Nursing Care Plan: Acute pain related to effects of labor and delivery process

Assessments Objectives Planning Rationale Implementation/Evaluation

SUBJECTIVE: At the end of nursing interventions
“Sobrang sakit na po, “ as the:
verbalized.
a. Patient will be able to make an Assess current knowledge of Allows the nurse to develop an
informed decision regarding pain obstetric pain control measures. individualized teaching plan for
OBJECTIVE: control options she would like to the patient.
Facial grimace use.
Uncomfortable Assess if patient attended Provides necessary information
Irritability childbirth classes; if yes, so the nurse can reinforce
determine the childbirth psychoprophylactic methods
Restlesness  techniques taught. of coping or initiate teaching of
Vital Signs: BP= 130/80 nonpharmacologic comfort
Pain Scale: 9 measures that can be used during
stages of labor.

Positive reinforcement and

Provide positive reinforcement encouragement provide the
and encouragement to patient and patient and support person a
support persons as they apply sense of control and self-
NURSING DIAGNOSIS: nonpharmacologic techniques confidence.
Acute pain related to learned in childbirth classes.
Assist with techniques as
effects of labor and necessary.
delivery process Allows for early intervention to
Assess anxiety level and decrease anxiety levels. High
implement measures to reduce levels of anxiety can increase the
anxiety as needed. perception of pain, decrease
ability to tolerate pain, and
decrease comprehension of verbal
instruction.

Provide teaching between uterine The patient is more attentive and

contractions. can better internalize information
when not in pain.

Teach patient pain control options Providing information allows the

available, giving the pros and patient tomake informed
b. Patient will express relief obtained cons of each. decisions regarding pain control.
from labor pain by the use of
childbirth techniques learned
and/or comfort Initiate teaching/reinforcing of These nonpharmacologic comfort
measures/analgesics/anesthetics nonpharmacologic comfort measures
given. measures that can be used during work by providing diversion
labor if needed (e.g., use of focal during uterine
point, visual imagery, breathing contractions. According to the
and relaxation techniques). Assist gate
with implementation of these control theory of pain, only a
 measures as needed. 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 Changing positions and using
maximum comfort—standing, counterpressure may help
sitting, squatting, sidelying, hands alleviate discomfort caused by
and knees—as needed. pressure of presenting parts on
bony structures, ligaments, or
tissues. Massage helps relieve
muscle tension and provide a
If patient is considering an diversion to inhibit pain
epidural, ensure that informed sensations.
c. Patient will have relaxed facial consent is obtained before
expressions and be able to rest administration of narcotics.
between uterine contractions. The patient will have to wait
several hours to sign an epidural
Assess for nonverbal signs of consent if narcotics are given
ineffective coping before the request for an epidural.
with pain and offer pain
medications and/or epidural
anesthesia. Some patients are hesitant to
make requests even when they
would like pharmacologic
Administer pain medications as interventions. It is common for
ordered and assist with epidural women in many cultures not to
placement. request assistance.

Pharmacologic intervention may

be needed to alleviate discomfort
Provide comfort measures (ice when nonpharmacologic methods
chips, petroleum jelly for dry lips, of pain control are perceived to
dry linens, etc.). be ineffective.

Keep patient informed of progress Enhances patient’s comfort level.

made after each vaginal
examination.

Progression of effacement,
Inform patient when uterine dilatation, and station encourages
contractions reach peak intensity the patient that she is making
(acme). 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.
REFERENCE:http://www.eu.elsevierhealth.com/media/us/samplechapters/9780721604787/Chapter%208%20Nursing%20Care%20During%20Labor%20and
%20Pain%20Management.pdf, retrieved October 15, 2013