1) The patient was experiencing active labor with cervical dilation at 8-9 cm, 100% effacement, and regular contractions.
2) Short term goals included helping the patient identify techniques to control pain and appear relaxed between contractions.
3) Nursing interventions included positioning changes, breathing exercises, comfort measures, and safety precautions.
4) After effective nursing care, the patient was able to use techniques to control discomfort and appeared ready for childbirth, achieving the goal.
1) The patient was experiencing active labor with cervical dilation at 8-9 cm, 100% effacement, and regular contractions.
2) Short term goals included helping the patient identify techniques to control pain and appear relaxed between contractions.
3) Nursing interventions included positioning changes, breathing exercises, comfort measures, and safety precautions.
4) After effective nursing care, the patient was able to use techniques to control discomfort and appeared ready for childbirth, achieving the goal.
1) The patient was experiencing active labor with cervical dilation at 8-9 cm, 100% effacement, and regular contractions.
2) Short term goals included helping the patient identify techniques to control pain and appear relaxed between contractions.
3) Nursing interventions included positioning changes, breathing exercises, comfort measures, and safety precautions.
4) After effective nursing care, the patient was able to use techniques to control discomfort and appeared ready for childbirth, achieving the goal.
Diagnosis Background Subjective: Short Term Goal: Independent: - Patient stated that Acute pain related Fetal maturity - Client will 1. Engage client conversation and 1. Engage in conversation to assess After 20 to 30 to cervical dilation observing her respiratory status every sensorium; monitor breathing pattern and minute of effective she had been having identify/use pulse. as evidenced by Fetus increases 15 minutes for 1 to 2 hours. nursing “a lot of false labor” techniques to control and hoped that this cervix being 8 – 9 weight and size pain or discomfort. 2. Position changes promote comfort to the intervention, 2. Elevate the head, alternate position was the “real thing”. cm dilated, fetus at - Client will report by turning side to side, and use of hip client and elevating the head prevents block patient is able to station+2, cervical Uterine stretch discomfort is roll. from migrating up and causing respiratory use techniques to Objective: effacement at minimized. depression. control - Cervix is at 8 -9 cm 100%, BOW Myometrial 3. Institute safety measures, like pain/discomfort, ruptured and activation - Client would appear encouraging the patient to move 3. Sudden movement may precipitate and appear relaxed dilation greenish in color slowly, keeping the siderails up and hypotension, and safety measures are done and concentrate - 100% effaced relaxed/resting and uterine Uterine supporting legs during position to establish rapport with the patient while - Cephalic between contractions. between changes. also promoting comfort. presentation contractions lasting contractions contractions and is - Station +2 55-to-60-seconds Long Term Goal: 4. Comfort measures minimize stimulation now ready for 4. Assist with comfort measures like - FHT 140 bpm and intervals at less Increase - Client would be free providing back or leg rubs, backrest, and promotes relaxation. childbirth. Goal is - Contractions at 55 – than 1minute. pressure on of untoward site repositioning, perineal care, etc. met. 60 second duration cervix effects of anesthetics 5. Breathing techniques may block pain and intervals are less 5. Review proper breathing techniques impulses which helps in concentration and if administered. Cervical with the client. relaxation. than 1 minute. - BOW ruptured and dilation - Client can perform 6. Encourage comfortable positioning. 6. An upright position, sitting, walking, or greenish in color activities of recovery swaying with partner may be most - Vital signs taken as Cervical or ADLs easily after comfortable in early labor. effacement Collaborative: follows: childbirth. 7. Administer analgesics by IV during PR: 90 bpm contractions, if indicated. 7. IV route is used for it ensures more rapid RR: 22 cpm Desire to push and equal analgesic absorption. BP: 124/80 mmHg 8. Assist with complementary therapies O2 sat: 98% 8. Alternative therapies can be used to as indicated, e.g., acupressure / mediate pain. acupuncture.