N C P : 1

S T
S TA G E O F L A B O R
CUES AND EVIDENCES NURSING DIAGNOSIS INTERVENTIONS RATIONALE EVALUATION
Subjective:
-Verbalized pain during contractions
-Rated pain as 10 in a scale of 0 as no pain
and 10 as most painful
-Verbalized that the pain started from the
lower back and radiated at the lower
abdomen
-Verbalized day palihog ko ug hapuhap,
kusog-kusoga gamay
-Verbalized unya ra nako na anseran day,
hulat lang sa kadot whene!er asked about
some information
-Verbalized agay e!ery time pain is
present
Objective:
-Vital signs
"# $%&' (
)R# *+ bpm regular, and bounding
RR# ,0 cpm, regular and effortless
-)# 110./0 mm0g
-1acial grimacing e!ery contractions
noticed
-2iaphoresis on the forehead
-(annot take one position for a longer
period of time
-2oes not answer 3uestions e!erytime the
pain is there
-45)6 7uly ,+, ,010
-82(6 5ay 1, ,010
-9:;6 $/ +.* weeks
-+ cm dilated
-%0 < effaced
-=tation ,
9ltered comfort6 9cute )ain
related to uterine contractions
>ndependent6
1&5onitor V.=
,& 8ncourage client to report type,
location, and intensity of pain, rating
on a scale of 0-10& ?ote associated
symptoms&
$&>dentify.promote position of comfort,
using aduncts as necessary
+&)ro!ide comfort
measures,encourage di!ersional
acti!ities as indicated
'& "each and encourage the use of
deep breathing e@ercises&
%&2o -ack rub
*& :ffer support by patting a womanAs
arm, brushing a wisp of hair off her
forehead, wiping her forehead with
cool cloth, etc&
/& 8@plain and answer 3uestions about
labor and deli!ery process&
1& 0eart rate usually increases with pain&
,& )ain is percei!ed, manifested and tolerated
indi!idually& =e!ere pain should be in!estigated
further for possible complications&
$& 4eft side lying position is recommended because
it frees the !ena ca!a thus not impeding the
circulation&
+&5ay promote rela@ation.redirect attention and
reduce analgesic dosage needs.fre3uency
'& -reathing techni3ues increase the womanAs pain
threshold, encourage rela@ation, pro!ide distraction,
enhance the ability to cope with uterine contractions,
and allow the uterus to function more efficiently&
%& "his alle!iates the pain by redirecting the focus of
the patient&
*& 4abor is a stressful e!ent in womanAs life& :ffering
support may help the woman feel safe and able to
continue in control&
/& (larifies doubtful mind of the patient and helps
the patient understand the pain she is feeling&
9t the end of our care,
the goal was partially
met as e!idenced by6
1& Vital signs were not
taken at the end of the
first stage of labor
,& Rated pain as 10 in a
range of 0 as no pain
and 10 as se!ere pain&
$& =eemed
uncomfortable in her
position
+& ;rimacing noticed
during contractions
'& Verbalized slight relief
of pain when back rub
was done
%& Verbalized normal ra
ud na siya dagway
basta manganak
*& Verbalized kaning
sakit kay normal ra ni&
:-78(">V8=6
Bithin our care, the patient will
ha!e decreased perception of
pain as e!idenced by6
1& V.= will remain or be
within normal range
C"#$%&'-$*&' (D )R#%0-
100 -)5D RR#1,-,0
()5D -p# 1,0-1+0.%0-E0
mm0gF
,& 9 pain rating of / or below
in a scale of 0-10, 0 as no
pain and 10 as the highest
perception of pain
possible
$& 2emonstration of a
rela@ed body posture
+& 5inimal facial grimacing
and e@cessi!e sweating
'& Verbalization of relief of
pain
%& !erbalization of her
understanding of the labor
and deli!ery process
*& !erbalization that the pain
she is feeling is ust
normal
CUES AND EVIDENCES NURSING DIAGNOSIS INTERVENTIONS RATIONALE EVALUATION
=ubecti!e6
-Verbalized that it is her first time to
deli!er a baby
-(laimed that she is an@ious about the
process of labor and deli!ery because
it is her first time
-Bhen instructed about proper
pushing, she said that she hoped she
9n@iety related to unknown outcome
of labor and deli!ery process
>ndependent6
1& 8stablish rapport with patient&
,&5onitor !ital signs
$& 9ssess the clientAs le!el of an@iety&
1& "o gain trust from patient&
,& =odium and water resorption may
contribute to de!elopment of intrapartal
to@emia.hypertension& 4oss of potassium
may contribute to reduction of myometrial
acti!ity&
$& "o determine what effects the client may
be e@periencing based on the le!el of
9t the end of our care, the goal
was partially met as e!idenced
by6
1& Vital signs were not
taken at the end of the
first stage of labor
:-78(">V8=6
Bithin our care, clientAs le!el of
an@iety will be reduced as e!idenced
by6
can do it since itAs her first time
:becti!e6
-2iaphoresis on the forehead
-Vital signs
"# $%&' (
)R# *+ bpm regular, and bounding
RR# ,0 cpm, regular and effortless
-)# 110./0 mm0g
-Restless
->nability to answer 3uestions when
pain is present
-1ace shows a that she is a bit worried
-?o support system inside the 2R
-45)6 7uly ,+, ,010
-82(6 5ay 1, ,010
-9:;6 $/ +.* weeks
-+ cm dilated
-%0 < effaced
-=tation ,
1& Vital signs are within normal range
"#$%&'-$*&' (,
)R#%0-100 bpm,
RR#1,-,0 cpm,
-)# 110-1+0.%0-E0 mm0g
,& 9cknowledgement of feelings and
identify healthy ways to deal with
them&
$& 9ppearing rela@ed&
+& Reporting reduced an@iety to a
manageable le!el
'& Verbalization of her understanding
of the labor and deli!ery process
%& 2emonstration of deep breathing
techni3ues
+& Validate what is the source of
an@iety&
'& 8ncourage client to share thoughts
and feelings
%& :ffer support by patting a womanAs
arm, brushing a wisp of hair off her
forehead, wiping her forehead with
cool cloth, etc&
*& )ro!ide accurate, consistent
information& 9!oid arguing with clientAs
perception of the situation&
/& 2emonstrate breathing and
rela@ation methods& )ro!ide comfort
measures
E&2etermine di!ersional needsD
encourage !ariety of acti!ities Ce&g&,
tele!ision, books, music, massageF
an@iety and to know appropriate actions for
the clientAs situation&
+& >dentification of specific source helps
client deal realistically with it&
'& )ro!ide opportunity to e@amine realistic
fears and misconceptions& =tress, fear, and
an@iety ha!e a profound effect on the labor
process, often prolonging the first phase
because of utilization of glucose reser!es&
%& 4abor is a stressful e!ent in womanAs life&
:ffering support may help the woman feel
safe and able to continue in control&
*& (an reduce an@iety and enable client to
make decisions and choices based on
reality&
/& Reduces stressors that might contribute
to an@ietyD pro!ide coping strategies&
E& 0elps di!ert attention away from labor,
making time pass more 3uickly&
,& Gsed deep breathing
e@ercises to redirect
focus and re3uested for
a back rub
$& 9ppeared restless
+& Verbalized that she had
still fear about the
process
'& !erbalized normal ra
ud na siya dagway
basta manganak
%& used deep breathing
techni3ues