Utilizing all of the above data you have collected, create a plan of care for this woman/family using

2-3 separate priority issues. Be very specific in the interventions. ASSESSMENT/NURSING DIAGNOSIS Nursing Diagnosis Diagnosis #1 Acute pain r/t uterine contractions during labor Subjective data: Mother requests epidural, increasingly loud as contractions progress. Outcome/Goal Intervention/ Implementation Assessed mothers level of pain Encouraged spouse to encourage her, Gave water, fanned mother, applied damp cloth to her forehead. Allowed mother to change position when needed. Rationale & Source Pain is a highly subjective state assessment of pain experience is the first step in planning pain management strategies (Gulanick, M & Meyers, J. (2006) pg 144) Support measures are often more effective when delivered by a familiar person (Perry, Evaluation Intervention was successful as evidenced by mother showed increased ability to cope with the pain.

Mother exhibits signs of ability to cope with discomfort

S.E., Hockenberry, M.J., Lowdermilk, D.L., & Wilson, D. (2005) pg 514)

Comfort measures to relieve diaphoresis, change in position helps relieve stiffness and helps avoid cramping. (Perry et al. (2005) pg514)

Objective data: Facial grimacing, clenched fists, diaphoresis, moaning

Nursing Diagnosis

Outcome/Go al

Intervention/ Implementation

Rationale & Source

Evaluation

Diagnosis #2

Fatigue r/t increased energy expenditure secondary to labor and birth.

Subjective data:

Mothers energy level restored following birth.

Talked to mother about and emphasized need for rest after the birth. Monitor mothers level of fatigue

Pt states exhaustion, wishes to sleep immediatel y after birth.

Objective data:

Fatigue is common in the postpartum period and involves both physiologic components associated with long labors, cesarean birth, anemia, and breastfeed and psychologic components related to depression and anxiety. The excitement and exhileration experienced after the birth of the infant may make rest difficult. Arranging specific periods for rest and sleep will ensure that the mother can restore depleted energy levels. (Perry et al. (2005) pg 614,
514) Monitoring mothers level of fatigue allows us to ensure mothers restoration of energy (Perry et al. (2005) pg 514)

Interventions effective as evidenced by mothers energy level increasing and increased movement following birth.

Pt exhibits visible lack of energy, very tired, limited concentrati on at times

Diagnosis #3

Fear r/t loss of control and unpredictab le outcome secondary to newborn distress at birth
Subjective data

Patient verbalizes or manifests a reduction or absence of fear.

Encourage patient to verbalize problems and concerns. Answer questions and concerns of patient if able to do so. (Doctor and translator did this) Maintain calm manner while interacting with mother. Encourage spouse to stay with mother until more information is provided about infant condition.

Mother has increased questioning , crying,

Objective data

Interventions were successful in alleviating Verbalizing fears and concerns provides validation patient fears as of their concerns and enables evidenced by reassessment. (Gulanick et patient states reduction of fear al. (2006) pg 69) when infant condition The health care provider explained. can transmit his or her own anxiety to the client. The patients feeling of stability increases in a calm and nonthreatening atmosphere. (Gulanick et al. (2006) pg 70) The presence of significant others reinforces feelings of security for the patient in times of fear. (Gulanick et al. (2006) pg 70)

Mother tense, visually upset, trembling, crying

References (APA Format) Gulanick. M & Meyers J. (2006) Nursing Care Plans: Nursing Diagnosis and Intervention (6th ed) St. Louis: Mosby Elsevier Perry, S.E., Hockenberry, M.J., Lowdermilk, D.L., & Wilson, D. (2005). Maternal child nursing

care. (3rd ed.). St. Louis: Mosby Elsevier