery > instruct in and encourage use of relaxation techniques, such as Deep breathing exercises DEPENDENT: > give medications as prescribed by the doctor or physician

RATIONALE
> to have comparison and baseline data > to determine if she needs more nursing care > to promote comfort

EVALUATION
After 6 hours of nursing intervention the goal met as evidenced by verbal reports about her pain that decrease from 6/10 to 4/10.

> to gain knowledge about her condition > to promote relaxation and relive of pain > to gain strength and comfort > to have baseline and comparison and to determine the needs of patient > to destruct attention and reduce tension

> it must be instructed and followed

ASSESSMENT
SUBJECTIVE: wag niyo akong iiwan dito ma ah? as verbalized by the patient. OBJECTIVE: >Palpitations >Sweating >Trembling >Restlessness >Muscle tension >stress >tension >poor eye contact >teary eye

DIAGNOSIS
Anxiety related to actual abdominal pain as manifested by teary eye and poor eye contact.

PLANNING
SHORT TERM GOAL: After 6 hours nursing intervention the patient will be able to verbalize that she feels more in control of his current situation. LONG TERM GOAL: After discharge the patient will be able to appear relax and report anxiety level decrease.

INTERVENTION
INDEPENDENT: > monitor Vital Sign > provide privacy by drawing curtains > provide peaceful and warm-ventilated environment > health teachings about her condition >encourage the patient to acknowledge and to express feelings >modify procedure and safety measures >stay with the client

RATIONALE
> to have comparison and baseline data > to respect patients condition > to promote comfort

EVALUATION
After 6 hours nursing intervention the goal met as evidenced by verbalizing the patient decrease of anxiety by having a feeling of comfort.

> to gain knowledge about her condition > to assist and to deal with problems >to provide decrease in tension > to promote comfort

ASSESSMENT
SUBJECTIVE: hirap na kong tumayo at magkikilos as verbalized by the patient. OBJECTIVE: > irritable > slowed movement > limited range of motion > postural instability > weakness > muscle strength is decrease

DIAGNOSIS
Impaired Physical Mobility related to decrease muscle strength as manifested by slowed movement, limited range of motion and weakness.

PLANNING
SHORT TERM GOAL: After 2 hours of nursing intervention the patient will participate in ADLs and desired activities. LONG TERM GOAL: After discharge the patient will be able to demonstrate techniques or behaviors that enable resumption of activities.

INTERVENTION
INDEPENDENT: > monitor Vital Sign > provide peaceful and warm-ventilated environment > health teachings about her condition > assist the patient to do some range of motion as an exercise > encourage patient to take some rest COLLABORATIVE: > consult with physical or occupational therapist, if indicated

RATIONALE
> to have comparison and baseline data > to promote comfort

EVALUATION
After 2 hours of nursing intervention the goal was partially met as possibly evidenced by letting the patient to participate in some activities.

> to gain knowledge about her condition > to promote muscular strength > to gain strength and comfort

> to develop individual exercise and mobility program, and identify appropriate mobility devices