Nursing Diagnosis and Nursing Plan

Nursing Diagnosis and Nursing Plan Disturbances in pain comfort are associated with increased frequency and intensity of uterine contractions. Objective: After carrying out nursing actions for 1 x 3 hours the patient can adapt to pain with KH: - Looks relaxed between contractions. - Can control the causes of pain. Intervention: a) Assess the degree of discomfort through verbal and non-verbal cues. b) Explain the cause of the pain. c) Teach clients how to control pain by using appropriate breathing/relaxation techniques and waist mass d) Assist with comfort measures eg: rubbing of legs, back, sacral pressure, change of position. e) Encourage the client to urinate every 1-2 hours, palpate above the symphysis to determine whether there is distension after the nerve block. f) Time and record the frequency, intensity and pattern of uterine contractions every 30 minutes g) Monitor vital signs. Resti injury/distress to the fetus is related to tissue hypoxia. Objective: After carrying out nursing procedures for approximately 1 x 3 hours, no injury occurred to the fetus with KH: FHR within normal limits. Intervention: a) Perform palpation (leopold) to determine fetal position, lying and presentation. b) Count the FHR and note periodic changes in response to uterine contractions. c) Note the progress of labor. Maternal injury resistance is associated with slowed gastric mortility, a physiological drive. Objective: After carrying out nursing actions for approximately 1 x 2 hours, no injury occurred to the mother with KH: - The client stated the risks and reasons and specific interventions were understood. - Clients cooperate to protect themselves/the fetus from injury. - Client is free from injury/complications Intervention: a) Monitor uterine activity, note the frequency, duration and intensity of contractions. b) Do bed rest when labor becomes more intensive. Avoid leaving clients without attention. c) Place the client in a slightly upright position on the left side d) Provide perineal care every 4 hours. e) Monitor temperature and pulse. f) Give ice cubes or clear liquids to clients if possible, avoid solid foods. g) Encourage the client to breathe short and fast or blow if there is an urge to push. Resti gas exchange disorders in the fetus are related to changes in O2 supply or blood flow: anemia and secondary bleeding. Objective: There is no gas exchange disturbance in the fetus with KH: - DJJ is within normal limits (120-160 x/minute). - The baby does not experience hypoxia during delivery. Intervention: a) Assess maternal factors or conditions that reduce uteroplacental circulation. b) Monitor DJJ every 15-30 minutes. c) Monitor DJJ immediately if the membranes rupture. d) Monitor the size of the fetus in the birth canal through vaginal examination. e) Assess changes in FHR during contractions. Acute pain and comfort disorders are related to tissue dilatation or stretching and hypoxia, mechanical pressure from the presenting part. Objective: Patients can tolerate pain with KH: - The client stated that the pain had decreased. - The client is able to use appropriate techniques to maintain control, resting between contractions. Intervention: a) Assess the degree of disability through verbal and non-verbal cues. b) Assess the client's changes to physical touch during contractions. c) Monitor the frequency, duration and intensity of uterine contractions. d) Help the client and teach him to change his breathing to be faster, for example: short, fast breaths. e) Provide a quiet environment with adequate ventilation. f) Do sacral/back rubs, change positions. g) Monitor cervical dilatation. h) Note the perineal protrusion. i) Encourage the client to urinate (latent phase) j) Provide encouragement and information about the progress of labor and provide reinforcement for the client/partner's efforts. k) Monitor maternal and fetal vital signs. l) Collaborative administration of analgesics. Resistant to decreased cardiac output associated with decreased venous return, hypovolemia, changes in systemic vascular resistance. Objective: There is no decrease in cardiac output with KH: - Vital signs correspond to the stage of labor. - There is no edema, FHR is within normal limits (120-160 x/minute). Intervention: a) Assess blood pressure and pulse between contractions, as indicated b) Note the presence and extent of edema. c) Monitor FHR during and between contractions. d) Infusion fluid balance. Lack of knowledge related to a lack of information sources. Objective: The client and family know about the birth process with KH: - The client understands the physiological response after giving birth. - Clients actively participate in efforts to encourage increased placental expulsion.about process labor Intervention: a) Discuss the normal process of third stage of labor. b) Explain the reasons for behavioral responses such as biting, tremors. c) Discuss recovery period routines during the first 4 hours after delivery.