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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.
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
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).