Subjective Acute pain related to increased After 1 hour of nursing Met M- Remind patient to

abdominal contractions as intervention, the patient have enough sleep

Mrs. J complaining of After 8 hours of nursing
evidenced by facial grimace, will identify breathing Nursing Care Plan
severe painful intervention, the patient E-Keep the surroundings
severe painful contractions, techniques to control pain will have a relaxed clean and well ventilated
Name: Mrs. J
contractions Age: 25
ultrasound result= breech of contractions as Independent Attitudes and reactions to
expression as pain due to
Chief Complaint: Severe painful contractions
presentation and a pain scale of evidenced by pain scale of 7 Assess degree of pain
Admitting/Working or
Diagnosis: In labor with pain arepresentation
Breech based on past T- instruct the patient to
contractions will not be
discomfort through verbal and experiences, understanding avoid strenuous activity to
9 out of 10. out of 10 present and facial
Objective nonverbal cues; note cultural of physiological changes, and avoid opening the sutures
grimace will not be seen
Cues Nursing Diagnosis Outcome Criteria Nursing
practices Intervention
on pain response Rationale
cultural expectations. Evaluation Discharge or
in episiotomy Planning
surgical
 
Facial grimace       incision  
May block pain impulses
Ultrasound result= Assist in use of appropriate within the cerebral cortex H- Educate patient to
Breech presentation After 8 hours of nursing breathing and/or through conditioned maintain proper hygiene
intervention, the patient relaxation techniques and in responses and cutaneous
Pain scale of 9 out of ten O- Follow up or have
will report pain as tolerable abdominal effleurage. stimulation. Facilitates
check up if there are any
with pain scale of 5 out of progression of normal labor
    problem in your health
10 after delivery of the baby
and your baby
and absence of facial
Monitor the labor progress
Time and record the frequency, D- Eat iron-rich foods
and provide information to
intensity, and duration of uterine the client. S- Educate patient’s
contractile pattern per protocol. partner to support and
Monitor maternal vital signs and
take care of the patient
FHB then note   To have comparison   of baseline
and the baby
decreased variability or data and Decreased FHR
bradycardia. variability is a common side S-Seek for spiritual help
effect of many anesthetics and lift up all the
and/or analgesics. These side problems to the Supreme
effects can begin 2–10 min after High and trust Him
administration of anesthetic,may
   
last for 5–10 min, on occasion.

Dependent

Give medications as ordered

Use of analgesics to relieve

 
pain and minimal use of
medication may enhance
relaxation, shorten labor,
limit fatigue and prevent
complications.
 

Assist during Internal Examination
to assess nature and amount of
vaginal show, cervical dilation,
effacement, fetal station, and
fetal descent.
Collaborative
Prepare for NSVD or CS birth
and collaborate with other
health team like
anesthesiologist, surgeon,
midwife.
References:
J. (n.d.). NCP: Labor Stage 1 Active Phase. Scribd. Retrieved July 28, 2020, from https://www.scribd.com/doc/20556582/NCP-Labor-Stage-1-Active-Phase
Martin, P. B. (2019, May 31). 36 Labor Stages, Induced and Augmented Labor Nursing Care Plans. Nurseslabs. https://nurseslabs.com/labor-stages-labor-induced-nursing-care-plan/2/
Cervical dilation should be
approximately 1.2 cm/hr in the
nullipara and 1.5 cm/hr in
the multipara; vaginal show
increases with a fetal descent.
Assessing the mother’s
condition would give indication
for delivery.
Other health team are
specifically designed in each
department to help maintain
the well being of the patient.
This health teams have their
specialization in each area.