ASSESSMENT DIAGNOSIS PLANNING INTERVENTIONS RATIONALE EVALUATION

SUBJECTIVE:  Acute pain  After an Independent Goal met.

 The patient complains related to labor hour of  After an hour
of having labor pain at process as nursing  Assessed  This is to of nursing
4 am. manifested by intervention, contraction monitor the interventions,
 The patient complains facial grimacing the client patterns, bloody progress of The patient
of having Pain scale of and pain scale will verbalize show and the labor and the verbalized
7/10 of 7/10. relief of pain degree of pain condition of relief of pain
scaling 2/10 and its both the scaling 2/10.
OBJECTIVE: or lower. characteristic, mother and
 Facial grimacing location, the baby.
 Audible moans from severity, Helps to
the client. duration, and identify areas
frequency. of chief
concern,
providing
baseline for
interventions.

 Assisted the  Left lateral

client in position
assuming a increases
comfortable venous return
position. and enhances
placental
circulation.
Position
changes
promote
comfort,
reduce muscle
tension,
relieve
pressure, and
promote fetal
descent.
 Encouraged
client to use  Relaxation can
 relaxation aid in reducing
techniques. tension and
Provide fear, which
instruction as magnify pain
necessary. and hamper
labor
 Demonstrated progress.
and encourage  To allow
deep breathing proper oxygen
exercises. supply in the
body and help
Dependent in relieving
pain.
 Administer
analgesic
medications  Relieves pain;
once dilation promotes
and relaxation and
contractions are coping with
established. contractions,
allowing client
Collaborative to remain
focused on
 Refer to work of labor.
physician any
Deviation that
may be  To provide
observed immediate
medical
intervention
NURSING CARE PLAN