NCP Labor Pain

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a.

NURSING CARE PLAN

Assessment Nursing Scientific Planning Intervention Rationale Evaluation


Diagnosis Explanation
Subjective: Labor pain Labor pain Short term: Independent Independent Short term:
“masakit yung related to related to  After 30 intervention Intervention  After 30
likod ko tapos cervical cervical minutes of  Assess  To know minutes of
dilation dilation is nursing where the identify if nursing
papunta sa
define as interventio location of it is true interventio
tiyan ko, recurrent ns, the ns, the
parang feeling the pain and labor or
pains felt by a patient will patient
ko contraction not.
woman in the demonstra was able
manganganak abdomen, te to
na ako.” As groin, and relaxation demonstr
verbalized by back during technique  Assess the  To ate
child birth due and deep intensity of determin relaxation
the mother.
to uterine breathing the pain e the technique
contractions exercises using pain intensity and deep
Objective: that causes scale (0 to of pain breathing
 BP: 115/70 the cervix to  After 2 10; 0 for no and to exercises
 PR: 64 stretch and hours of pain and 10 provide
 RR: 16 dilate. nursing for worst effective  After 2
 T: 36.2 interventio pain) nursing hours of
ns, the nursing
 1 cm interventi
patient will interventio
cervical ons
exhibit ns, the
dilation decrease patient
 Presence of level of was able
 Provide
uterine pain.  To to exhibit
comfort
contraction provide decrease
measure like level of
comfort
back rub, pain.
 Level of and
helping
pain = 8/10 safety to
position of
the
 Facial comfort.
patient.
grimace
 Uncomforta
ble
 Suggest use  To
 Irritability
of relaxation promote
technique relaxation
and deep and may
breathing enhance
exercises coping
abilities.

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. ACTUAL FDARs

Date and Time Focus Data – Action – Response


October 03, 2019 Labor pain related to D>
7:30 am cervical dilation Subjective:
 “masakit yung likod ko tapos papunta sa
tiyan ko, parang feeling ko manganganak
na ako.” As verbalized by the mother.
Objective:
 Received patient on bed, conscious with a
IVF of D5LR infusing well on the right hand
at 550mL and regulated at 17gtts/min.
 BP: 115/70
 PR: 64
 RR: 16
 T: 36.2
 1 cm cervical dilation
 Presence of uterine contraction

 Level of pain = 8/10

 Facial grimace
 Uncomfortable
 Irritability

A>
 Monitored and taken the vital signs and
was recorded.
 Checked IVF
 Morning care done
 Instruct the mother to the side lying
position when lying on bed.
 Assess the location of the pain and
contractions
 Assess the intensity of the pain using pain

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scale (0 to 10; 0 for no pain and 10 for
worst pain)
 Provide comfort measure like back rub,
helping position of comfort.
 Suggest use of relaxation technique and
deep breathing exercises.
R>
 The patient was able to identify the pain
that she experienced.
 The patient was able to demonstrate
relaxation technique and deep breathing
exercise to relief her pain.
 The patient was able to exhibit decrease
level of pain.
 No furthermore complications
Handed over to the nurse on duty

This study source was downloaded by 100000797295483 from CourseHero.com on 12-16-2022 06:58:12 GMT -06:00

https://www.coursehero.com/file/65044170/NCP-Labor-Paindocx/
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