VII.

NURSING CARE PLAN

Name of Patient: A.R. Impression/Diagnosis: Pregnancy

Age & Sex: 22 y/o, F Ward/Bed: N/A
 DEFINING NURSING DIAGNOSIS OUTCOME NURSING INTERVENTION RATIONALE EVALUATION
CHARACTERISTICS IDENTIFICATION/OBJECTIVE
LONG TERM: INDEPENDENT:
SUBJECTIVE: Pain and discomfort r/t Goals are met as
uterine contraction Within a week of nursing  Offer the patient appropriate  Massage is one of the most evidenced by reduced
“Naga sakit akon tiyan intervention, the patient will comfort measures like massage helpful non-pharmacological level of abdominal pain
upod sang cramp nga ga RATIONALE: recognize and utilize the methods during labor pain relief technique. The and lesser cramping
extend sa lower back ko”, to control pain and discomfort presence of stimulation like extended to her lower
as verbalized by the Pain and discomfort such as brought by the active phase of massage causes the opposite back.
patient. Abdominal pain with labor. of pain impulses to be stronger
cramping extended to lower and faster via tiny nerve fiber.
back is felt during the 1st SHORT TERM:
stage of labor and delivery  To determine the intensity of
due by low uterine segments After 4 hours of nursing  Assess the intensity of the pain pain and to provide effective
in combination with intervention, the patient will be using scale (0 to 10; 0 for no nursing interventions.
OBJECTIVE: isometric contraction of the able to: pain and 10 for worst pain).
uterus. Pain usually is felt in  Allows for the development of
- Temperature=37.1°C the abdomen or back during  Identify some non-  Assess current knowledge of an individualized teaching plan
- Pulse Rate=88 bpm contractions (labor pains) pharmacological methods obstetric pain control measures for the client.
- Respiratory that reduce discomfort/pain
Rate=20cpm REFERENCE:  Promotes relaxation and may
- Blood (Nanda Diagnoses, 2022)  Verbalize understanding of enhance patient’s coping
Pressure=130/80 the use of obstetric pain  Provide diversional activities. abilities by refocusing
mmHg control measures. attention.
- cervix is dilated at
3cm, • Demonstrate use of relaxation  Coach use of appropriate  May block pain impulses
- 50% effaced skills and diversional within the cerebral cortex
breathing/relaxation techniques
- fetal head at (-3) activities, as indicated. through conditioned responses
and abdominal effleurage
station and cutaneous stimulation and
- membranes are intact gives client a means of coping
- fetal heart tones
with and controlling the level
heard by stethoscope
on the left lower of discomfort.
abdominal quadrant DEPENDENT
at 140 beats per
minute DEPENDENT
 Nubain is a preoperative
- bladder is distended analgesic, supplement for
 Administer Nubain as
- Facial grimace surgical anesthesia, obstetric
prescribed by the physician.
- Agitated facial analgesic during labor.
expression
References: Doenges, M. E.,
Moorhouse, M. F., & Murr, A. C.
(2019). Nurses pocket guide:
diagnoses, prioritized interventions,
and rationales. Philadelphia: F.A.
Davis Company.