DAVAO DOCTORS COLLEGE

General Malvar St., Davao City

Nursing Program

NURSING CARE PLAN

Name of Patient: Patient M. Date of Admission:August 8, 2022 at 1:55 am Room: OB ward

Age: 29 Sex: Female Civil Status: Married Chief Complaint: Consistent labor pain
Religion: N/A Attending Physician: Dr. Lorca

GOALS & NURSING

DATE/ CUES NURSING DIAGNOSIS RATIONALE EVALUATION
OBJECTIVES INTERVENTIONS
TIME

August Subjective: Nsg Dx: After 8 hours of 1. Assess the 1. Pain can affect a GOAL
8, 2022 “awakened by a tense nursing patient’s pain patient’s physical and PARTIALLY MET
1:55 AM and rigid feeling of Acute pain related to increasing intervention, the level by verbal, mental capacities to
uterine contraction.” uterine contractions as patients will be pain scale, and engage in labor and to After 8 hours of
evidenced by complained able to: nonverbal learn and execute self- nursing
“complaint of pain in abdominal pain indicators. Use a care and newborn interventions, the
the abdomen and 1. Identify and 1 to 10 scale and following delivery. goal was partially
increased fetal RATIONALE/ use techniques evaluate met.
movement” SCIENTIFIC BASIS: to deal with pain response to
Oxytocin dramatically increases or discomfort. techniques used. 1. The patient
Objective: the strength and frequency of 2. Appear identified and
● Vital signs: uterine contractions and can be relaxed or resting 2. Time and record 2. Monitor the labor used techniques
BP: 120/90 mmHg used to initiate labor if labor between the frequency, progress and provide to deal with pain or
● 7 cm cervical does not begin spontaneously. contractions. intensity, and information for the discomfort.
dilation, 80-90% During natural labor, uterine 3. Report duration of client. Give the patient 2. The patient did not
Effaced, Intact contractions increase in discomfort is uterine frequent progress fully appear
Bag of water intensity and force the fetus into contractile reports during labor, so relaxed or rested
 (BoW), the birth canal. minimized. pattern per she will not become between
● Station: +1 Pain from uterine contractions protocol. discouraged or fearful contractions.
cephalic in and dilation of the cervix during this way at a seeming 3. The patient did not
presentation, the first stage of labor is lack of progress. entirely report
FHT of 156 bpm transmitted by afferent fibers to minimization of
the sympathetic chain of the 3. Assess and 3. The degree of discomfort.
posterior spinal cord at T10 to record the nature dilation and contractile
T12 , and T11 . In early labor, and amount of pattern affects the
pain is transmitted primarily to cervical dilation, choice and timing of
T11 to T12 . vaginal show, medication.
Furthermore, pain during the effacement, fetal
first stage may be referred to, station, and fetal
that is, the nerve impulses from descent.
the uterus and cervix stimulate
spinal cord neurons, 4. Offer the patient 4. Massage is one of
innervating both the uterus and appropriate the most helpful non-
the abdominal wall. As a result comfort pharmacological pain
the woman experiences pain measures during relief techniques.
over the abdominal wall labor for a
between the umbilicus and conducive
symphysis pubis, around the environment.
iliac crests to the gluteal area,
radiating down the thighs, and 5. Instruct and 5. Breathing and
in the lumbar and sacral support proper relaxation strategies
regions. breathing, may help normal labor
relaxation, and progress while
abdominal blocking pain
REFERENCES:
lighting impulses. Abdominal
 techniques. lifting is a labor pain
Carpenito, L. J. (2017). Nursing
relief technique that
diagnosis: Application to clinical
involves stroking the
practice (5th ed.). Wolters
top of the stomach
Kluwer.
without pressing
inside.

6. Change the 6. Position changes

patient’s position promote comfort and
by turning from help the fetus adapt to
side to side. the size and shape of
the client’s pelvis.

REFERENCES: Martin, P. (2022). 41 labor stages, induced and augmented, Dystocia Labor Nursing Care Plans. Nurseslabs. Retrieved from:
https://nurseslabs.com/labor-stages-labor-induced-nursing-care-plan/2/

Rose Marie M. Mier

Name of student