eff ects of labor Nursing Care Plan: Acute pain r elated to eff
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.
NURSING DIAGNOSIS: Acute pain r elated to effects of l abor and deli very process process
b.
Patient will express relief obtained from labor pain by the use of childbirth techniques learned and/or comfort measures/analgesics/anesth etics given.
Planning
and delivery pr ocess ocess
Rationale
Assess current knowledge of obstetric pain control measures.
Allows the nurse to develop an individualized teaching plan for the patient.
Assess if patient attended childbirth classes; if yes, determine the childbirth techniques taught.
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.
Provide positive reinforcement and encouragement to patient and support persons as they apply nonpharmacologic techniques learned in childbirth classes. Assist with techniques as necessary.
Positive reinforcement and encouragement provide the patient and support person a sense of control and self-confidence.
Assess anxiety level and implement measures to reduce anxiety as needed.
Allows for early intervention to decrease anxiety levels. High levels of anxiety can increase the perception of pain, decrease 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., use of focal point, visual imagery, breathing and relaxation techniques). Assist with implementation of these measures as needed.
These nonpharmacologic comfort measures work by providing diversion 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
Implementation/Evaluation Implementation/Evaluation
pathway, pain is being inhibited.
c.
Patient will have relaxed facial expressions and be able to rest between uterine contractions.
Provide massage and/or counterpressure and/or assist patient to find position of maximum comfort — standing, sitting, squatting, sidelying, hands and knees — as needed.
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.
If patient is considering an epidural, ensure that informed consent is obtained before administration of narcotics.
The patient will have to wait several hours to sign an epidural consent if narcotics are given before the request for an epidural.
Assess for nonverbal signs of ineffective coping with pain and offer pain medications and/or epidural anesthesia.
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.
Administer pain medications as ordered and assist with epidural placement.
Pharmacologic intervention may be needed to alleviate discomfort when nonpharmacologic methods of pain control are perceived to be ineffective.
Provide comfort measures (ice chips, petroleum jelly for dry lips, dry linens, etc.).
Enhances patient’s comfort level.
Keep patient informed of progress made after each vaginal examination.
Progression of effacement, dilatation, and station encourages the patient that she is making progress and that the discomfort will not last forever.
Inform patient when uterine contractions reach peak intensity (acme).
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
