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NCP

The document summarizes a nursing assessment and care plan for a laboring patient experiencing pain. The patient reported severe abdominal pain (8/10). Vital signs were taken. The plan was to establish rapport, identify the patient's ability to perform tasks, assess pain level, and remind the patient to empty her bladder. Nursing interventions like position changes, deep breathing, relaxation techniques, and possible IV medication were aimed to decrease the patient's pain to 6/10 within 30 minutes. The goal of pain reduction was met.

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Ma R Dy
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336 views

NCP

The document summarizes a nursing assessment and care plan for a laboring patient experiencing pain. The patient reported severe abdominal pain (8/10). Vital signs were taken. The plan was to establish rapport, identify the patient's ability to perform tasks, assess pain level, and remind the patient to empty her bladder. Nursing interventions like position changes, deep breathing, relaxation techniques, and possible IV medication were aimed to decrease the patient's pain to 6/10 within 30 minutes. The goal of pain reduction was met.

Uploaded by

Ma R Dy
Copyright
© Attribution Non-Commercial (BY-NC)
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as DOCX, PDF, TXT or read online on Scribd
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Assessment

Diagnosis

Background Knowledge Stretching of the peritoneum overlying of the uterus.

Planning

Intervention
Independent: > Establish rapport.

Rationale

Evaluation

Subjective: Sobrang sakit na po ng tiyan ko As verbalized by the pt. Objectives: > Facial grimace > Irritability > Uncomfortable >Restlessness Vital sign taken as follows: BP- 100/80 PR-82bpm RR-23/min T-37.3C

Acute pain related to physical agent such as laboring.

Stretching of the cervix during dilatation.

After 30 minutes of nursing interventions, the patient will able to verbalize the decrease of pain from P/S 8/10 to 6/10.

> To promote Nurse-patient relationship. >To perform interventions properly.

> Identify the patients ability to perform the task. > Assess level of pain.

> It serves as a baseline of assessment. > A full bladder is not only uncomfortable but can also stall pain.

After 30 minutes of nursing interventions, the patient have been verbalized the decrease of pain from P/S 8/10 to 6/10.

> Remind her to empty her bladder every hour.

Stretching of the ligaments.

> Help her to change position to encourage the progress of labor. > If back is hurting, do counter pressure with your hand as hard as she tolerated. >Encourage the patient to use deep breathing exercise. > Teach the patient some relaxation technique such as: watching TV, listen to music or offer a discussion. Dependent: > With doctors order, an IV medication to relieve the pain may introduce.

> Some position will provide pain relief.

GOAL WAS MET!!!

Compression of nerve ganglia in the cervix.

> Doing this in hand and knees position will also help to relieve the pain.

Hypoxia of contracted myometrium.

> It promotes relaxation and coping abilities.

Labor pain.

> It promotes relaxation and diverts her focus from the pain.

> IV medication can promote relaxation and reduce the sensation of pain.

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