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Name of Patient: L.H.

Age/Sex: 23/F Room/Bed #:


Chief Complaint: Labor Pains Physician: Dr. Tuason Diagnosis: _____________
Date/Time Cues Need Nursing Diagnosis Patient Outcome Interventions Implementations Evaluation
January S: C Labor Pains related Patient will be • Provide comfort measures such as 3 January 30,
30, 2020 “Gasakit akong tiyan to fetal explusion as able to back rest and position changes 2020 @ 11PM
@ mao nagpaadto nako O evidenced by strong participate in R: Promotes relaxation and reduces
4:00pm diri. Di ko katulog ug uterine contractions, nonpharmacolog the need for anesthesia. Position After 8 hours of
tarong tungod sa G grimaced face, ic measures to changes enhance circulation, reduces providing
kasakit.” as verbalized guarding behavior, reduce muscle tension. bedside care,
by the patient. N being self-focused discomfort after • Coach proper deep breathing the goal was
when having 8 hours of exercises 2 partially met
O: I conversations providing R: It may block pain impulses within since the client
• LMP – 4/16/19 nursing care as the cerebral cortex through cooperate in
• G1P0 T R: manifested by conditioned responses and cutaneous proper deep
• AOG – 40 Labor pains are longer hours of stimulation and gives client a means breathing
weeks and 5 I associated with rest, less of coping with and controlling the level exercises but
days via LMP; uterine contractions grimaced face, of discomfort 4 the client still
38 weeks and V since it usually cooperation of • Provide a quiet environment that is has a grimaced
6 days via causes discomfort in patient during properly ventilated, and a room free of face since the
USD E the lower back and instructions of unnecessary personnel patient is
• Feeling of abdomen. performing R: Non-distracting environment undergoing
restlessness Contractions move in nonpharmacolog provides optimal opportunity for rest labor process
• Grimaced a wave-like motion ic measures and relaxation between contractions 6 which is a
Face P from the top of the • Assess client’s desire for physical normal part of
• Positioning to uterus to the bottom touch during contractions pregnancy.
side to ease E which will make your R: Touch may serve as a distraction,
pain abdomen become provide supportive re-assurance and
• Narrowed R hard. Usually, encouragement, and may aid in Adrienn Kyle R.
focus contractions are maintaining sense of control and Aala, St.N
C stronger during labor 5 BSN 2-A
• VS: reducing pain
pain. • Offer encouragement and positive
BP – 120/90
E reinforcement
CR – 69
PR – 67 R: Reduces fear, lower anxiety levels,
P and help minimize pain and distracts 1
RR – 18
T – 36. 7 patient when in pain
T
• With strong Reference: • Massage lower back
uterine U WebMD (2020). R: To minimize pain during
contractions, Pregnancy and Signs contractions
3-5 minutes A of Labor. Retrieved
interval, on February 4, 2020
duration of 60 L from
seconds https://www.webmd.c
• With an IVF of om/baby/labor-
D5LR 1L @ P signs#1
120 cc/hr
A

Bibliography
Doenges et. al (2016). Nurse’s Pocket Guide: Diagnoses, Prioritized Interventions, and Rationales 14th Edition. Retrieved on February 3, 2020 from pp 615-619
Herdman et. al (2019). NANDA International Inc. Nursing Diagnoses Definitions and Classifications. Retrieved on February 3, 2020 from p.449.
CLUSTERING OF CUES

Cognitive-Perceptual Pattern Activity/Exercise Pattern


• Grimaced face • VS (as of 01/28 @ 4:00pm)
• Pain management: positioning to side to ease pain • BP – 120/90
• Narrowed focus • CR – 69
• Feeling of restlessness • PR – 67
• “Gasakit akong tiyan mao nagpaadto nako diri. Di ko katulog ug • RR – 18
tarong tungod sa kasakit.” as verbalized by the patient. • T – 36. 7
• AOG – 40 weeks and 5 days via LMP; 38 weeks and 6 days via USD • FHT- 130s
• IE upon admission (01/28 @ 2:15pm done by Dr. Alerta) 6 cms • IE upon admission (01/28 @ 2:15pm done by Dr. Alerta) 6 cms
dilated, Fully Effaced, Intact Bag of Water dilated, Fully Effaced, Intact Bag of Water
• EFM upon admission: Moderate to strong uterine contractions lasting • EFM upon admission: Moderate to strong uterine contractions lasting
60 seconds with an interval of 7 to 8 minutes; 60 seconds with an interval of 7 to 8 minutes

Nutritional-Metabolic Pattern Sleep/Rest Pattern


• VS (as of 01/28 @ 4:00pm) • Sleeping pattern altered starting 3rd trimester; disturbed sleep pattern
• BP – 120/90 d/t frequent quickening of the fetus and frequent changing of position
• CR – 69 during sleeping time.
• PR – 67 • Restlessness, grimaced face, presence of dark eyebags, dozing &
• RR – 18 observed difficulty maintaining sleep state
• T – 36. 7 • Verbalization of not feeling rested:
• FHT- 130S • “Sleepy ko pirmente kay putol-putol akong tulog kay makamata ko
• With an IVF of D5LR 1L @ 120 cc/hour everytime mag busog.”
• NPO once she was on active labor
• Verbalizations of interrupted sleep:
Sexual-Reproductive Pattern “Nagamata-mata ko pirme kay ginaposition nako akong tiyan kay
• LMP – 4/16/19 sigeg lihok si baby, dili ko komportable, usahay kusog kaayo so
• Estimated Date of Confinement: 1/23/2020 makamata jud ko.”
• G1P0A0 “Sauna tong wala pa gain-ani, 9pm to 6am akong tulog usually. Karon
• AOG – 40 weeks and 5 days via LMP; 38 weeks and 6 days via USD kay makamata mata ko kapila isa ka gabii”
• Regular menstrual cycle: 3-4 days, 2-3 pad/day “Gasakit akong tiyan mao nagpaadto nako diri. Di ko katulog ug
tarong tungod sa kasakit.”
• Menarche: 11 years old
• Frequent awakening d/t labor pains and frequent labor and vital signs
• Last Sexual Contact: 2nd week of January
monitoring.
Disturbed Sleep Pattern

_____________________

A Nursing Care Plan Presented to


The Faculty of Nursing Department
MRS. RODELIE BOOC-GULLE, RN

_____________________

In Partial Fulfillment of
the Requirements in NCM 209
DELIVERY ROOM NURSING ROTATION

By

Paula Joyce G. Abad, St.N


February 5, 2020
Labor Pains

_____________________

A Nursing Care Plan Presented to


The Faculty of Nursing Department
MRS. RODELIE BOOC-GULLE, RN

_____________________

In Partial Fulfillment of
the Requirements in NCM 209
DELIVERY ROOM NURSING ROTATION

By

Adrienn Kyle R. Aala, St.N


February 5, 2020

Name of Patient: L.H. Age/Sex: 23/F Room/Bed #:


Chief Complaint: Labor Pains Physician: Dr. Tuason Diagnosis:
Date/Time Cues Need Nursing Diagnosis Patient Outcome Interventions Implementations Evaluation
Subjective: S • Assess normal sleep patterns.
January • Verbalization Disturbed sleep After 8 hours of R: The amount of sleep a person 7 January 28, 2020
28, 2020 s of L pattern related to nursing requires varies with lifestyle, @ 11PM
@ 4:00pm interrupted labor pains and interventions, health and age. A woman’s usual
sleep: E frequent quickening patient will sleep pattern serves as a basis “The goal is
“Nagamata-mata ko of the fetus as achieve at least for planning adequate sleep time. completely met.”
pirme kay E manifested by 8 hours of sleep, • Implement comfort measures
ginaposition nako grimaced facial as evidenced by such as back rub. 5 After 8 hours of
akong tiyan kay P expression, rested R: Physical discomfort especially interventions, pt.
sigeg lihok si baby, restlessness and appearance, during pregnancy can directly was able to display
dili ko komportable, / difficulty maintaining verbalization of influence the woman’s ability to improvement in
usahay kusog kaayo sleep state. feeling rested, fall asleep. sleeping pattern as
so makamata jud R and • Teach pt. to avoid junk foods evidenced by
ko.” Rationale: improvement in and juices before bedtime, 9 rested appearance
E Sleep deprivation sleep pattern. instead suggest drinking milk. and verbalization
“Sauna tong wala pa and disturbed sleep R: Spicy and greasy goods can of feeling rested:
gain-ani, 9pm to 6am S pattern refer to cause indigestion and heartburn;
akong tulog usually. anything that Milk contains Tryptophan, a “Mas nakatulog
Karon kay makamata T interferes with sleep, precursor of serotonin thought to kog tarong karon
mata ko kapila isa ka such as pain, induce and maintain sleep. compared
gabii” frequent change in • Evaluate sleep patterns for gahapon.”
P sleep/wake cycle and quality, quantity, time taken to 8
“Gasakit akong tiyan etc. Sleep problems fall asleep and feeling on
mao nagpaadto nako A are common among awakening.
diri. Di ko katulog ug pregnant women. R: The cycle of interrupted sleep
tarong tungod sa T Women who have results in reduced REM sleep,
kasakit.” as experienced which the body requires for rest. Paula Joyce G.
verbalized by the T disturbed sleep have • Teach the importance of Abad, St.N
patient. longer hours of labor adequate sleep during 10 BSN 2 A
E
than those who sleep pregnancy and post-partum
• Verbalization R longer hours. periods.
of not feeling R: Pregnancy involves many
rested: N physical and emotional stressors
“Sleepy ko pirmente that necessitate the need for
kay putol-putol increased periods of sleep.
akong tulog kay References:
makamata ko Ackley, B. et al • Let the patient be in a 4
everytime mag (2019). Nursing comfortable left side lying
busog.” Diagnosis Handbook: position.
12, 21. St Louis, MO: R: Lying on back is not
Objective: Elsevier recommended in the 1st stage of
• LMP: 4/16/19 labor because it can reduce
• G1P0 El-Kazek, A. et blood supply to the baby and
• AOG: 40 al (2016). The may lead to longer labor.
weeks and 5 Relationship • Teach breathing patterns, such 2
days via Between Sleep as breathing through the
LMP; 38 Disturbance in Late mouth during contractions to
weeks and 6 Pregnancy and Labor manage pain.
days via USD Outcomes. IOSR R: Patterned breathing enhances
• Restlessness Journal of Nursing & O2 flow to the baby and is also
• Grimaced Health Science. 5(6), vital to the contracting uterus.
Face p. 174-180. ISSN: • Monitor the interval, duration, 3
• Presence of 2320-1940 and severity of uterine
dark eyebags contractions.
• Dozing R: To monitor progress of labor.
• Observed • Administer sedative as 1
difficulty ordered: Nalbuphine 5mg +
maintaining Promethazine IVTT
sleep state R: Nalbuphine and Promethazine
• VS (as of are usually used to sedate
01/28 @ pregnant women on labor.
• Decrease or adjust external 6
4:00pm)
BP – 120/90 stimuli such as noise, lights
CR – 69 and temperature.
PR – 67
RR – 18 R: External stimuli can hamper
T – 36. 7 the woman’s ability to fall asleep.
FHT- 130s
• IE upon
admission
(01/28 @ References:
2:15pm done
by Dr. Alerta) Green, C. (2016). Maternal
6 cms dilated, Fully Newborn Nursing Care Plans (3rd
Effaced, IBOW ed.). p. 18-19. Jones & Bartlett
• EFM upon Learning. ISBN: 9781284038538
admission:
Moderate to strong Gulanick, M. & Myers, J.
uterine contractions (2006). Nursing Care Plans: Nursing
lasting 60 seconds Diagnosis and Interventions (6th
with an interval of 7 ed.).p 178-179. Mosby. ISBN:
to 8 minutes. 9780323059886
• Hours of
labor: 5 hours
prior to
admission
(DOA: 01/28
@ 2:15pm)
• Sedatives as
ordered:
Nalbuphine
5mg +
Promethazin
e IVTT
Bibliography:
Ackley, B. et al (2019). Nursing Diagnosis Handbook: 12, 21. St Louis, MO: Elsevier
El-Kazek, A. et al (2016). The Relationship Between Sleep Disturbance in Late Pregnancy and Labor Outcomes. IOSR Journal of Nursing & Health
Science. 5(6), p. 174-180. ISSN: 2320-1940
Green, C. (2016). Maternal Newborn Nursing Care Plans (3rd ed.). p. 18-19. Jones & Bartlett Learning. ISBN: 9781284038538
Gulanick, M. & Myers, J. (2006). Nursing Care Plans: Nursing Diagnosis and Interventions (6th ed.)..p. 178-179. Mosby. ISBN: 9780323059886