Nursing Care Plan

Patient Initials: Chief Complaint: Name of student

nurse: Angelica M. Corpuz
Age & Gender: Admitting Diagnosis: Level/Block: 3BSN-3
Birthdate: Date of confinement: Hospital/Area: Marian Birthing Home Facility
Address: Clinical Instructor: Mrs. Jobelle Lomibao, RN
Date: January 17, 2023
Assessment Data Nursing Diagnosis Nursing Analysis Planning Interventions Rationale Evaluation

Acute pain related to Pain during labor is Within 30 minutes of Independent: After 30 minutes of
Pressure on adjacent caused by nursing interventions, ⮚ Assess degree of ⮚ Attitudes and instructing proper
structures as contractions of the the patient will be discomfort reactions to pain nursing intervention:
evidenced by muscles of the alleviated, if not through verbal are individual
restlessness. uterus and by relieved, from pain. and nonverbal and based on ⮚ The patient will
pressure on the cues. past experiences, report that pain
cervix. Continuously monitor understanding and discomfort
the patient for the entire of physiological is minimized.
This pain can be felt duration of labor after changes, and
as strong cramping doing the interventions. cultural ⮚ The patient
in the abdomen, expectations. will identify
groin, and back, as and use
well as an achy techniques to
feeling. ⮚ Time and ⮚ Monitor the control pain
record the labor progress and discomfort.
Pain, if left frequency, and provide
unalleviated, may intensity, and information for ⮚ Patient will be
become duration of the client. monitored for
uncomfortable for uterine the entire
the mother and may contractile duration of
 hinder the labor pattern per labor.
during the delivery protocol.
process.
⮚ Keeps bladder
⮚ Encourage client free of
to void every 1– distension,
2 hr. which can
increase
discomfort,
result in possible
trauma,
interfere with
fetal descent,
and prolong
labor.
Interdependent:
⮚ Assist with ⮚ Promotes
comfort relaxation and
measures (e.g., hygiene;
back/leg rubs, enhances feeling
sacral of well-being.
pressure, back
rest).
⮚ May block pain
⮚ Assist in use of impulses and
appropriate give comfort to
breathing the patient.
and/or
relaxation
techniques.

Dependent:
⮚ Administer ⮚ May help relieve
analgesic during the pain and
contractions, if discomfort that
indicated. is felt.