ARELLANO UNIVERSITY

COLLEGE OF NURSING
2600 LEGARDA ST, SAMP. MANILA

SUBJECT: INP DATE: October 20, 2020

NAME: Nicole Jane Z. Cuenco CI: Ma’am Violy Dunca

ACIVITY I

CASE SCENARIO: CITA, G4P2 ( 2 TERM LIVING, 1 ABORTION ) WAS ADMITTED AT 1 PM

TODAY DUE TO LABOR PAINS. THE CERVIX WAS 3 CM, CEPHALIC, INTACT BOW. FHT=
144/MIN, BP=120/80, PR= 80/MIN, T= 36.5 C. SHE LIVES IN REMOTE VILLAGE, 5 HOURS AWAY
FROM THE HEALTH FACILITY. AT 6 PM, CONTRACTIONS WERE MODERATE, 3 IN 10 MIN. IE
SHOWED CERVIX 4 CM DILATED. FHT= 148/MIN. VITAL SIGNS REMAINED THE SAME. SHE
VOIDED URINE SPONTANEOUSLY. AT 10 PM, YOUR IE SHOWED 6 CM DILATED CERVIX,
WITH SPONTANEOUS RUPTURE OF MEMBRANES WITH CLEAR AMNIOTIC FLUID. FHT=
150BPM, VS SAME. AT 12 AM, ANOTHER IE DONE SHOWED 8CM DILATED CERVIX,
MECONIUM STAINED FLUID. BP=110/70, PR=92/MIN, T= 37.5 C, FHT= 140/MIN.

I. OBJECTIVES:
 To provide the students a standard critical thinking and skills in caring for pregnant
with labor pain using the applicable and effective nursing process.
 Formulate nursing diagnosis related to the physiological and psychological aspects of
labor and birth.
 Implement nursing care for a pregnant woman during labor such as health teaching
 Develop expected outcomes to meet the needs of a pregnant woman throughout labor
process as well as manage seamless transitions across differing health care settings.
II. PLAN OF ACTIVITIES

DATE AND TIME FOCUS PROGRESS NOTES

1PM Labor pain D:
- Patient was admitted
due to labor pain
- Cervix was 3 cm,
cephalic, intact bow.
- FHT= 144/min
- Vital signs: BP=120/80,
PR= 80/MIN, T= 36.5
C

A:

- Assess for referred

pain, as appropriate
- Assess pain, noting
location, intensity
(scale of 0-10) duration
- Determine client’s
acceptable level of pain
and pain control goals.
- Measure the length of
the latent phase
- Suggest use of
relaxation technique
and deep breathing
exercise.
- Encourage patient to
walk and make
preparations for birth
- Provide alternative
methods of pain relief
such as back rub,
helping position of
comfort.
- Encourage the patient
to continue to be active
and to use any non-
pharmacotherapeutic
measures she finds
effective.
D:
- Contractions were
6PM moderate, 3 in 10 min.
ie showed cervix 4 cm
dilated. FHT= 148/min.
vital signs: BP=120/80,
PR= 80/MIN, T= 36.5
C
 - Patient voided urine
spontaneously.
A:
- Monitor skin color and
temperature and vital
signs
- Encourage the patient
be active participants in
labor
- Suggest continuing use
of deep breathing
exercise.
- Encourage diversional
activities and relaxation
techniques

10PM D:
- IE showed 6 cm dilated
cervix, with
spontaneous rupture of
membranes with clear
amniotic fluid.
- FHT= 150bpm
- Vital signs: BP=120/80,
PR= 80/MIN, T= 36.5
C
A:
- Encourage the patient
be active participants in
labor
- Suggest continuing use
of deep breathing
exercise.
- Initiate teaching,
diversional activities
and relaxation
techniques
12AM
D:
- Assess current knowledge
of obstetric pain control
measures
- Assess for referred
pain, as appropriate
- Assess pain, noting
location, intensity
(scale of 0-10) duration
- IE done showed 8cm
dilated cervix,
meconium stained
 fluid.
- VS: BP=110/70,
PR=92/MIN, T= 37.5
C, FHT= 140/MIN.
-

R:
- Patient was able to make
an informed decision
regarding pain control
options she would like to
use
- Verbalized
nonpharmacological
regimen
- Demonstrate use of
relaxation skills and
diversional activities, as
indicated
- Verbalized pain is
relieved/controlled

III. LEARNING INSIGHTS

Nursing care during labor and birth gave me the opportunity to develop critical understanding
of the nursing process. Through the ideas and knowledge acquired in this course, I was able
to appreciate the roles of nurses in every hospital setting through this course I was able to
recognize the importance of nurses. I learned the importance of assessing the patient through
taking vital signs, FHT, interviewing their health history to include pregnancy and delivery
history asking chief complaints, and prioritizing whom to attend first. I had also give health
teachings and support to pregnant women during labor.

IV. RECOMMENDATION

When establishing expected outcomes for a woman in labor and her partner, be certain they
are realistic and that they can be met. Although labor usually takes place over a relatively
short time frame it is important not to project a definite time limit for labor to be completed
because the length of labor to be completed because the length of labor can vary greatly from
woman to woman and still be within normal limits. And as much as possible, interventions
during labor should always be carried out between contractions so the woman can use a
prepared childbirth technique to limit the discomfort of contraction. During labor should be
ongoing to preserve the safety of the woman and her new born. After birth, an evaluation
helps to determine woman’s opinion of her experience with labor and birth. Ideally, the
experience should not only be one she was able to endure but also one that allowed her self-
esteem to grow and the family to bond to intensify through a shared experience . it is
advantageous to talk to a women following birth about their labor experience because doing
so serves as a means of evaluating nursing care labor. It also provides a woman the chance to
“work through” the experience and incorporate into her self- image.