Nursing Care Plan: Acute pain related to effects of labor and delivery process
Assessments Objectives
SUBJECTIVE: At the end of nursing
“Sobrang sakit na po, “ as interventions the:
verbalized.
a. Patient will be able to
make an informed
OBJECTIVE: decision regarding
Facial grimace pain control options
Uncomfortable she would like to use.
Irritability
Restlesness  determine the childbirth
Vital Signs: BP= 130/80
Pain Scale: 9
NURSING DIAGNOSIS:
Acute pain related
to effects of labor
and delivery
process
b. Patient will express
relief obtained from
labor pain by the use
of childbirth
techniques learned
and/or comfort
measures/analgesics/
anesthetics given.
Planning
Assess current knowledge of
obstetric pain control
measures.
Assess if patient attended
childbirth classes; if yes,
techniques taught.
Provide positive
reinforcement and
encouragement to patient
and support persons as they
apply nonpharmacologic
techniques learned in
childbirth classes. Assist with
techniques as necessary.
Assess anxiety level and
implement measures to
reduce anxiety as needed.
Provide teaching between
uterine contractions.
Teach patient pain control
options available, giving the
pros and cons of each.
Initiate teaching/reinforcing
of nonpharmacologic comfort
measures that can be used
during labor if needed (e.g.,
Rationale Implementation/Evaluation
Allows the nurse to develop
an individualized teaching
plan for the patient.
Provides necessary
information so the nurse can
reinforce psychoprophylactic
methods
of coping or initiate teaching
of nonpharmacologic comfort
measures that can be used
during stages of labor.
Positive reinforcement and
encouragement provide the
patient and support person a
sense of control and self-
confidence.
Allows for early intervention
to decrease anxiety levels.
High levels of anxiety can
increase the perception of
pain, decrease ability to
tolerate pain, and decrease
comprehension of verbal
instruction.
The patient is more attentive
and can better internalize
information when not in pain.
Providing information allows
the patient tomake informed
decisions regarding pain
control.
These nonpharmacologic
comfort measures
work by providing diversion
 use of focal point, visual
imagery, breathing and
relaxation techniques). Assist
with implementation of these
measures as needed.
Provide massage and/or
counterpressure and/or assist
patient to find position of
maximum comfort—standing,
sitting, squatting, sidelying,
hands and knees—as needed.
If patient is considering an
epidural, ensure that
c. Patient will have informed consent is obtained
relaxed facial before administration of
expressions and be narcotics.
able to rest between
uterine contractions.
Assess for nonverbal signs of
ineffective coping
with pain and offer pain
medications and/or epidural
anesthesia.
Administer pain medications
as ordered and assist with
epidural placement.
Provide comfort measures
(ice chips, petroleum jelly for
dry lips, dry linens, etc.).
Keep patient informed of
progress made after each
vaginal examination.
Inform patient when uterine
contractions reach peak
intensity (acme).
during uterine
contractions. According to
the gate
control theory of pain, only a
limited
number of sensations can
travel along neural pathways
at any one time, so when
activities fill the pathway,
pain is being inhibited.
Changing positions and using
counterpressure may help
alleviate discomfort caused
by pressure of presenting
parts on bony structures,
ligaments, or tissues.
Massage helps relieve muscle
tension and provide a
diversion to inhibit pain
sensations.
The patient will have to wait
several hours to sign an
epidural consent if narcotics
are given before the request
for an epidural.
Some patients are hesitant to
make requests even when
they would like
pharmacologic interventions.
It is common for women in
many cultures not to request
assistance.
Pharmacologic intervention
may be needed to alleviate
discomfort when
nonpharmacologic methods
of pain control are perceived
to be ineffective.
Enhances patient’s comfort
level.
 Progression of effacement,
dilatation, and station
encourages the patient that
she is making progress and
that the discomfort will not
last forever.

Knowledge that a uterine

contraction has reached peak
intensity often promotes
relaxation, which reduces
muscle tension and pain
sensations.
REFERENCE:http://www.eu.elsevierhealth.com/media/us/samplechapters/9780721604787/Chapter%208%20Nursing%20Care%20During%20Labor%20and
%20Pain%20Management.pdf, retrieved October 15, 2013