NCP: Labor

Assessment Diagnosis Planning Intervention Rationale Evaluation

Subjective: Short term Independent

“ Haan ko Severe pain After 30 After the 8
related to
•Assess vital •Baseline data
kayan” (diko minutes of hours of
signs every 15 for early
na kaya) as strong uterine nursing nursing
minutes. detection of life
verbalized by contractions , diagnosis, the intervention,
threatening
the patient. as evidenced patient will be the patient
complications
by able to use shows signs of
and for
Pain Scale: 9 verbalizations, appropriate being at ease
maternal blood
out of 10 (10 facial breathing and comfort as
loss.
being the grimacing, techniques to evidenced by
highest, 1 guarding enhance calm behavior
being the behavior comfort and •This prevents and utilizing
lowest) maintain •Encourage bladder breathing
control of the the client to distension, techniques.
Objective: labor process. void every 1- which Patient
2hr increases verbalized pain
Long term: discomfort, decreases
•Facial mask increases the from a scale of
of pain
After 8 hours risk of trauma, 9/10 to 2/10 as
•Restlessness of nursing interferes with evidence by:
fetal descent,
•Verbalization intervention,
the patient will and prolongs (-) facial mask
of pain
be able to labor. of pain
(moaning
verbalize relief (-) Tense
during and
between
from pain and •Breathing (guarded body)
discomfort. exercises
contractions)
divert and
•Tense focus attention
(guarded body
•Monitor and help
posture)
cervical reduce cortical
dilation and pain
Vital signs as note perineal perception.
follows: bulging or
vaginal show •To avoid
BP: 130/90
pregnancy
PR: 24
RR: 90 complications
TEMP: 36.4
•Instruct the
patient on
breathing
techniques

Dependent:
 •Keep an eye
out for possible
bleeding and
impediment
delivery as per
doctor’s order.

NCP: Leak of Bag Water

Assessment Diagnosis Planning Intervention Rationale Evaluation

Subjective: Risk for Short term: Independent:

"Ma’am bleeding
pumutok na po related to labor After 1 hour of ● Evalua Goal met after
yung complication nursing te ● Choice 1 hour of
panubigan ng as evidenced diagnosis, the degree and nursing
asawa ko” as by minimal patient will of timing intervention,
verbalized by vaginal demonstrate a discom of the patient
the patient’s bleeding decrease in fort medic demonstrated
SO. anxiety. throug ation decreased
h medic anxiety as
verbal ations evidence by
Long term: and are reporting fewer
Objective: nonver affecte intrusive and
After 8 hours bal d by distressing
● Positio of nursing cues degree thoughts.
ning to diagnosis, the of
ease patient will be dilation
pain able to report and After 8 hours
● Moani pain at a contra of nursing
ng/ manageable ctile intervention,
wincin level. pattern the patient
g reports pain at
● Sweati ● Deter manageable
ng mine ● Presen level and
● Facial the ce of verbalization of
mask availab suppor relief of pain
of pain ility of/ tive with V/S in
● Restle and partner normal range.
ssness prepar ,
ation family/f
Vital signs as of riend
follows: suppor can
t provid
BP: 130/90 person e
PR: 89 emotio
RR: 23 nal
TEMP: 36.4 suppor
t and
 enhan
ce
level of
comfor
Dependent: t

● Prepar
e the
patient
for a ● Once
transfe the
r in water
deliver bag
y room breaks
once ,
the deliver
water y soon
bag follows
has
leaked

NCP: Bleeding after delivery

Assessment Diagnosis Planning Intervention Rationale Evaluation

Subjective: Risk for Short term: ● Monito ● Baseli Goal met, after
“mayroon pang bleeding as After 2hrs of r vital ne 1 hour of
pakonti-konting evidenced by nursing signs data nursing
dugong minimal diagnosis, the for intervention,
lumalabas” as early the patient
vaginal patient will be
verbalized by detecti demonstrated
bleeding. free of signs of
the patient on of a decrease in
active bleeding
life anxiety as
threate evidenced by
Long term:
Objective: ning reporting fewer
Pallor After 8hrs of compli intrusive and
Restlessness nursing cations distressing
Irritability intervention, and for thoughts.
Minimal the patient will matern
bleeding be able to al Goal met, after
Vital signs: execute the blood 8 hours of
promotion of loss. nursing
wellness as intervention,
evidenced by l the patient
providing developed
report pain at
information to
manageable
the client or ● Monito ● Choice level and
family about r and verbalization of
the problem perine timing relief of anxiety
that of with V/S in
um
predispose to medic normal range.
and
bleeding ations
fundal
complications are
height
affecte
in a
d by
postpa degree
rtum of
client dilation
with and
trauma contra
ctile
pattern

● Encour
age
● To
bed reduce
rest postpa
until rtum
bleedi compli
ng cation
decrea vaginal
ses. bleedi
ng

● Apply
pressu ● To
sooth
re and
vaginal
cold and
pack perine
to the al pain
after
lower
deliver
abdom y and
en. it
reduce
s pain
and
can
also
help
reduce
swellin
g
Dependent:

● Admini
ster
anti ● To
hemorr restore
(?) lost
hage
blood
medic and
ation fluids
as per
doctor’
s
order.

Collaborative:

● Dietary
measu
res to
improv
e ● In
blood order
clotting to
preven
, such t
as excess
foods ive
rich in bleedi
ng,
Vit. K. vitamin
K is
crucial
since it
aids
the
liver in
produc
ing the
protein
s that
permit
your
blood
to clot
normal
ly.
NCP: Insomia (Postpartum)

Assessment Diagnosis Planning Intervention Rationale Evaluation

Subjective: Impaired Short term: IndependentO Goal met, after

“ Hindi na ako sleeping After 2 hrs of bserve and To determine 2 hrs of
nakakatulog pattern related nursing obtain usual sleep nursing
gaya nung to insomnia as intervention, feedback form pattern and intervention,
evidenced by provide
dati” as the patient patient’s S/O the patient
nonrestorative
verbalize by report regarding the comparative report
sleep
the patient. improvement patient’s sleep baseline improvement
of sleeping- problems, of sleeping-
Objective: rest pattern usual bedtime, rest pattern as
Increased number of evidenced by
Absenteeism Long term: hours of sleep. attainment of
After 8hrs of progress
Frequent nursing towards
yawning during intervention, improvement
day time the patient will of sleeping-
report increase Dependent: rest pattern
altered sense of well- Administer
attention being and Ramelteon Goal met, after
feeling rested (Rozerem) as 8hrs of nursing
Dark circles prescribed by intervention,
around the Doctor’s order Ramelteon is a the patient will
eyes and monitor Melatonin report increase
effects of receptor sense of well-
prescribed agonists that being and
medications to use to treat feeling rested
promote sleep insomnia as evidenced
by the
response to
Collaborative: interventions.
Refer to sleep
specialist as
indicated or
desired

Follow-up
evaluation or
intervention
 may be
needed when
insomnia is
seriously
impacting the
client’s quality
of life, and
productivity

NCP: Readiness for Enhanced Family Process

Assessment Diagnosis Planning Intervention Rationale Evaluation

OBJECTIVE: Readiness for Short term: Independent:

communication enhanced After 2 hrs of Goal met, after
pattern Family nursing ● Deter 2 hrs of
family Process interventions, mine ● A nursing
adaptation to possibly the patient will family better interventions,
changes evidenced by verbalize positio way to the patient will
expresses expressing understanding n: determ verbalize
desire willingness to of desire for parent( ine a understanding
enhance family enhanced s),child family of desire for
dynamics. family rend,m may enhanced
dynamics ale/fe be to family
male, determ dynamics as
Long term: and ine the evidenced by
After 8hrs of extend attribut attainment of
nursing ed es of or progress
intervention, family affecti towards
the patient will on , desired
demostrate strong outcomes
individual emotio
involvement in nal Goal met, after
problem- ties, a 8hrs of nursing
solving to sense intervention,
improve family of the patient will
communication belong demostrate
s ing, individual
and involvement in
durabil problem-
ity of solving to
 memb improve family
ership communication
s as evidenced
by
● Promo modifications
● Establi tes a to lifestyle
sh warm,
nurse- caring
family atmos
relatio phere
nship in
which
family
memb
ers
can
share
though
ts,
ideas,
and
feeling
s
openly
and
non-
judgm
entally

● Identif ● Allow
y individ
effectiv ual
e family
parenti memb
ng ers to
skills realize
alread that
y some
being of
use what
and has
additio been
nal done
ways alread
of y has
handli been
ng helpful
difficult and
behavi encour
 ors ages
them
to
learn
new
skills
to
manag
e
family
interac
tion in
a more
effectiv
e
manne
r

Dependent:

● Refer ● Family
to effectiv
classe eness,
s or selp-
suppor help,
t psycho
groups logy,
, as and
approp religio
riate us
affiliati
ons
can
provid
e role
model
s and
new
inform
ation
to
enhan
ce
family
interac
tions.
Cultural: ● These
beliefs
● Deter may
mine chang
cultura e with
l and stress
or ors or
religio circum
us stance
factors s like
influen financi
cing al, lost
family or gain
interac of
tion family
memb
ers,
and
person
al
group