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NCP - Labor Active

The patient was experiencing abdominal pain and contractions. Nursing interventions were focused on monitoring vital signs, providing pain medication, teaching about the condition, and promoting relaxation. After 6 hours the patient's pain had decreased from 6/10 to 4/10. The patient also expressed anxiety about being left alone, so nursing care included privacy, comfort, and reassurance. Mobility was impaired due to weakness, so nursing aimed to assist with range of motion and rest in order to participate in activities. Goals of care were to improve symptoms and educate the patient.

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Karizza Mae Celis
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6K views4 pages

NCP - Labor Active

The patient was experiencing abdominal pain and contractions. Nursing interventions were focused on monitoring vital signs, providing pain medication, teaching about the condition, and promoting relaxation. After 6 hours the patient's pain had decreased from 6/10 to 4/10. The patient also expressed anxiety about being left alone, so nursing care included privacy, comfort, and reassurance. Mobility was impaired due to weakness, so nursing aimed to assist with range of motion and rest in order to participate in activities. Goals of care were to improve symptoms and educate the patient.

Uploaded by

Karizza Mae Celis
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

SUBJECTIVE: Medyo sumasakit na ang tiyan ko as verbalized by the patient. OBJECTIVE: > P abdominal contraction Q pricking sensation R lower back radiating to the abdomen S 6/10 T 9am onwards; contraction frequency for every 2 mins. Lasting for 60 secs. or more > facial grimace > irritable

DIAGNOSIS
Acute Pain related to abdominal contractions as possibly evidenced by 6/10 of pain scale and facial grimace.

PLANNING
SHORT TERM GOAL: After 6 hours of nursing intervention the patients pain scale will decrease from 6/10 to 4/10. LONG TERM GOAL: After discharge the patient will be able to report improvement about her condition.

INTERVENTION
INDEPENDENT: > monitor Vital Sign > monitor the frequency and duration of her contraction > provide peaceful and warm-ventilated environment > health teachings about her condition > instruct deep breathing exercises > promote rest > labor watch and assisting in labor delivery > instruct in and encourage use of relaxation techniques, such as Deep breathing exercises DEPENDENT: > give medications as prescribed by the doctor or physician

RATIONALE
> to have comparison and baseline data > to determine if she needs more nursing care > to promote comfort

EVALUATION
After 6 hours of nursing intervention the goal met as evidenced by verbal reports about her pain that decrease from 6/10 to 4/10.

> to gain knowledge about her condition > to promote relaxation and relive of pain > to gain strength and comfort > to have baseline and comparison and to determine the needs of patient > to destruct attention and reduce tension

> it must be instructed and followed

ASSESSMENT
SUBJECTIVE: wag niyo akong iiwan dito ma ah? as verbalized by the patient. OBJECTIVE: >Palpitations >Sweating >Trembling >Restlessness >Muscle tension >stress >tension >poor eye contact >teary eye

DIAGNOSIS
Anxiety related to actual abdominal pain as manifested by teary eye and poor eye contact.

PLANNING
SHORT TERM GOAL: After 6 hours nursing intervention the patient will be able to verbalize that she feels more in control of his current situation. LONG TERM GOAL: After discharge the patient will be able to appear relax and report anxiety level decrease.

INTERVENTION
INDEPENDENT: > monitor Vital Sign > provide privacy by drawing curtains > provide peaceful and warm-ventilated environment > health teachings about her condition >encourage the patient to acknowledge and to express feelings >modify procedure and safety measures >stay with the client

RATIONALE
> to have comparison and baseline data > to respect patients condition > to promote comfort

EVALUATION
After 6 hours nursing intervention the goal met as evidenced by verbalizing the patient decrease of anxiety by having a feeling of comfort.

> to gain knowledge about her condition > to assist and to deal with problems >to provide decrease in tension > to promote comfort

ASSESSMENT
SUBJECTIVE: hirap na kong tumayo at magkikilos as verbalized by the patient. OBJECTIVE: > irritable > slowed movement > limited range of motion > postural instability > weakness > muscle strength is decrease

DIAGNOSIS
Impaired Physical Mobility related to decrease muscle strength as manifested by slowed movement, limited range of motion and weakness.

PLANNING
SHORT TERM GOAL: After 2 hours of nursing intervention the patient will participate in ADLs and desired activities. LONG TERM GOAL: After discharge the patient will be able to demonstrate techniques or behaviors that enable resumption of activities.

INTERVENTION
INDEPENDENT: > monitor Vital Sign > provide peaceful and warm-ventilated environment > health teachings about her condition > assist the patient to do some range of motion as an exercise > encourage patient to take some rest COLLABORATIVE: > consult with physical or occupational therapist, if indicated

RATIONALE
> to have comparison and baseline data > to promote comfort

EVALUATION
After 2 hours of nursing intervention the goal was partially met as possibly evidenced by letting the patient to participate in some activities.

> to gain knowledge about her condition > to promote muscular strength > to gain strength and comfort

> to develop individual exercise and mobility program, and identify appropriate mobility devices

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