General Santos Doctors’ Medical School Foundation, Inc.

Bulaong Subd., Brgy. West, General Santos City, Philippines Telephone Nos. (083) 552-9793 |
gsdmsfihumanresource@gmail.com

NAME:Kieth Bryle Lorilla

SECTION: BSN 2A
CLINICAL INSTRUCTOR: Nessy Lou Prado Espanola, RN

NURSING CARE PLAN

 Assessment Diagnosis and Planning Intervention Rationale Evaluation
Inference
Subjective:
c Labor pain related After 8 hours of  Identify stage and  Choice and After 8 hours of
2
to Muscle nursing phase of labor; timing of nursing intervention
Patient verbalized: Contractions as intervention the perform vaginal medications are the patient was:
“taas man kog evidenced by pain patient will: examination noting affected by
pain tolerance scale of 8-9/10 nature and amount degree of
pero ang sakit kay  Participate in of vaginal show, dilatation and  Patient
naa jyud sa 8 to 9” decision- cervical dilatation, contractile participated in
Inference: making for effacement, fetal pattern. decision making
Objective: pain station, and fetal for pain
BP: 120/60 Labor pain is a management descent. management.
RR: 17 bpm natural and normal plan to include
PR: 85 cpm part of the personal  Evaluate degree of  Attitudes and
T: 36.7 c childbirth process. preferences discomfort through reactions to
OsStat: 98 It typically occurs and cultural verbal and pain are
FHR: 131cpm as the uterus beliefs. nonverbal cues; individual and
contracts to help  Engage in note cultural based on past  Patient engaged
push the baby nonpharmacol influences on pain experiences, in
through the birth ogic measures response. understanding nonpharmacologi
canal. This pain is to reduce of physiological c measures to
often described as discomfort changes, and reduce discomfort
intense and pain. familial/cultural such as breathing
rhythmic, starting  Pain will be expectations. and masages.
as mild discomfort managed and  Pain is managed
and increasing in patient will  Provide/encourage  Promotes and patient
intensity as labor understand use of comfort relaxation and understood that
progresses. that the pain is measures such as hygiene, which the pain is part of
Women part of giving back/leg rubs, sacral enhance feeling giving birth.
experience labor birth. pressure, back rest, of well-being
pain differently,  Report pain at mouth care, and may reduce  Patient reported
with some manageable repositioning, hot the need for that pain is at a
describing it as level. compresses to analgesia or manageable
manageable with perineum and anesthesia. level.
breathing abdomen. Position
techniques and changes can
relaxation also enhance
methods, while circulation and
others may opt for reduce muscle
pain relief options tension.
such as epidurals
or other  Time and record the  Information
medications. frequency, intensity, necessary for
Understanding and and duration of choosing
managing labor uterine contractile appropriate
pain is an essential pattern per protocol. interventions
aspect of childbirth and preventing
preparation, and or limiting