Diagnosis: G2P1 (1011) Pregnancy Uterine 40-41 weeks cephalic in labor Nursing Diagnosis Analysis Goal and Intervention

Rationale Objectives s Acute Pain R/T Immediate Goal: After tissue trauma cause: an 8 hour Acute Pain shift of Subjective: nursing Intermediat intervention Pain Scale: e cause: s, the 6 out of 10 tissue clients pain (10 being is relieved the highest, trauma and 1 being the Root controlled. lowest) Cause: Normal Objectives: 1. Obtain 1. To rule out Objective: Spontaneo After clients worsening of Guarding us Delivery nursing assessment underlying behavior intervention of pain to condition/ Positioning Scientific s,: include development of to avoid Implication: 1. the client location, complications. pain Labor in will be able characteristi (NANDA 11th ed., Facial NSD is a to report the c, onset, p. 500) grimace physiologic characteristi frequency, Expressive process c of pain. quality, behavior during intensity, 2. Observations (irritability) which the and may or may not Slowed products of precipitating be congruent with movement conception factors. verbal reports or VS as (ie, the Reassess may be only follows: fetus, each time indicator present T= 36.5 membranes pain is when client is PR= 86 , umbilical reported. unable to RR= 24 cord, and 2. Observe verbalize. BP=100/70 placenta) nonverbal (NANDA 11th ed., are cues/ pain p. 500 expelled behaviors. 3. These are outside of usually altered in the uterus. acute pain Labor is (NANDA 11th ed., achieved p. 501) with 4.To promote changes in nonpharmacologi the cal pain biochemical 3. Monitor management. connective 2. the client skin and (NANDA 11th ed., tissue and will be able color p.501) with to perform temperature 5. To promote gradual pain and vital nonpharmacologi effacement managemen signs. cal pain and t. management. dilatation of 4. (NANDA 11th ed.,

Evaluatio n The clients pain was relieved and controlle d.

the uterine cervix as a result of rhythmic uterine contraction s of sufficient frequency, intensity, and duration.

Demonstrat e and encourage deep breathing exercises.

p.501)

3. the client will be able to rest and sleep continuously .

6. To distract attention and reduce tension. (NANDA 11th ed., p. 501) 5. Provide 7. To distract comfort attention and measure reduce tension. (touch, (NANDA 11th ed., repositionin p. 501) g every 2 8. To prevent hours), quiet fatigue. (NANDA environment 11th ed., p. 502) , and calm activities. 6. Encourage use of relaxation techniques such as focused breathing, CDs/tapes. 7. Encourage diversional activities (TV, radio) 8. Encourage adequate rest periods.