Nursing Care Plan: Acute pain related to effects of labor and delivery process Assessments SUBJECTIVE: Sobrang sakit

na po, as verbalized. OBJECTIVE: Facial grimace Uncomfortable Irritability Restlesness Vital Signs: BP= 130/80 Pain Scale: 9 Objectives At the end of nursing interventions the:
a. Patient will be able to make an informed decision regarding pain control options she would like to use.

Planning

Rationale

Implementation/Evaluation

Assess current knowledge of obstetric pain control measures.

Allows the nurse to develop an individualized teaching plan for the patient. 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. Positive reinforcement and encouragement provide the patient and support person a sense of control and self-confidence.

Assess if patient attended childbirth classes; if yes, determine the childbirth techniques taught.

NURSING DIAGNOSIS:

Acute pain related to effects of labor and delivery process

Provide positive reinforcement and encouragement to patient and support persons as they apply nonpharmacologic techniques learned in childbirth classes. Assist with techniques as necessary. 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 ability to tolerate pain, and decrease comprehension of verbal instruction. The patient is more attentive and can better internalize information when not in pain. Providing information allows the patient tomake informed decisions regarding pain control.

Provide teaching between uterine contractions.

Teach patient pain control options available, giving the pros and cons of each.

b.

Patient will express relief obtained from labor pain by the use of childbirth techniques learned and/or comfort measures/analgesics/anesth etics given.

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

pathway, pain is being inhibited.

Provide massage and/or counterpressure and/or assist patient to find position of maximum comfortstanding, sitting, squatting, sidelying, hands and kneesas 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.

c.

Patient will have relaxed facial expressions and be able to rest between uterine contractions.

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. Pharmacologic intervention may be needed to alleviate discomfort when nonpharmacologic methods of pain control are perceived to be ineffective. Enhances patients comfort level.

Administer pain medications as ordered and assist with epidural placement.

Provide comfort measures (ice chips, petroleum jelly for dry lips, dry linens, etc.). 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. Knowledge that a uterine contraction has reached peak intensity often promotes relaxation, which reduces muscle tension and pain sensations.

Inform patient when uterine contractions reach peak intensity (acme).

REFERENCE:http://www.eu.elsevierhealth.com/media/us/samplechapters/9780721604787/Chapter%208%20Nursing%20Care%20During%20Labor%20and% 20Pain%20Management.pdf, retrieved October 15, 2013