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    Sanaani NURSING CARE PLAN

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    Nur Sanaani
    This document summarizes a nursing care plan for a 30-year-old pregnant woman, Mrs. Ana Duterte, who is 39 weeks pregnant and experiencing back pain. The nurse assessed the patient, diagnosed her with acute pain related to labor and delivery, and planned several interventions including monitoring vital signs, teaching pain management techniques, and assessing cervical dilation. The expected outcomes were that the patient would experience relief from her pain and learn ways to cope with labor.

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    Sanaani NURSING CARE PLAN

    Uploaded by

    Nur Sanaani
    34 views2 pages
    This document summarizes a nursing care plan for a 30-year-old pregnant woman, Mrs. Ana Duterte, who is 39 weeks pregnant and experiencing back pain. The nurse assessed the patient, diagnosed her with acute pain related to labor and delivery, and planned several interventions including monitoring vital signs, teaching pain management techniques, and assessing cervical dilation. The expected outcomes were that the patient would experience relief from her pain and learn ways to cope with labor.

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    sanaani NURSING CARE PLAN

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    This document summarizes a nursing care plan for a 30-year-old pregnant woman, Mrs. Ana Duterte, who is 39 weeks pregnant and experiencing back pain. The nurse assessed the patient, diagnosed her with acute pain related to labor and delivery, and planned several interventions including monitoring vital signs, teaching pain management techniques, and assessing cervical dilation. The expected outcomes were that the patient would experience relief from her pain and learn ways to cope with labor.

    Copyright:

    © All Rights Reserved
    Download as DOCX, PDF, TXT or read online from Scribd
    Download as docx, pdf, or txt
    34 views2 pages

    Sanaani NURSING CARE PLAN

    Uploaded by

    Nur Sanaani
    This document summarizes a nursing care plan for a 30-year-old pregnant woman, Mrs. Ana Duterte, who is 39 weeks pregnant and experiencing back pain. The nurse assessed the patient, diagnosed her with acute pain related to labor and delivery, and planned several interventions including monitoring vital signs, teaching pain management techniques, and assessing cervical dilation. The expected outcomes were that the patient would experience relief from her pain and learn ways to cope with labor.

    Copyright:

    © All Rights Reserved
    Download as DOCX, PDF, TXT or read online from Scribd
    Download as docx, pdf, or txt
    of 2

    SANAANI, NUR-FATIMA, M.

    BSN-2H

    Ateneo De Zamboanga University


    College Of Nursing
    RLE
    Level 2-H

    CLIENT: MRS, ANA DUTERTE

     AGE: 30 Y.O
     OCCUPATION:PUBLIC TEACHER
     GRAVIDA: 3
     PARA: 2
     TRIMESTER: 3RD, 39 WEEK PREGNANT
    DATE INITIATE: 8:00 AM, 7/20/19

    ASSESSMENT DIAGNOSIS OUTCOME INTERVENTION RATIONALE EVALUATIO


    N
     SUBJECTIVE Nursing diagnosis:  At the end  Monitor vital Patients vital
    DATA: Acute pain related to of the signs and Monitoring vital signs had
    o chief effects of labor and session perform signs, To know already
    complaints of delivery patient, will preliminary the measurable normalized
    back pain on learn how assessment pain ,to be able
    and off “hndi to cope  Initiate to collaborate
    ko na po kaya with pain teaching/reinforc any sign of labor Patient initiate
    ma’am, ang control, ement of non- progression that the pain
    sakit na ng option and pharmacologic had subside
    likod ma’am” what she comfort from the
    as being would like measurement that laboring
    verbalized to use can be initiate Allowing nurse
     Patient will during the labor to initiate Patient
    experience progression individual experience
    relief from  Provide teaching plan relief from the
     OBJECTIVE DATA: obtaining techniques in for Patient laboring
    o Uncomfortabl from labor relieving pain,
    SANAANI, NUR-FATIMA, M.
    BSN-2H

    e by the use massage, and Provide


    o Cervix is of counter pressure, necessary Patients
    dilated at 3 cm childbirth assisting in information for experience
    on admission. techniques repositioning to nurse can relief/relaxes
    o Pain scale:8 learning/ minimized pain reinforce, with with an
    o Fetal heart rate comfort uncomfortability medication if expression of
    o ( FHT ) 140/  PT. will  Assessing for the OB, doctor relief ,after
    min have dilation and prescribed, or laboring
    o Patient vital relief/relax Effacement of the non-
    expression cervix of pharmacologic
    signs:
    and will be patient(cervix will comfort
    o BP- 120/80 begin to dilate at
    mmHg, able to measurement
    8cm ) that can help
    o Pulse between
    uterine  IV line started initiate in labor
    -88/min, with D5LR 1
    o RR- 22/min, contraction
    s Liter at 25
    o Temp- 37*C gtts/min

     Post -op
    Medicati
    on:

    o Ceftriaxon
    e I gram
    once a day
    x 3 days
    o Tramadol
    100 mg
    IV every 8
    hour PRN
    for pain

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