NCP Labor Pain
Patient’s name: K.M
Age: 17
Diagnosis: Pain related to increased uterine contractions and pressure on pelvic structures
Assessment
Nursing Diagnosis
Scientific Analysis
Goals/Objectives
Interventions
Rationale
Evaluation
Subjective:
“Ang sakit ng tiyan ko at ng likod ko, humihilab” as verbalized by the patient
Objective:
BP: 120/70 mmHg
PR: 71 bpm
RR: 17bpm
Temp: 36.6 C
Pain scale: 8
Pain related to increased uterine contractions and pressure on pelvic structures as evidenced by reports of pain with a pain scale of 8 (10 as the highest)
Pain is a highly subjective state in which a variety of unpleasant sensation and a wide range of distressing factors may be experienced by the sufferer. Pain may be a symptom of illness. Pain may also arise from emotional, psychological, cultural or spiritual distress. Pain can be very difficult to explain, because it is unique to individual.
Stretching of the peritoneum overlying the uterus. Stretching of cervix during dilation Stretching of the ligaments Compression of nerve ganglia in cervix There is hypoxia of contracted myometrium Labor pain.
(Gulanick/Myers: Nursing care plans: Nursing Diagnosis ed.page 144)
After 6 hours of nursing intervention, the patient will be able to report pain reduced.
Specifically. The patient will be able to report of pain scale of 3 from having a pain scale of 8 (10 as the highest)
Verbalization pain within tolerable limits throughout the duration of labor
Verbalize comfort as controlled with non-pharmacologic methods
Absence of expressive behavior such as restlessness, moaning,
Sighing, irritability and
Facial grimacing
Demonstrate use of relaxation skills or diversional activities.
Display relaxed facial expression
Assess pain characteristics
Monitor vital signs every 15 minutes for 2 hours and 30 minutes until stable.
Evaluate the patients response and medications or therapeutics aimed at abolishing or relieving pain
Assess contraction patterns,
Age: 17
Diagnosis: Pain related to increased uterine contractions and pressure on pelvic structures
Assessment
Nursing Diagnosis
Scientific Analysis
Goals/Objectives
Interventions
Rationale
Evaluation
Subjective:
“Ang sakit ng tiyan ko at ng likod ko, humihilab” as verbalized by the patient
Objective:
BP: 120/70 mmHg
PR: 71 bpm
RR: 17bpm
Temp: 36.6 C
Pain scale: 8
Pain related to increased uterine contractions and pressure on pelvic structures as evidenced by reports of pain with a pain scale of 8 (10 as the highest)
Pain is a highly subjective state in which a variety of unpleasant sensation and a wide range of distressing factors may be experienced by the sufferer. Pain may be a symptom of illness. Pain may also arise from emotional, psychological, cultural or spiritual distress. Pain can be very difficult to explain, because it is unique to individual.
Stretching of the peritoneum overlying the uterus. Stretching of cervix during dilation Stretching of the ligaments Compression of nerve ganglia in cervix There is hypoxia of contracted myometrium Labor pain.
(Gulanick/Myers: Nursing care plans: Nursing Diagnosis ed.page 144)
After 6 hours of nursing intervention, the patient will be able to report pain reduced.
Specifically. The patient will be able to report of pain scale of 3 from having a pain scale of 8 (10 as the highest)
Verbalization pain within tolerable limits throughout the duration of labor
Verbalize comfort as controlled with non-pharmacologic methods
Absence of expressive behavior such as restlessness, moaning,
Sighing, irritability and
Facial grimacing
Demonstrate use of relaxation skills or diversional activities.
Display relaxed facial expression
Assess pain characteristics
Monitor vital signs every 15 minutes for 2 hours and 30 minutes until stable.
Evaluate the patients response and medications or therapeutics aimed at abolishing or relieving pain
Assess contraction patterns,