176252810 Nursing Care Plan of Labor Pain PDF

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Summary

Sample care plan for nursing made by students....

Description

Nursing Care Plan: Acute pain related to effects of labor and delivery process Assessments SUBJECTIVE: “Sobrang sakit na po, “ as verbalized.

Objectives At the end of nursing interventions the: a.

OBJECTIVE: Facial grimace Uncomfortable Irritability Restlesness Vital Signs: BP= 130/80 Pain Scale: 9

Patient will be able to make an informed decision regarding pain control options she would like to use.

Planning

Assess current knowledge of obstetric pain control measures.

Assess if patient attended childbirth classes; if yes, determine the childbirth techniques taught.

Provide positive reinforcement and encouragement to patient and support persons as they apply nonpharmacologic techniques learned in childbirth classes. Assist with techniques as necessary.

NURSING DIAGNOSIS:

Acute pain related to effects of labor and delivery process

Assess anxiety level and implement measures to reduce anxiety as needed.

b.

Patient will express relief obtained from labor pain by the use of childbirth techniques learned and/or comfort measures/analgesics/ anesthetics given.

Rationale

Allows the nurse to develop an individualized teaching plan for the patient. Provides necessary information so the nurse can reinforce psychoprophylactic methods of coping or initiate teaching of nonpharmacologic comfort measures that can be used during stages of labor. Positive reinforcement and encouragement provide the patient and support person a sense of control and selfconfidence.

Allows for early intervention to decrease anxiety levels. High levels of anxiety can increase the perception of pain, decrease ability to tolerate pain, and decrease comprehension of verbal instruction.

Provide teaching between uterine contractions.

The patient is more attentive and can better internalize information when not in pain.

Teach patient pain control options available, giving the pros and cons of each.

Providing information allows the patient tomake informed decisions regarding pain control.

Initiate teaching/reinforcing of nonpharmacologic comfort measures that can be used during labor if needed (e.g.,

These nonpharmacologic comfort measures work by providing diversion

Implementation/Evaluation

use of focal point, visual imagery, breathing and relaxation techniques). Assist with implementation of these measures as needed.

Provide massage and/or counterpressure and/or assist patient to find position of maximum comfort—standing, sitting, squatting, sidelying, hands and knees—as needed.

c.

Patient will have relaxed facial expressions and be able to rest between uterine contractions.

If patient is considering an epidural, ensure that informed consent is obtained before administration of narcotics.

Assess for nonverbal signs of ineffective coping with pain and offer pain medications and/or epidural anesthesia.

Administer pain medications as ordered and assist with epidural placement.

Provide comfort measures (ice chips, petroleum jelly for dry lips, dry linens, etc.). Keep patient informed of progress made after each vaginal examination.

during uterine contractions. According to the gate control theory of pain, only a limited number of sensations can travel along neural pathways at any one time, so when activities fill the pathway, pain is being inhibited.

Changing positions and using counterpressure may help alleviate discomfort caused by pressure of presenting parts on bony structures, ligaments, or tissues. Massage helps relieve muscle tension and provide a diversion to inhibit pain sensations.

The patient will have to wait several hours to sign an epidural consent if narcotics are given before the request for an epidural. Some patients are hesitant to make requests even when they would like pharmacologic interventions. It is common for women in many cultures not to request assistance. Pharmacologic intervention may be needed to alleviate discomfort when nonpharmacologic methods of pain control are perceived to be ineffective. Enhances patient’s comfort level.

Inform patient when uterine contractions reach peak

intensity (acme). Progression of effacement, dilatation, and station encourages the patient that she is making progress and that the discomfort will not last forever. Knowledge that a uterine contraction has reached peak intensity often promotes relaxation, which reduces muscle tension and pain sensations.

REFERENCE:http://www.eu.elsevierhealth.com/media/us/samplechapters/9780721604787/Chapter%208%20Nursing%20Care%20During%20Labor%20and %20Pain%20Management.pdf, retrieved October 15, 2013...