POLYTECHNIC COLLEGE OF DAVAO DEL SUR, INC.

MaCArthur Highway, Brgy. Kiagot, 8002 Digos City Davao del Sur, Philippines
Telefax: (63) (82) 237-4827 E-mail: digospcds@yahoo.com

NURSING CARE PLAN

Name of Patient: Attending Physician:

Age: 29 Status: married Diagnosis: G1P0______
Occupation: housewife ___________ Religion: Roman Catholic _ Chief Complaint:_ Labor pain
Address: _ ________Date of Admission:

Date/ Cues Needs Nursing Scientific Basis Goals/Criteria/ Nursing Rationale Evaluation
Time Diagnosis
Objective Interventions

Acute pain
Normally, After 8 hrs of 1. To monitor the After 8 hours
related to
03//10/2 contractions of nursing labor progress of nursing
Subjective: PAIN/ uterine 1. Monitor time,
3 involuntary interventions, and provide intervention,
DISCO contraction frequency,
Pt. Verbalized muscles, such as information
7-3 MFORT and cervical intensity, and
“sakit akong the heart, ● The client will for the client.
dilation duration of
tiyan ug stomach, and have a relaxed The client has
uterine
bat’ang” with a intestine, do not facial a relaxed facial
contractile
cause pain. This expression and expression and
Pain scale of pattern
concept makes be able to rest is able to rest
6/10 uterine between uterine between
contractions contractions. 2. Provides uterine
unique because 2. Routinely
information to contractions.
Objective: they do cause assess pain
● The patient will aid in
pain. During noting
>G1P0 be able to determining
contractions, location,
demonstrate choice or The patient
>AOG: 41.2 blood vessels intensity (scale
relaxation effectiveness was able to
wks constrict, of 0-10), and
technique and of demonstrate
reducing the duration.
>facial deep breathing interventions. relaxation
blood supply to technique and
grimace exercises. 3. A
uterine and deep breathing
> restlessness cervical cells, 3. Provide a quiet non-distracting exercises.
● The client will
resulting in and environment
>client anoxia to muscle verbalize comfortable provides
periodically fibers. This perceived or environment optimal The heart rate
caresses anoxia can cause actual reduction (appropriate opportunities also decreased
abdomen pain in the same of pain as temperature for relaxation as aeb 84bpm.
when way blockage of evidenced by a and between
the cardiac pain rate of ventilation, contractions. The client
contractions
arteries causes 3/10 or less. clean and well- The verbalizes
occur.
the pain of a maintained environment of perceived
heart attack. As room). the labor room reduction of
labor progress can be pain with a
and contractions controlled by pain scale of
> VS taken 3/10.
become longer 4. Provide a having the
and recorded
and more massage and client listen to
intense, the counterpressur familiar music
ischemia to cells e and assist brought from GOAL MET
Temperature:
increases, the patient to find home, which
36.8
anoxia position of can produce a
PR: 78 increases, and maximum calming effect.
the pain comfort-
RR: 19 intensifies. standing,
BP: 110/70 sitting, 4. Changing
squatting, positions and
FHT: 140 sidelying, using
hands and counterpressur
knees as e may help
needed. alleviate
discomfort
caused by
5. Initiate pressure of
teaching/ presenting
reinforcing of parts on body
nonpharmacol structures,
ligaments, or
 ogic comfort tissues.
measures that Massage helps
can be used relieve muscle
during labor if tension and
needed (e.g. provide a
use of focal diversion to
point, visual inhibit pain
imagery, sensations.
breathing and
relaxation
techniques).
Assist with
implementatio 5. To promote
n of these relaxation and
measures as pain reduction
needed.

6. To avoid
bladder
distention and
promote
comfort
6. Encourage
client to void
every 1–2 hr
7. Early
recognition of
possible
7. Instruct the
adverse effects
patient to
allows for
report any
prompt
feelings of dob
intervention.
or chest pain,
dizziness,
nervousness,
and irregular
 heartbeat.
8. Enhances
patient’s
8. Provide
comfort level
comfort
measures (ice
chips,
petroleum jelly
for dry lips,
dry linens,
etc.).

9. Offer 9. Provides
encouragement emotional
to the patient support, which
by updating reduces fear
her regarding and anxiety
her labor levels, and
progress and help minimize
provide pain
positive
reinforcement.

Dependent:
Dependent:
10.Administer pain
medications as 10. Judicious use
ordered and assist of a
with epidural pharmacologic
placement. agent assists
the client in
coping with
contractions
and may
facilitate labor.
Pharmacologic
management
of pain during
labor and birth
includes
analgesia,
which reduces
or decreases
awareness of
pain