NURSING CARE PLAN (INTRA-PARTUM)

ASSESSMENT NURSING NEED PLANNING INTERVENTION EVALUATION

DIAGNOSIS
Subjective: “Sakit Acute pain C Within 8 hours of  Assess Patient’s Uterus for

akong puson inig related to labor O nursing intervention: contractility

mugahi” contractions R: Contractions can be

G Patient will verbalize
assessed for severity.
Objective: R: Unpleasant a decrease in the pain
N
 Acknowledge the pain
sensory and scale from 4/10 to
 Vital Signs: I GOAL MET
experience and convey
emotional 1/10.
Temp. = 35.9 C
T acceptance of client’s
experience
PR = 83 bpm response to pain.
arising from I

RR = 18 breaths/min R: Reduces defensive

actual or V
responses, promotes
BP =110/90 potential tissue
E
trust, and enhances
damage or
 Pain scale: -
cooperation with regimen.
prescribed in
4/10
terms of such
P  Encourage patient to have

adequate rest periods.

 (+) Uterine damage E R: Prevent fatigue that can

Contractions (International R impair ability to manage or

 Grimaced Association for cope with pain.

C
Face the Study of  Teach Patient proper
E
 Guarding of Pain); sudden breathing exercises to relax
P
lower mid or slow onset abdomen.

abdomen of any intensity T R: Breathing exercises aid in

(hypogastrium) from U relaxation of the abdomen to

 Pain felt upon reduce pain felt on pt.’s

Reference: A
occurrence of uterus.
Doenges, M., L
uterine  Administer prescribed
Moorhouse,
contractions. medications for pain.
M., & Murr, A.
 Patient in P R: For maintaining
(2016).
labor A “acceptable” level of pain.
Nurse’s
 6 cm cervical Notify physician
Pocket Guide: T
dilatation
Diagnoses, T
Prioritized E if regimen is inadequate to

Interventions, R meet pain control goal.

and Rationales Combinations of medications

N
(14th ed.). may be used on prescribed

Philadelphia: intervals.

F.A. Davis  Advice the mother to refrain

Company. from strenuous tasks.

R: Preventing doing

strenuous task would allow

less work needed by

abdominal muscles to reduce

contractions.

 Inform Patient that labor-pain

of is normal and it is usually

painful.
 R: Patient needs to

understand that labor-pain is

normal during pregnancy.

 Allow patient to find a

comfortable position where in

pain is less than usual.

R: Proper positioning during

labor is recommended in

order to reduce pain felt and

increase comfort during labor

while preparing for delivery.