Western Mindanao State University

College of Nursing
Zamboanga City

Alternative Learning System

Related Learning Experience
Nursing Care Plan

PLANNING
NURSING
ASSESSMENT OBJECTIVE IMPLEMENTATION EVALUATION
DIAGNOSIS INTERVENTION RATIONALE
OF CARE
LABOR
Subjective Cues: STAGE: - The client - Assess the - Support the client in her ability - By verbal, pain - The client has
ACTIVE will client’s pain to manage pain until her scale, and identified
PHASE identify/us level. epidural can be given. nonverbal techniques in
e indicators. Use a 1 controlling
ACUTE PAIN techniques to 10 scale and discomfort as
RELATED TO to control evaluate response observed and
STIMULATION pain/disco - Engage - Altered sensorium may also be to techniques used. verbalized.
OF BOTH mfort. client in an early indicator of developing - Discomfort as
PARASYMPAT - The client conversatio hypoxia. Interference with - Assess sensorium has minimized as
HETIC AND will report ns respiratory functioning occurs if and monitor observed and
Objective Cues: SYMPATHETI discomfort analgesia is too high, paralyzing breathing patterns verbalized.
C NERVE is the diaphragm. Her respiratory and pulse. - The client has
ENDINGS, AND minimized status is observed every 15 appeared relaxed
TISSUE . minutes for 1 to 2 hours. between
DILATION AS - The client - Elevate contractions as
EVIDENCED will head - Position changes promote - Approximately 30 verbalized by the
BY appear comfort and help the fetus adapt degrees, alternate patient.
RESTLESSNES relaxed/re to the size and shape of the position by turning
S, MUSCLE sting client’s pelvis. Elevating the side to side, and
TENSION, AND between head prevents the block from use of hip roll.
VERBALIZATI contractio migrating up and causing
- Assess BP
ONS. ns respiratory depression.
and pulse
- every 1–2 min
- Maternal hypotension, the most
after regional
common side effect of regional
injection for the
block anesthesia, may interfere
first 15 min, then
with fetal oxygenation.
every 10–15 min
 - Administer for the remainder
emergency of labor
medications - Narcan is used to reverse
as indicated. - Naloxone (Narcan)
opiate-induced respiratory
or ephedrine
depression, usually in the
(Ephedra).
infant, caused by opioid drugs
Succinylcholine
such as meperidine. It can be
chloride and assist
given by the IV route or
with intubation, as
through the endotracheal tube
appropriate.
during resuscitation. Adrenaline
may be required for
hypotensive episodes not
responsive to IV fluid bolus.
Systemic toxic reaction to
epidural anesthetic may alter
sensorium or cause convulsions
if medication is absorbed into
the vascular system.
Reference/s:
- Martin, P. (2017, May 3). 45 Labor Stages, Induced and Augmented, Dystocia, Precipitous Labor Nursing Care Plans. Nurseslabs. https://nurseslabs.com/labor-stages-labor-induced-
nursing-care-plan/2/