SAINT PAUL UNIVERSITY DUMAGUETE

COLLEGE OF NURSING

IN PARTIAL FULFILLMENT OF THE REQUIREMENT IN

NCM 107 (RELATED LEARNING EXPERIENCE)

SUBMITTED TO:

________________________________________

SUBMITTED BY:

_________________________________________

DATE:

____________________

Proposed By: Mrs. Sharry Mae G. Awayan, RN, MAN

 SAINT PAUL UNIVERSITY DUMAGUETE
COLLEGE OF NURSING

NURSING CARE PLAN FORM

Patient’s Name (Initials):______________________________ Admitting Diagnosis/Medical Diagnosis/CC:_____________________________

Age:_________________ Sex:_____________ Physician (Initials): _______________________________
Room No:____________ Diet:____________________________________________

SUBJECTIVE OBJECTIVE NURSING DIAGNOSIS SCIENTIFIC ANALYSIS PLANNING INTERVENTIONS RATIONALE EXPECTED OUTCOME
Acute pain Acute pain Acute Pain (PARA SA ACUTE Acute Pain Acute Pain
Acute pain related PAIN) Acute Pain
to uterine To understand the After 5 hours of 1. Monitor vital Maternal
The patient Uterine contractions from concept of why nursing hypotension, the Patient will express
signs( bp, pr, rr)
verbalized, “Lami contractions: labor as evidenced pain is experienced interventions the most common side relief and easing of
every 15-30 pain which is
na kaau iutong.” by pain scale of 9, during uterine patient will be effect of regional
minutes tolerable.
● Lasts for 65- facial grimacing, contractions, the controlled and be block anesthesia,
80 sec and clenching of concept of labor able to incorporate 2. Monitor may interfere with
● Interval: 2 hands into fists. and delivery needs relaxation fetal oxygenation.
frequency,
The patient mins and 40 to be considered. techniques and Patient will be able
duration, and Monitors the labor
complains of strong sec According to March diversional to feel comfort
of Dimes (2018), activities into pain intensity of uterine progress and from prescribed
pain contraction
Pain scale of 9 labor is the process control program. contractions. screens for an analgesics given.
and increased pain
by which the fetus The patient will abnormal uterine
intensity. Facial grimacing Definition: and the placenta also 3. Monitor cervical
verbalize response.
leave the uterus. understanding of dilation and inform
Hands clenched Acute pain is The pregnant the entire labor patient when Patient will have no
Cervical dilation
into fists defined as an mother as well as process. uterine signs of bladder
should be about 1.2 distension.
unpleasant sensory the health care contractions reach
Cervical dilation: 10 and emotional providers usually cm/hr for nullipara
peak intensity and 1.5 cm/hr for
cm as of 12:15 pm experience which know when the (RISK FOR
(acme) multipara; vaginal
results from an woman is in true INFECTION)
actual or potential labor when she 4. Monitor FHT show increases
tissue damage or experiences strong After 5 hours of with a fetal
every 15-30 min by
described in terms and regular nursing descent.
of such damage. It contractions. The intervention which Doppler.

Proposed By: Mrs. Sharry Mae G. Awayan, RN, MAN

 Risk for Infection is characterized by different stages of includes the 5. Encourage client
Risk for Infection a sudden or slow labor constitute to ultrasound scan to void. Fetal tachycardia or
onset with an different intensity measures and bradycardia is a
The patient intensity that may of contraction. As speculum vaginal 6. Assist client to sign of possible
verbalized, “Gamay either go from mild the labor examination of the use consciously damage that may
raman ang ako na V/S taken as to severe. It has a progresses, the cervix and the controlled require
feel nga tubig niagi. follows: predictable end intensity also vagina. Inducing
breathing at level intervention.
and usually lasts increases. It is the baby early will
IV (pant-blow).
less than 6 months during the also be performed
Can improve labor
· T: 37.2C (Doenges, transition phase of to avoid risk fetal 7. Provide physical
Moorhouse, & the first stage of infections. progress and the
“Mogahi ako tiyan · PR: 80 presence and
Murr, 2019). In labor that risk of trauma to
panangsa. Kung b/min positive
relation to labor contractions reach the bladder
mogahi man mga · RR: 20 reinforcement for
and delivery, their peak reduces.
40 seconds then cycles/min uterine intensity. During the client/couple
mawala then · BP: 110/80 contractions during the transition efforts. Redirects and
mobalik na pod mmhg, the transition phase, the
phase of the 1st contractions 8. Determine the focuses attention;
pagka 30 minutes
stage of labor usually last for level of discomfort reduces pain
na pod” as
contractions are about 60 to 90 through verbal perception within
verbalized by
FHB: 130 beats per usually very strong, seconds and occurs the cerebral cortex.
patient. and nonverbal cues
minute at left lower that lasts for about every 2 to 3
and examine the
quadrant. 60 to 90 seconds minutes. The
impact of pain on Gives emotional
and occurring every cervical dilation
one’s personal and support that can
2-3 minutes. reaches to 8 to 10
According to cm where 10 cm is cultural life. reduce fear,
Fundal height was Stanford Children's considered as full decrease the level
Hospital (2021), it is dilation of the 9. Assess clients’ of anxiety, and
taken at 28 cm.
at this phase that cervix. It is also at need for physical minimize pain.
pregnant mothers this phase that the touch during
5cm dilation, 80% usually feel the woman would contractions. Attitudes toward
effaced, station +2. need to push. The experience
pain and reactions
pain experienced immense pain and 10. Administered
by the woman discomfort. The analgesics as to pain are
during this phase is pain does not go ordered and assist individual and
largely caused by away even if the
Proposed By: Mrs. Sharry Mae G. Awayan, RN, MAN
 contractions of the woman changes with epidural
muscles of the position which is placement. based on past
uterus and by another sign of true experiences,
pressure on the labor (Silbert-Flagg cultural
cervix. The pain is & Pillitteri, 2018). background, and
characterized by a self-concept.
strong cramping The pain associated
sensation in the with labor is
abdomen, groin, significantly due to Touch may serve as
and back (Ben- uterine a distraction, it can
Joseph, 2018). contractions. Sutter provide comfort,
Health (2021) encouragement,
defines labor and may help
contractions as
maintain pain
periodic tightening
and relaxing of the control/relief.
uterine muscle
which is triggered Prudent use of a • The patient
Reference: by the release of pharmacological will be able to
oxytocin. Each agent helps the participate in
woman patient to cope ultrasound
experiences varied with contractions scanning for the
levels pain and and can facilitate position of the
discomfort related fetus to be
Risk For Infection labor.
to labor identified and the
contractions. cervical dilation of
Discomfort or a dull 1. Monitor vital the patient will be
ache in a woman’s signs, and white measured.
1. The occurrence
back and lower blood cell (WBC) • Patient will
of chorioamnionitis be able to feel
abdomen, as well count, as indicated.
as pressure in the (intra-amniotic comfort using pads
pelvis may be 2. Examine vagina infection) increases after perineal care.
experienced. Other and assess within 4 hours after • The patient
women would feel secretions by rupture of will be able to
the pain in their membranes, as participate in the
collecting fluid
sides and thighs. administration of
Proposed By: Mrs. Sharry Mae G. Awayan, RN, MAN
 Contractions are using speculum. antibiotic to
often described to evidenced by prevent fetal
be as strong as 3. Examine the fluid elevations of WBC infections due to
menstrual cramps to test for PROM count and rupture of
for some women ( Premature abnormal vital membrane.
(Cleveland Clinic, Rupture of • Patient will
signs.
2018). be able to feel
Membrane) using
2. uterine
pH test, Nitrazine
contractions after
test, and Fern test. hours of
3. During the administration of
4. Monitor and intrapartal period
Reference: oxytocin through IV
describe the the risk of for early induction
character of chorioamnionitis of labor.
amniotic fluid. increases 1hr or
5. Once PROM is more before the
confirmed, labor due to
additional test to impulsive rupture
assess the presence of membranes. EVALUATION
Color changes of Acute Pain
of infection using
nitrazine paper Patient expresses
amniocentesis.
from yellow to dark relief and easing of
6. Use aseptic pain which is
blue indicate
tolerable.
technique for all presence of
invasive procedures alkaline amniotic. Patient can feel
ex. vaginal Excess bloody comfort from
examination. show, which is prescribed
more alkaline than analgesics given.
7. Provide frequent
vaginal secretions,
perineal care and Patient has no signs
may cause similar
pad changes. of bladder
changes on distension
8. Change linens nitrazine paper.
and woman’s gown Ferning indicates
Proposed By: Mrs. Sharry Mae G. Awayan, RN, MAN
 as needed. Risk for Infection
rupture of The patient was
9. Carry out good membranes. able to perform the
hand washing ultrasound
techniques before 4. Amniotic fluid has scanning
and after comfortably.
a foul smell, becomes
procedures. thicker and yellow
The patient was
tinged when it is
10. Administer able to feel comfort
infected.
prophylactic when using the
pads after perineal
antibiotic IV, if 5. Amniotic fluid test, care.
indicated. an invasive prenatal
diagnostic test that The patient was
detects chromosomal able to participate
abnormalities in the in administration of
fetus. Provides antibiotic.
information about
accuracy and Patient was able to
correctness of the feel contractions
diagnoses of PROM after hours of
administration of
and infection.
oxytocin through iv.

6. Antibiotic
administration during
the intrapartal period
may be disputable
because of antibiotic
load for the fetus, it
may help protect
against development
of chorioamnionitis
in the client at risk.

Proposed By: Mrs. Sharry Mae G. Awayan, RN, MAN

 7. Helps prevent the
growth of bacteria;
eliminates
contaminants that
might contribute to
maternal
chorioamnionitis or
fetal sepsis.

8.

9. Reduces risk of
acquiring/spreading
infective agents.

10.

Proposed By: Mrs. Sharry Mae G. Awayan, RN, MAN