NURSING CARE PLAN

Assessments Nursing Diagnosis Planning Intervention Rationale Evaluation

SUBJECTIVE: LABOR PAINS After 1 hour of Nursing Evaluate degree of discomfort Attitudes and reactions to Goal met
When asked in a pain scale RELATED TO Intervention the patient through verbal and non-verbal pain are individual and
of 10, the Patient ALTERED will be able to: cues. Note the cultural based on past experiences, After 1hour of Nursing
answered “8” CHARACTERISTICS influences on pain response understanding of Intervention the patient
OF CHEMICALLY -Participate in decision physiological changes and was able to:
OBJECTIVE: STIMULATED making for pain familial/cultural
Anxious CONTRACTIONS management plan to expectation. -Make decision for pain
Vital Signs: AND DELIVERY include personal management plan and
Temperature-37.4c PROCESS preferences and cultural decide on which pain
BP-130/80mmHg belief. control option she prefer.
PR-92bpm Determine availability and Presences of supportive
RR-16cpm preparation of support partner, family/friend can -Participate and perform
-Make an informed person(s). provide emotional support the nonpharmacologic
decision regarding pain and enhance level of measures and expressed
control options she would comfort. that the pain relief was
like to use. obtained or controlled

-Engage patient in
nonpharmacologic Provide/encourage used of
measures to reduce comfort measures and hygiene
discomfort/pain (e.g. shower or hot tub use.)
Provide massage and/or
-Express that pain relief counter pressure (e.g. Back and
obtain or controlled. leg rubs). Repositioning patient
to find position of maximum
comfort (e.g. standing, sitting,
squatting, side lying, hands and
knees—as needed.)
Promote relaxation and
hygiene, which enhance
feeling of well-being.
Massage helps relieve
muscle tension and provide
a diversion to inhibit pain
sensations. Changing
positions and using counter
pressure may help alleviate
discomfort caused by
pressure of presenting
parts on bony structures,
ligaments, or tissues.
Position changes can also
enhance circulation, reduce
muscle tension.

Coach use appropriate May block pain impulses

breathing and relaxation within cerebral cortex
technique and abdominal through condition
effleurage based on stage of responses and cutaneous
labor. stimulation and gives client
a means of coping with
controlling the level of
discomfort.

Provide for a quite Non distracting

environment that is adequately environment provides
ventilated, dimly lit, and free optimal opportunity for
unnecessary personnel. rest and relaxation.

Provide safety measure. (E.g. Pain can make patient

Encourage client to move anxious and restless.
slowly, bed in low position, Position changes can risk
race side rales). for fall and other injury.