ILOILO DOCTORS’ COLLEGE

COLLEGE OF NURSING
West Avenue, Molo, Iloilo City

NURSING CARE PLAN

Defining Characteristics Nursing Diagnosis Outcome Identification Nursing Interventions Rationale Evaluation
Subjective: Acute pain R/T increasing uterine Long Term: Independent: After nursing
contractions After 9 hours of Monitor vital sign To acquire baseline intervention the patient
Increasing uterine contractions intervention she will every 15 minutes will be able to:
Pain scale 9/10 report pain or  Report pain or
discomfort is relieved Engage the client in If the drug is discomfort is
or controlled. discussion to test absorbed into the relieved or
Objective: Verbalize methods sensory perceptions, bloodstream, systemic controlled. Verbalize
 Cervix fully dilated Unpleasant sensory and emotional that provide relief. and observe toxic reactions with methods that
 Fetal head (+1) experience associated with actual Follow prescribed breathing patterns impaired sensorium provide relief.
 Vaginal bleeding or potential tissue damage, or pharmacological and pulse every 15 occur. An impaired Follow prescribed
 Lengthening of the cord described in terms of such damage regimen minutes for 1 to 2 sensorium may be a pharmacological
 Blood pressure 120/70 mmHg (International Association for the hours. precursor to hypoxia, regimen
Study of Pain); sudden or slow Short Term: while excessive  Patient verbalize
VS:
 Blood Pressure=110/80 mmHg. onset of any intensity from mild to After 3 hours of analgesia paralyzes relief of pain after
severe with an anticipated or nursing intervention, the diaphragm and labor and delivery.
predictable end, and with a the patient will be interferes with  Exhibit decrease
duration of less than 3 months. able to: respiratory function. level of pain.
 Feeling in control
Note: Nursing Diagnosis should be  Exhibit decrease throughout the labor
base from (NANDA- Approved level of pain. Elevate the patient’s Respiratory and delivery process
Nursing Diagnosis)  Feeling in control head 30 degrees, then depression is  Patient and fetus
throughout the vary positions by prevented when the remain
labor and shifting side to side head of the patient is physiologically
delivery process and hip rolling elevated. Position stable with use of
 Patient and fetus modifications let the pharmacologic
remain fetus adjust to the size interventions.
physiologically and form of the
stable with use of client’s pelvis and
pharmacologic enhance comfort,
interventions particularly in a
 Patient verbalize lateral position that
relief of pain increases venous
after labor and return and improves
delivery. placental circulation.
On the other hand, a
flat on-bed position
causes hypotension,
which decreases
placental blood flow
and fetal oxygenation

Encourage the patient This prevents

to void every 1–2 distension of the
hours and assess for bladder, which causes
bladder distension by discomfort, potential
palpating the trauma, difficulty
suprapubic area. with fetal descent,
and labor extension.
A full bladder might
induce delivery
complications such as
postpartum bleeding
and birth delay.

Offer the patient Massage is one of the

appropriate comfort most helpful non-
measures during pharmacological pain
labor. relief techniques. The
presence of
stimulation, such as
vibrations, stroking,
or massage, causes the
opposite of pain
impulses to be
stronger and faster
via tiny nerve fibers.

Instruct and support Breathing and

with proper relaxation strategies
breathing, relaxation, may help normal
and abdominal lifting labor progress while
techniques. blocking pain
impulses. Abdominal
lifting, on the other
hand, is a labor pain
relief technique that
involves stroking the
top of the stomach
without pressing
inside.
Encourage eating
nutritious food and To gain nutrients,
increasing fluid energy and replace
intake.Encourage to fluid loss after the
breastfeed. delivery

To provide nutrients
that the baby needs
Dependent: to grow, develop and
protect against
IVF of D5LRS 1L to run infection and
at 30gtts/minute. diseases.

Amoxicillin 500
mg/tablet, 1 tablet every
8 hours.Mefenamic Acid To maintain and
500 mg/capsule, 1 replace body fluids
capsule every 6 hours
then prn for pain.Ferrous and nutrition, and for
Sulfate with Folic Acid rehydration.
1 tab OD for 1 month.
To prevent bacterial
infection.
Oxytocin 1 ampule

To decrease pain and

Collaboration:
blood loss.

Right mediolateral
episiotomy
To prevent iron
deficiency anemia
Amniotomy
cause of vaginal
bleeding

To stimulate uterine
contractions in labor
and childbirth.

To widen vaginal
opening to shorten
labor and delivery

For the fetal head t

contact the cervix mo
re directly to shorten
the labor and delivery