DELA CENA, Patricia Beatrice S.

BSN 303 Subgroup 1D

NDx: Labor pain RT uterine contraction and cervical dilation AEB facial expression of pain, distraction behavior, and alteration in respiratory rate

Nursing Goals and

Cues Analysis Intervention Rationale Evaluation
Diagnosis Objectives

Subjective Labor pain RT Labor pain occurs Goal

 Client uterine due to the After 5 hours of
verbalized contraction and contraction of the nursing intervention,
“Nagsisimu cervical uterus. During the client must be able
la na pong dilation AEB these to report that pain is at
humilab facial contractions, manageable level.
‘tong tiyan expression of blood vessels
ko, nurse. pain, constrict, thereby Objective
Masakit pa distraction reducing the After 1 hour of nursing
naman po behavior, and blood supply to intervention, the client
pag alteration in the uterine and must be able to:
humihilab respiratory rate cervical cells, Independent Independent Effectiveness
na.” resulting in  Identify at least 3 1. Monitor vital 1. Serves as baseline Was the client able to
anoxia to the nonpharmacologi signs of both foundation of identify at least 3
Objective muscle fibers. cal methods that the client and knowledge for any nonpharmacological
 Client Anoxia can cause reduce the fetus. possible changes on methods that reduce
winces the same pain in discomfort/pain. the condition of the discomfort/pain?
slightly the same way client. _Met
when blockage of the _Partially Met
cardiac arteries  Verbalize 2. Assess current 2. Allows for the _Unmet
uterine
causes the pain of understanding of knowledge of development of an
contraction
occurs. a heart attack. As the use of obstetric pain individualized Was the client able to
 Client labor progresses, obstetric pain control teaching plan for the verbalize understanding of
periodically contractions control measures. client. the use of obstetric pain
caresses become longer measures. control measures?
abdomen and more intense, 3. Provide/encour 3. Promotes relaxation _Met
when the ischemia to  Verbalize sense age use of and hygiene which _Partially Met
contractions cells increases, of control of comfort will enhance feeling _Unmet
occur. anoxia increases, response to acute measures (e.g., of wellbeing and
 Recorded and the pain situation and back/leg rubs, may reduce the need Was the client able to
respiratory intensifies. positive outlook sacral pressure, or analgesia or verbalize sense of control of
rate is 22 for the future. anesthesia. Position response to acute situation
back rest,
rpm. Pain also changes can also and positive outlook for the
repositioning,
probably results  Demonstrate use enhance circulation future?
from the and/or and reduce muscle _Met
of relaxation shower/hot tub
stretching of the tension. _Partially Met
cervix and skills and use). _Unmet
perineum. This diversional 4. May block pain
phenomenon is activities, 4. Coach use of impulses within the Was the client able to
the same as the as indicated. appropriate cerebral cortex demonstrate use of
intestinal pain breathing/relax through conditioned relaxation skills and
that results when ation responses and diversional activities,
accumulating gas cutaneous as indicated?
techniques and
stretches the stimulation and _Met
abdominal
intestines. Other gives client a means _Partially Met
probable causes effleurage. of coping with and _Unmet
of discomfort controlling the level
may come from of discomfort. Efficiency
the pressure of the Were the nursing
fetal presenting interventions efficient in
part on tissue, 5. Reduces bladder improving the client’s
including the 5. Recommend distention. condition?
building pressure that client void _Met
on the every 1-2 _Partially Met
surrounding hours. _Unmet
organs such as the 6. Non-distracting
bladder, urethra, environment Appropriateness
6. Provide a quiet
and the lower provides optimal Were all the nursing
environment
colon. interventions appropriate to
that is opportunity for rest
the client’s condition?
adequately and relaxation
References: _Met
Silbert-Flagg, J., ventilated, between _Partially Met
& Pilliterri, A. dimly lit, and contractions. _Unmet
(2018). Maternal free of
and Child Health unnecessary Adequacy
Nursing: Care of personnel. Were the number of nursing
the Childbearing 7. Provides emotional interventions enough to
and Childrearing 7. Offer support, which can answer the problem of the
Family (8th ed.). encouragement, reduce fear, lower client?
Wolters Kluwer. provide anxiety levels, and _Met
. help minimize pain. _Partially Met
information
_Unmet
about labor
progress, and Acceptability
provide Were the nursing
positive interventions acceptable to
reinforcement the client?
for client’s _Met
efforts. 8. Gives client more _Partially Met
8. Review options to choose _Unmet
 nonpharmacolo from in the
gical ways to management of her
lessen pain, pain.
including
techniques such
as Therapeutic
Touch (TT),
self-hypnosis,
and relaxation
skills.
9. Promotes relaxation
9. Provide and may enhance
diversional patient’s coping
activities. abilities by
refocusing attention.

Dependent
Dependent 1. Client is scheduled
1. Keep client for repeat cesarean
NPO as section.
prescribed by
the physician.

2. Nubain is a pre-
2. Administer operative analgesic,
Nubain as supplement for
prescribed by surgical anesthesia,
the physician. obstetric analgesic
during labor.

Collaborative
1. Judicious use of a
Collaborative
pharmacologic agent
1. Assist
assists the client in
anesthesiologist
coping with
if epidural or
contractions and
caudal
may facilitate labor.
anesthetic is to
be used.

References:
Doenges, M. E., Moorhouse,
M. F., & Murr, A. C. (2019).
Nurses pocket guide:
diagnoses, prioritized
interventions, and rationales.
Philadelphia: F.A. Davis
Company.