CUES/ NURSING SCIENTIFIC BASIS OUTCOME NURSING INTERVENTIONS RATIONALE EVALUATION

EVIDENCES DIAGNOSIS CRITERIA

Acute pain The uterine muscle, INDEPENDENT:
SUBJECTIVE: related to muscle the biggest muscle in
contractions as a woman's body,
-Pt. complains evidenced by contracts and relaxes
about the pain verbalization of on a regular basis
on her lower pain, restlessness throughout labor.
back radiating and diaphoresis. Something causes the
towards the pituitary gland to
lower stomach produce oxytocin, a
hormone that induces
uterine tightness.
When genuine labor
contractions will begin
is impossible to COLLABORATIVE:
anticipate.
Contractions are
OBJECTIVE: commonly
characterized as a
-FHR: irregular, cramping or
144-190 bpm tightening sensation
-Cervix is 6cm that begins in the
dilated back and progresses
in a wave-like motion
to the front. Some
report the contraction
feels like back
pressure. The
abdomen gets firm to
the touch during a
contraction. The job
of labor is done
during the birthing
process through a
series of contractions.
These contractions
force the uterus's
upper section
(fundus) to tighten
and thicken, while the
cervix and lower
region of the uterus
stretch and relax,
allowing the baby to
pass from within the
uterus and into the
birth canal for
delivery.

Source:

Labor Contractions.
Shutter Health (n.d.).
Retrieved March 9,
2023, from
https://www.shutter
Health.org/health/
labo
r-delivery/labor-contra
ctions
SOURCE:
NURSING CARE PLAN