NURSING CARE PLAN

ASSESSMENT EXPLANATION OF OBJECTIVE/GOAL NURSING INTERVENTION SCIENTIFIC RATIONALE EVALUATION

THE PROBLEM
 Diagnostic (Dx): ➢ Assessment of pain experience is the first step in Short Term Goal:
Subjective Data: Pathophysiology of Short Term Goal: · Assess and document pain planning pain management strategies. The most
>chief complaints of the problem in characteristics: intensity, character, reliable source of information about the pain is the The Goals were fully
active labor pains After 30 minutes of onset, duration, and aggravating and patient. met after 30 mins of
diagram.
nursing interventions, ➢ Attention to associated signs may help the nurse in Nursing Intervention
occurring every 15 relieving factors of pain.
the patient will be the patient was able
minutes interval · Assess for signs and symptoms relating evaluating pain. (An increase in vital signs readings,
to decide the
able to make to pain. restlessness and inability to concentrate are some of
preferred pain
Stretching of the
informed decision · Assess the patient’s willingness or the examples)
control to use AMB
Regarding pain ability to explore a range of techniques ➢ Often a combination of therapies (e.g., mild patient was seen
peritoneum
control Options she aimed at controlling pain. analgesics with distraction or heat) may be more massaging and
overlying the
would like to Use effective. Some patients will feel uncomfortable walking.
Objective Data: uterus exploring alternative methods of pain relief.
↓ As manifested by: Therapeutic (Tx):
>BP:120 / 80mmHg However, patients need to be acquainted that there
>PR 80bpm verbalizing the use of · Foresee the need for pain relief.
are other approaches to manage pain.
Stretching of the Massage, trying to
>RR 22bpm ➢ Early intervention may decrease the total amount of Long Term Goal:
relax, walking · Acknowledge reports of pain
>Temp. 36.5 cervix during analgesic required.
immediately.
>FHT 138bpm dilation ➢ An immediate response to reports of pain may The Goals were fully
· Administer analgesics as ordered if met after the end of
>SPO2 92% ↓ decrease anxiety in the patient. Demonstrated
prescribed. my shift, the patient
>Weight 62kgs Long Term Goal: concern for the patient’s welfare and comfort fosters
· Support the client’s use of non- was able to express
>Dark line in the Stretching of the the development of trusting relationship.
pharmacological methods to control the relief obtained
abdomen as noted ligaments After the end of my ➢ For optimum relief of pain.
pain (e.g., distraction, imagery, from labor pain AMB
>6cm dilatation to ↓ shift the patient will ➢ These methods divert the client’s attentions of pain
relaxation, and application of heat and verbalized reports
express relief, to other stimulus and consequently decreases
the cervix and 70% cold) about her being
Labor pain Obtained from labor awareness and experiences of pain. relaxed and normal
effaced · Provide rest periods to promote relief, ➢ One’s experiences of pain may become exaggerated
pain By the use of respiratory functions
sleep, and relaxation. as a result of exhaustion. Pain may result in fatigue,
childbirth technique
which may result in exaggerated pain. A peaceful and
learned and or Educative (Edx): quiet environment may facilitate rest.
comfort measure · Explain the cause of pain and what ➢ To teach the patient in managing her pain and
given aggravates it, if known. discomfort in the absence of the healthcare provider.
As manifested by · Demonstrate the use of appropriate ➢ To avoid monotony of confinement and prevents
having controlled non-pharmacological approaches to patient from focusing on her pain experience.
Nursing Diagnosis:
pain, appearing control pain (e.g., relaxation breathing,
Acute pain related ➢ It will guide the nurse to institute modifications to
relaxed and normal application of heat, distraction
to interventions, whether to modify or reinforce
respiratory functions techniques such as music listening or interventions.
labor process and
delivery process television watching.
AMB patients chief · Instruct patient to evaluate and report
effectiveness of pain management
complain used.