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    jay kusain
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    The nursing care plan summarizes the care provided to a patient experiencing labor pain. The patient reported 10/10 pain during contractions. The nursing diagnosis was labor pain related to uterine contractions and cervical dilation. The goals of care were for the patient to report manageable pain, appear relaxed between contractions, and participate in behaviors to reduce pain like deep breathing. Interventions included discussing the labor process, establishing rapport, monitoring the patient and baby, instructing relaxation techniques, assisting with positioning changes, and providing comfort measures. The evaluation found the patient's pain was manageable and she was able to participate in behaviors to enhance comfort during contractions.

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    Nursing Care Plan in Delivery

    Original Title

    NCP-DR-1

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    The nursing care plan summarizes the care provided to a patient experiencing labor pain. The patient reported 10/10 pain during contractions. The nursing diagnosis was labor pain related to uterine contractions and cervical dilation. The goals of care were for the patient to report manageable pain, appear relaxed between contractions, and participate in behaviors to reduce pain like deep breathing. Interventions included discussing the labor process, establishing rapport, monitoring the patient and baby, instructing relaxation techniques, assisting with positioning changes, and providing comfort measures. The evaluation found the patient's pain was manageable and she was able to participate in behaviors to enhance comfort during contractions.

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    © All Rights Reserved
    Download as DOCX, PDF, TXT or read online from Scribd
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    Download as docx, pdf, or txt
    178 views2 pages

    NCP DR 1

    Uploaded by

    jay kusain
    The nursing care plan summarizes the care provided to a patient experiencing labor pain. The patient reported 10/10 pain during contractions. The nursing diagnosis was labor pain related to uterine contractions and cervical dilation. The goals of care were for the patient to report manageable pain, appear relaxed between contractions, and participate in behaviors to reduce pain like deep breathing. Interventions included discussing the labor process, establishing rapport, monitoring the patient and baby, instructing relaxation techniques, assisting with positioning changes, and providing comfort measures. The evaluation found the patient's pain was manageable and she was able to participate in behaviors to enhance comfort during contractions.

    Copyright:

    © All Rights Reserved
    Download as DOCX, PDF, TXT or read online from Scribd
    Flag for inappropriate content
    Download as docx, pdf, or txt
    of 2

    GENERAL SANTOS DOCTORS’ MEDICAL SCHOOL FOUNDATION INC.

    NCM: 107n RLE EXPOSURE


    Area: Delivery Room Inclusive Dates: September 2019
    Patient: Ms. G.C Attending Physician: Students Name:
    Age and Sex: Female Diagnosis: Year and Section: BSN2
    Chief Complaint: Labor pain Group: Group 4
    NURSING CARE PLAN
    ASSESSMENT DIAGNOSIS AND INFERENCE OBJECTIVES NURSING INTERVENTION RATIONALE EVALUATION
    Subjective Cues: Ng Dx: Goal: Short Term 1. Discuss anticipated changes 1. Helps prepare client because
    Patient Verbalized: Labor Pain related to /differences of the labor progress and induction procedures and use of The goal is met. Client
    - “Sakit Kaayo akong balakang” uterine contractions and After 1 hr of nursing contractions. oxytocin can result in rapid onset of report pain
    - “ Sakit kaayo akong likod ug cervical dilatation. intervention strong, frequent contractions, manageable. Client
    akong puwerta” which often interfere negatively appear relaxed
    - ”10/10 ang kasakit pag start • Client will report with the client’s ability to use between contraction
    na sad mag gahi akong tiyan” Inference/ Background pain is manageable. learned coping techniques, which a and participated in
    Knowledge: slower buildup in the contractile behaviors to diminish
    • Client will appear pattern would allow. pain sensations and
    Labor is a series of events by relaxed between enhance comfort such
    which uterine contractions contractions. 2. Establish a rapport that enables 2. Answers to questions can as deep breathing and
    and abdominal pressure expel client/ partner to feel comfortable alleviate fear and promote back rubbing technique.
    a fetus and placenta from • Client will during the interview. understanding.
    uterus.(Pillitteri 2018) participate in
    Pain during labor is caused by behaviors to 3. Initiate nurses role during delivery 3. Nurses are often responsible to
    Objective Cues: contractions of the muscles diminish pain such as monitoring contractions during put together a personalized birthing
    of the uterus and by pressure sensations and labor and delivery; Monitoring the vital plan for each mother to ensure that
    -restlessness on the cervix. This pain can enhance comfort. signs of the mother and the heart rate each delivery is safe for the mother
    - moaning be felt as strong cramping in of the baby. and the baby.
    -crying the abdomen, groin, and
    -Facial Grimace back, as well as an achy 4. Instruct client to use relaxation or 4. Encourages relaxation and gives
    -Increased muscle tone when feeling. Some women simple breathing techniques. client a means of coping with, and
    bearing down experience pain in their sides controlling the level of, discomfort.
    -Verbalization of pain. or thighs as well. Also, Relaxation can aid in reducing
    -8 cm dilatation (kidshealth.org) tension and fear, which magnify
    - uterine contraction pain and hamper labor progress.

    13
    5. Assist client with change of position. 5. Prevents/limits muscle fatigue;
    enhances circulation.

    6. Provide comfort measures such as 6. Promotes relaxation, reduces


    back rub. tension and anxiety and enhances
    client’s coping and sense of control.
    7. Instruct patient on how to properly
    bearing down
    7. Properly bearing down help to
    speed the labour up and it will
    prevent the baby from being
    distress.

    13

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