Diagnosis: G2P1 (1011) Pregnancy Uterine 40-41 weeks cephalic in labor

Nursing Diagnosis Analysis Goal and Intervention Rationale Evaluatio

Objectives s n
Acute Pain R/T Immediate Goal: After The
tissue trauma cause: an 8 hour client’s
Acute Pain shift of pain was
Subjective: nursing relieved
 Pain Scale: Intermediat intervention and
6 out of 10 e cause: s, the controlle
(10 being tissue client’s pain d.
the highest, trauma is relieved
1 being the and
lowest) Root controlled.
Cause:
Objective: Normal Objectives: 1. Obtain 1. To rule out
 Guarding Spontaneo After client’s worsening of
behavior us Delivery nursing assessment underlying
 Positioning intervention of pain to condition/
to avoid Scientific s,: include development of
pain Implication: 1. the client location, complications.
 Facial Labor in will be able characteristi (NANDA 11th ed.,
grimace NSD is a to report the c, onset, p. 500)
 Expressive physiologic characteristi frequency,
behavior process c of pain. quality,
(irritability) during intensity, 2. Observations
 Slowed which the and may or may not
movement products of precipitating be congruent with
 VS as conception factors. verbal reports or
follows: (ie, the Reassess may be only
T= 36.5 fetus, each time indicator present
PR= 86 membranes pain is when client is
RR= 24 , umbilical reported. unable to
BP=100/70 cord, and 2. Observe verbalize.
placenta) nonverbal (NANDA 11th ed.,
are cues/ pain p. 500
expelled behaviors. 3. These are
outside of usually altered in
the uterus. acute pain
Labor is (NANDA 11th ed.,
achieved p. 501)
with 4.To promote
changes in nonpharmacologi
the cal pain
biochemical 3. Monitor management.
connective 2. the client skin and (NANDA 11th ed.,
tissue and will be able color p.501)
with to perform temperature 5. To promote
gradual pain and vital nonpharmacologi
effacement managemen signs. cal pain
and t. management.
dilatation of 4. (NANDA 11th ed.,
the uterine Demonstrat p.501)
cervix as a e and
result of encourage 6. To distract
rhythmic deep attention and
uterine breathing reduce tension.
contraction exercises. (NANDA 11th ed.,
s of p. 501)
sufficient 5. Provide 7. To distract
frequency, comfort attention and
intensity, measure reduce tension.
and (touch, (NANDA 11th ed.,
duration. repositionin p. 501)
g every 2 8. To prevent
hours), quiet fatigue. (NANDA
environment 11th ed., p. 502)
, and calm
activities.
6.
3. the client Encourage
will be able use of
to rest and relaxation
sleep techniques
continuously such as
. focused
breathing,
CDs/tapes.
7.
Encourage
diversional
activities
(TV, radio)

8.
Encourage
adequate
rest periods.