NCP Pain 1

Name of patient: Maria L.
-4 hours of care may not be enough to reach

Age: 19 you target/objectives
Gender: Female - Unlikely to decrease pain scale from 8 to 0-3
Chief of complaint: Intense Lower Back Pain without the use of anesthesia (epidural)
Date and Time of Admission: November 30, 2023 - Acupressure/acupuncture may not be an
Date and Time of Discharge: December 4, 2023 appropriate practice in all hospitals
Evaluation – must be relevant to your objectives- no
pain scale
Date Cues Nursing Objective of Care Interventions Rationale Evaluation

Diagnosis
November Subjective: Acute pain Short term: Independent Independent Goal Met:
30,2023 “Sakit kaayo ang related to After 4 hours of care, 1. Assess vital signs, To know any After 4 hours of
baba sa akong uterine the client will be able especially the deviation from care, the client
10:00 am likod, dili na jud contractions to: blood pressure normal ranges identified/used
nako makaya ang and cervical - identify/use techniques to
ka sakit” as dilation as techniques to 2. Provide and Position changes control
verbalized by the evidenced control encourage the use enhance pain/discomfort
patient by 8 cm pain/discomfor of comfort circulation, and She also
dilation t measures (e.g reduce muscle reported that the
- Pain scale repositioning, tension. discomfort is
of 8/10 - report pain back/leg rubs, and minimized. She
scale 0-3. backrest) appeared to be
Objective: relaxed/rested
- appear to be between
- Diaphoresi relaxed/resting 3. Routinely assess Monitor treatment contractions and
s between the client's pain progress is free of
- Grimace contractions level untoward side
Face effects when
- Flushing of 4. Educate and assist To promote analgesia/anesth
Skin the client in relaxation and etic agents that
- Curling of relaxation and pain reduction are administered.
toes breathing
- Tightening techniques
grasp
5. Offer Provide emotional
encouragement by support which can
Dilation: 8 cm updating her reduce fear, lower
Fetal station: +2 regarding her labor anxiety levels,
● G-1 progress and and help minimize
Vital Signs: providing positive pain
T: 37°C reinforcement
HR: 100bpm
BP: 120/80 mmHg 6. Provide diversional Enhances coping
activities by refocusing
attention
Contraction:
7. Encourage to void Keeps the bladder
Duration: 50s every 1-2 hr. free from
Interval: 3 min Palpate above distension, which
Frequency: 2 symphysis pubis to can increase
times every determine discomfort, result
minute distention, in possible
Intensity: Strong especially nerve trauma, interfere
block. with fetal descent,
and prolong labor.
Interdependent Interdependent
Pain Management:
1.Coordinate with Collaborating with
anesthesiologists or pain specialists allows
management specialists to for a personalized
provide pain relief options approach to pain
such as epidurals, management based
analgesics, or non- on the mother's
pharmacological methods needs and medical
like breathing techniques, considerations.
massage, and positioning.
Labor Support: Collaborate This fosters better

with a support persons communication
chosen by the mother to between the mother,
provide emotional and healthcare
physical support, ensuring a providers, and the
supportive environment support team,
throughout labor. facilitating a more
positive birth
experience and
creating a sense of
security and
comfort for the
mother.
Dependent Dependent
1.Provide assistance with Acupuncture
complementary therapies relieves pain in
as indicated, such as labor and
acupressure/ decreases the
acupuncture need for
analgesics,
forceps vacuum
use, and duration
of labor.
2.Administer opioids Opioids, when

administered
like fentanyl or
intravenously, can
morphine via IV route act relatively
as prescribed by the quickly, providing
physician. rapid relief. These
medications can
help manage
discomfort.
Note: Opioids
come with potential
side effects, such as
drowsiness, nausea,
vomiting, and can
potentially affect
the baby. Therefore,
their use should be
carefully monitored
by healthcare
professionals.
References:
Jin, J., & Son, M. (2021, August 3). Pain management during vaginal childbirth. JAMA, 326(5), 450.
https://doi.org/10.1001/jama.2021.10702
Labor and delivery: Pain medications. (2022, June 11). Mayo Clinic. https://www.mayoclinic.org/healthy-lifestyle/labor-and-
delivery/in-depth/labor-and-delivery/art-20049326
Magner, M. (2023, October 26). Labor and Delivery: Nursing Diagnoses, Care Plans, Assessment & Interventions.
Nursetogether. https://www.nursetogether.com/labor-and-delivery-nursing-diagnosis-care-plan/#acute-pain
Making sense of childbirth pain relief options. (n.d.). ACOG. https://www.acog.org/womens-health/experts-and-stories/the-

latest/making-sense-of-childbirth-pain-relief-options
Martin, P. (2017, May 3). 36 Labor Stages, Induced and Augmented Labor Nursing Care Plans. Nurseslabs.
https://nurseslabs.com/labor-stages-labor-induced-nursing-care-plan/
NCP: Labor Stage 1 Active phase. (n.d.-b). Scribd. https://www.scribd.com/doc/20556582/NCP-Labor-Stage-1-Active-

Phase?fbclid=IwAR250iK9iZmuh-ZC8HCVuylp6-_VjTPeGkTfu_3j2UKkPCucNiYmDEzF4ik
Studocu. (n.d.). Acute Pain due to Labor Process NCP - NURSING CARE PLAN Identified Problem: Abdominal and back
pain - Studocu. https://www.studocu.com/ph/document/mindanao-state-university-iligan-institute-of-technology/health-
of-mother-child-and-newborn/acute-pain-due-to-labor-process-ncp/24688370?
fbclid=IwAR3Tw6y_bW7Hj1idHW2kRMRzIIBPYMLKpOzD6lf24q_GNLtstQKqBdOcKZY
World Health Organization, & World Health Organization. (2020, September 9). Every woman’s right to a companion of
choice during childbirth. The World Health Organization. https://www. who. int/news/item/09-09-2020-every-woman-s-
right-to-a-companion-of-choice-during-childbirth.

NCP Pain 1

Uploaded by

Copyright:

Available Formats

NCP Pain 1

Uploaded by

Document Information

Original Title

Copyright

Available Formats

Share this document

Share or Embed Document

Sharing Options

Did you find this document useful?

Is this content inappropriate?

Copyright:

Available Formats

NCP Pain 1

Uploaded by

Copyright:

Available Formats

Name of patient: Maria L.

-4 hours of care may not be enough to reach

Date Cues Nursing Objective of Care Interventions Rationale Evaluation

Labor Support: Collaborate This fosters better

2.Administer opioids Opioids, when

Making sense of childbirth pain relief options. (n.d.). ACOG. https://www.acog.org/womens-health/experts-and-stories/the-

NCP: Labor Stage 1 Active phase. (n.d.-b). Scribd. https://www.scribd.com/doc/20556582/NCP-Labor-Stage-1-Active-

You might also like

Pfad - The Proxy pFad of © 2024 Garber Painting. All rights reserved.