The nursing care plan summarizes the care for a 22-year-old pregnant female patient experiencing pain and discomfort from uterine contractions. Over the short term, the plan is for the patient to learn methods to reduce discomfort through activities like massage and relaxation techniques. The nursing interventions include assessing the patient's pain level, providing diversional activities, and coaching the patient on appropriate breathing and relaxation skills. The long term goal is for the patient to recognize and utilize pain control methods during the active phase of labor within a week.
The nursing care plan summarizes the care for a 22-year-old pregnant female patient experiencing pain and discomfort from uterine contractions. Over the short term, the plan is for the patient to learn methods to reduce discomfort through activities like massage and relaxation techniques. The nursing interventions include assessing the patient's pain level, providing diversional activities, and coaching the patient on appropriate breathing and relaxation skills. The long term goal is for the patient to recognize and utilize pain control methods during the active phase of labor within a week.
The nursing care plan summarizes the care for a 22-year-old pregnant female patient experiencing pain and discomfort from uterine contractions. Over the short term, the plan is for the patient to learn methods to reduce discomfort through activities like massage and relaxation techniques. The nursing interventions include assessing the patient's pain level, providing diversional activities, and coaching the patient on appropriate breathing and relaxation skills. The long term goal is for the patient to recognize and utilize pain control methods during the active phase of labor within a week.
Name of Patient: A.R. Impression/Diagnosis: Pregnancy
Age & Sex: 22 y/o, F Ward/Bed: N/A DEFINING NURSING DIAGNOSIS OUTCOME NURSING INTERVENTION RATIONALE EVALUATION CHARACTERISTICS IDENTIFICATION/OBJECTIVE LONG TERM: INDEPENDENT: SUBJECTIVE: Pain and discomfort r/t Goals are met as uterine contraction Within a week of nursing Offer the patient appropriate Massage is one of the most evidenced by reduced “Naga sakit akon tiyan intervention, the patient will comfort measures like massage helpful non-pharmacological level of abdominal pain upod sang cramp nga ga RATIONALE: recognize and utilize the methods during labor pain relief technique. The and lesser cramping extend sa lower back ko”, to control pain and discomfort presence of stimulation like extended to her lower as verbalized by the Pain and discomfort such as brought by the active phase of massage causes the opposite back. patient. Abdominal pain with labor. of pain impulses to be stronger cramping extended to lower and faster via tiny nerve fiber. back is felt during the 1st SHORT TERM: stage of labor and delivery To determine the intensity of due by low uterine segments After 4 hours of nursing Assess the intensity of the pain pain and to provide effective in combination with intervention, the patient will be using scale (0 to 10; 0 for no nursing interventions. OBJECTIVE: isometric contraction of the able to: pain and 10 for worst pain). uterus. Pain usually is felt in Allows for the development of - Temperature=37.1°C the abdomen or back during Identify some non- Assess current knowledge of an individualized teaching plan - Pulse Rate=88 bpm contractions (labor pains) pharmacological methods obstetric pain control measures for the client. - Respiratory that reduce discomfort/pain Rate=20cpm REFERENCE: Promotes relaxation and may - Blood (Nanda Diagnoses, 2022) Verbalize understanding of enhance patient’s coping Pressure=130/80 the use of obstetric pain Provide diversional activities. abilities by refocusing mmHg control measures. attention. - cervix is dilated at 3cm, • Demonstrate use of relaxation Coach use of appropriate May block pain impulses - 50% effaced skills and diversional within the cerebral cortex breathing/relaxation techniques - fetal head at (-3) activities, as indicated. through conditioned responses and abdominal effleurage station and cutaneous stimulation and - membranes are intact gives client a means of coping - fetal heart tones with and controlling the level heard by stethoscope on the left lower of discomfort. abdominal quadrant DEPENDENT at 140 beats per minute DEPENDENT Nubain is a preoperative - bladder is distended analgesic, supplement for Administer Nubain as - Facial grimace surgical anesthesia, obstetric prescribed by the physician. - Agitated facial analgesic during labor. expression References: Doenges, M. E., Moorhouse, M. F., & Murr, A. C. (2019). Nurses pocket guide: diagnoses, prioritized interventions, and rationales. Philadelphia: F.A. Davis Company.
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