CARE MAP

Date: 11/20/19 Student: Yasmin Santibanez Pt. Initials: BH Age:23 Wt:220

Med. Diagnosis &/or Admission Diagnosis: Hospital Course Data: (SBAR) Lab: CBC, blood type/ crossmatch,
coagulation studies
Augmentation of labor via amniotomy Pt 23 years of age G3P1 arrives at hospital with
increased contractile pain @3:00 am on Diagnostic:
Etiology & Pathophysiology
11/7/19. Pt is admitted into L&D 39 wks
Amniotomy (artificial rupture of the amniotic sac) is often done in gestation, dilation at 5 cm, 90% effaced and -2 Medication:
conjunction with induction or stimulation of labor to permit internal station.
electronic fetal monitoring. Morphine IV

Patient Problems/Needs Patient Problems/Needs Patient Problems/Needs

Priority #1 Priority #2 Priority #3

Acute Pain Infection Fatigue

AEB AEB AEB

All Supporting Assessment Data All Supporting Assessment Data All Supporting Assessment Data

Facial expression of pain Artificial rupture of membranes for 3 hours. Increased energy requirements
Contractions frequency 2-4, duration of 40-110
Presence of pain 8/10
Manual palpation of contractions: moderate
Pt screaming and crying
Intensified contractile pattern
Pt expresses pain 8/10 Onset of labor from 3:00 – 13:00
Pt appears to be restless in bed 2 Pt. centered Outcomes (Short & Long term)

2 Pt. centered Outcomes (Short & Long term)

2 Pt. centered Outcomes (Short & Long term)
Short term: Pt will be able to cope with labor pain until
delivery of baby
Longterm: Pt will use appropriate techniques to maintain
control of pain during shift as coached by RN and relatives.
Short: Pt will display to be afebrile, VS WNL,
amniotic fluid with normal odor, FHR reassuring.
Longterm: Pt will be free from signs of infection
during this shift.
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Short: Pt will effectively participate in
pushing and delivery
Longterm: Pt will be able to rest between
feedings after delivery of baby. Involve
Pt’s spouse in care.
 Evidence Based Interventions Evidence Based Interventions Evidence Based Interventions

1. Repositioning of the mother
2. Encourage relaxation/ breathing techniques
3. Provide comfort measures like applying
counter pressure, providing touch and
massage, hydrotherapy
4. Inform of available pain management
options
5.Administer pain medications
1. Monitor temperature, pulse and WBC, amniotic fluid color and 1. Asses fatigue level
odor
2.Encourage rest/relaxation techniques between contractions.
2. Minimize repeated vaginal exams, unless indicated
Provide environment conducive to rest
3.Demonstrate good hand washing
4.. Encourage perineal care after AROM and as indicated: change 3. Monitor fetal descent, presentation and position frequent
under pad/ linen when wet position changes
5. Provide aseptic conditions for delivery
4. Keep Pt/couple informed of the progress labor
6. Provide PO hydration
5.Assist with requested pain management

Rationale for Interventions Rationale for Interventions

Rationale for Interventions
1.Allows for fetus to reposition and lessen mothers pain
sensation, helps with coping as it promotes relief
2. Helps decreasing anxiety and tension
3. Promotes comfort and enhances sense of well
being
4. Pain management achieved by blocking pain
impulse receptors
1. Increased temperature or pulse >100 bpm indicated
infection. WBC >25,000 cause by infection.
2.To avoid infection exams should be limited after
membranes ruptured to decrease entrance of foreign
organisms
3.Reduces risk of acquiring/spreading infective agents
4.Helps promote cleanliness prevents the development of
ascending infection
1.Pt that has not rested at onset of labor can experience greater
feelings of exhaustion
2.Conserves energy needed for pushing efforts and delivery
3.Malpostion & malpresentation may prolong labor and increase
fatigue.
4. Helps provide needed psychological energy to continue labor

5. Helps prevent postpartum infections and endometritis

Evaluation &/or Modification of Outcomes Evaluation &/or Modification of Outcomes Evaluation &/or Modification of Outcomes

Short term: Pt will be successful in coping with pain in
preparation and delivery of baby
Long-term: Pt will use other techniques to maintain
control pain levels during labor
Short term: Pt will be free of signs of
infections during this shift.
Long term: Pt will remain healthy during the
postpartum period.
Short term: Pt will be successful in delivery of baby
Long term: Spouse of patient will continue to be
involved in pt support system and care.

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References: Martin, Paul. “36 Labor Stages, Induced and Augmented Labor Nursing Care Plans.” Nurseslabs, 31 May 2019,
nurseslabs.com/labor-stages-labor-induced-nursing-care-plan/#a4.

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