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  • NCM 107 Skills Lab NCP

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    Moises Clerick Balloguing
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    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.

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    Nursing Care Plan on NSD

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    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.

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    23 views1 page

    NCM 107 Skills Lab NCP

    Uploaded by

    Moises Clerick Balloguing
    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.

    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 1

    Nursing Scientific

    Assessment Planning Nursing Intervention Rationale Evaluation


    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.

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