Nursing Care Plan: Acute pain related to effects of labor and delivery process

Assessments Objectives Planning Rationale Implementation/Evaluation

SUBJECTIVE: At the end of nursing
“Sobrang sakit na po, “ as interventions the:
verbalized.
a. Patient will be able to Assess current knowledge of Allows the nurse to develop an
make an informed decision obstetric pain control measures. individualized teaching plan for the
OBJECTIVE: regarding pain control patient.
Facial grimace options she would like to
Uncomfortable use. Assess if patient attended childbirth Provides necessary information so
Irritability classes; if yes, determine the the nurse can reinforce
childbirth techniques taught. psychoprophylactic methods
Restlesness  of coping or initiate teaching of
Vital Signs: BP= 130/80 nonpharmacologic comfort measures
Pain Scale: 9 that can be used during stages of
labor.

Provide positive reinforcement and Positive reinforcement and

encouragement to patient and
support persons as they apply
nonpharmacologic techniques
NURSING DIAGNOSIS: learned in childbirth classes. Assist
Acute pain related to with techniques as necessary.
effects of labor and Assess anxiety level and implement
delivery process measures to reduce anxiety as
needed.
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.

Provide teaching between uterine The patient is more attentive and can
contractions. better internalize information when
not in pain.

Teach patient pain control options Providing information allows the

available, giving the pros and cons of patient tomake informed decisions
each. regarding pain control.

b. Patient will express relief Initiate teaching/reinforcing of These nonpharmacologic comfort

obtained from labor pain
by the use of childbirth
techniques learned and/or
comfort
measures/analgesics/anesth
etics given.
nonpharmacologic comfort measures
that can be used during labor if
needed (e.g., use of focal point,
visual imagery, breathing and
relaxation techniques). Assist with
implementation of these measures as
needed.
measures
work by providing diversion 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

c. Patient will have relaxed
facial expressions and be
able to rest between uterine
contractions.
REFERENCE:http://www.eu.elsevierhealth.com/media/us/samplechapters/9780721604787/Chapter%208%20Nursing%20Care%20During%20Labor%20and
%20Pain%20Management.pdf, retrieved October 15, 2013
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 informed consent is
obtained before administration of
narcotics.
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).
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.