NURSING CARE PLAN

DELIVERY ROOM
Problem: Labor Pain

Assessment Explanation of the Objectives Implementation Rationale Evaluation

Problem
Subjective Labor pains are STO: Introduce self to the Builds rapport and after 8 hours of
data: experienced when the within the hours client as student nurse reduces communication nursing
“ Masakit na contraction of the of labor, 30 for the shift. barriers between client interventions
talaga tyan ko” uterus becomes minutes to 8 and nurse the mother was
As verbalized intense pressing on hours, the mother During labor able to
With a pain the nerve endings will be instructed Gather baseline data Serves as an initial effectively
scale of 9/10 located in the how to effectively such as temperature, assessment so as to know deliver a
with the abdomen to the use her energy to respiratory rate, pulse where to start healthy baby
highest at 10 lumbar area during perform rate and blood pressure intervention and which and was able to
and lowest rate labor. It is not only techniques that include amount of things need to be follow the
at 0. the contractions that will effectively bleeding (pads used) prioritized directions given
stimulate the nerves deliver her baby and interval, frequency by the nurse
Objective but also the size of and to reduce her and intensity of labor when bearing
data: the fetus that will anxiety. contractions. down and
-facial grimace pass through the breathing
-guarding pelvic inlet of the LTO: Watch out for Meconium and fouls through pursed
behavior mother. Within 8 hours meconium stained, foul smelling amniotic fluid is lip.
-bears down When the pelvis, after the labor to smelling amniotic fluid indicative of high risk
during perineum and the the delivery of the babies and needs to be The mother’s
contractions uterus prepare fetus and placenta immediately endorsed for pain scale also
-interval – themselves for the Mother’s pain immediate delivery or dropped down
every 2- 3 expulsion of the fetus will be reduced to action. to 5 in a scale of
minutes the contraction a manageable 0-10, with 10
-frequency – becomes frequent and scale of 5/10 in a Observe for nonverbal Nonverbal cues are often being the
every 3 intensifies as the scale of 0- 10 cues such as facial seen in patients who are highest level
minutes labor progresses. Pain with 10 as the expressions and body in pain, these will aid in after the
-duration – 3 from the abdomen highest and 0 is movements to gather proper assessment since administration
minutes due to the the lowest data about severity of some patients cannot of prescribed
-irritability contractions radiate Through pain. describe what they feel drug, massages
observed to the lumbar area following and and are more likely to and rest periods
-restlessness where pain is also carrying out the become irritable and that allowed the
noted felt. doctor’s orders restless. mother enough
-tries to relieve about bed rest, IV time to regain
self by mouth incorporation for Feel the intensity of Assessing the intensity, her strength
breathing pain, diversional contractions on the frequency and duration after labor and
-massages activities, health abdomen of the client of contractions will tell delivery.
lumbar area teachings and to be sure when to ask the nurse what stage the
-abdomen feels other types of the mother to bear mother is already in and
rigid pain management. down if the mother is ready for
-BOW delivery or not.
ruptured

Nsg Dx: Massage in circular Massage is therapeutic, it

Abdominal motion the lumbar area can relieve the pain
pain radiating of the client during through touch and help
to lumbar area labor the blood circulate
related to making a certain muscle
continuous relax and stronger.
uterine
contraction and Perform nipple Nipple stimulation is
passage of stimulation by gently effective with mothers
fetus through massaging the nipples who have difficulty in
pelvic inlet on the mother with labor due to less amount
secondary to fingertips to release of oxytoxin the release of
labor. oxytoxin the hormone will aid in
dilation of the cervix for
faster delivery.

Assist the attending Since nurses are not

physician when allowed to perform I.E,
checking for the assisting the physician
dilation of the cervix of and taking note of the
the mother cervical dilation will also
tell the nurse if mother is
ready for delivery or
needs more time for
labor.

Encourage the mother Bearing down is effective

to bear down when she in the expulsion of the
feels the contraction of fetus during delivery,
her uterus during during labor it is being
delivery taught to the mother so
she will have an idea
when to bear down
during delivery.

Encourage the mother Purse lip breathing will

to do purse lip minimize the use of
breathing during labor energy while in labor and
and delivery during delivery
Of the baby

During delivery Due to the large size of

Assist the mother to the abdomen of the
assume lithotomy mother, assisting her to
position on the delivery assume a lithotomy
table position on the delivery
table will make the
mother feel comfortable.

Gather baseline data The baseline data will

particularly vital signs serve as an assessment
 for the status of the
mother and maybe
essential to know if there
are any deviations to be
reported to the attending
physician

Incorporate oxytoxin Hyosine and oxytocin

in D5LRS x 1l as will aid in the dilation of
prescribed by the the cervix to lessen the
doctor time of labor

Administer 2 ampules This medication will

HNBB intermuscularly soften the cervix further
to aid in the dilation of
the cervix

Allow the mother to Rest periods will make

rest when tired of the mother gain energy to
bearing down continue with the bearing
down and to make the
mother comfortable
during delivery

Remind mother to bear Reminding the mother to

down only when bear down only when
contraction is felt there is contraction to
make the delivery of the
baby more effective and
will cause less pain and
less effort during
 delivery.

Remind mother again Remember to remind the

about mouth breathing mother about purse lip
Or pursed lip breathing breathing so as to
conserve energy during
labor and delivery

After Delivery After care and perineal

Perform after care care will make the
mother comfortable and
will prepare the mother
to be transferred to the
ward so she will have
bedrest according to the
advise of the physician.

Apply diaper to mother The diaper will catch all

after perineal care and secretions and blood
episiotomy from the mother to serve
as a basis for blood lost
after birth

Record time of Proper documentation

delivery, sex of baby, will serve as a legal
and date of delivery document for the making
of birth certificates and
other documentations
needed.
ward
give the mother Do not give the mother
prescription drugs anything that is not
depending on the need prescribed by the
and as prescribed by physician. Prescription
the physician drugs will also lessen the
pain the mother is feeling
after giving birth.

massage the fundus of Massaging the fundus

the mother every now after giving birth will
and then to make it make the uterus
firm and contracted contracted thus lessening
the bleeding and
lessening the opportunity
for shock

advise the mother not Bedrest will make the

to get up but to stay in mother regain her
bed for the following strength after the delivery
hours as prescribed by and this will also
the attending physician minimize the bleeding.

assess the mothers Assessing signs for shock

circulation and vital will help prevent it as
signs while taking into soon as possible
consideration signs of
shock

provide comfort Comfort measures will

measures – extra help the mother have
blanket, quiet more relaxation time and
environment, dim will also make the
lighted room or mother regain most of
surrounding her lost energy during
labor and delivery
endorse client to family Significant others can
or significant others take part in the patient
and to staff nurse care thus maximing well
being of the client due to
the involvement of the
family. This can also
reduce anxiety on the
part of the client.

record and document Records and documents

observations and data serves as legal basis and
about client and client as a report about the
care. patient’s condition.

Advising the client about

Include health certain things that needed
teachings that will to be done after birth
make the client especially breastfeeding
understand and aim for will help the mother lose
her well being such as weigth, have a healthier
diet, lifestyle, lifestyle and not get
breastfeeding and pregnant for a few
activities months after birth thuis
giving herself and her
baby good health.