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    DR NCP 2

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    Wenn Joyrenz Maneclang
    The nursing care plan is for a patient in labor named M.Q.M. The patient is complaining of difficulty relaxing between contractions and lower back pain. The nursing diagnosis is deficient knowledge of effective pushing techniques. The nursing interventions include instructing the patient on effective pushing positions and techniques. The objective is that after 30 minutes of instruction, the patient will be able to push effectively. Observation of the perineum during pushing is also included to ensure safety of the mother and baby.

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    DR NCP 2

    Uploaded by

    Wenn Joyrenz Maneclang
    72 views2 pages
    The nursing care plan is for a patient in labor named M.Q.M. The patient is complaining of difficulty relaxing between contractions and lower back pain. The nursing diagnosis is deficient knowledge of effective pushing techniques. The nursing interventions include instructing the patient on effective pushing positions and techniques. The objective is that after 30 minutes of instruction, the patient will be able to push effectively. Observation of the perineum during pushing is also included to ensure safety of the mother and baby.

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    The nursing care plan is for a patient in labor named M.Q.M. The patient is complaining of difficulty relaxing between contractions and lower back pain. The nursing diagnosis is deficient knowledge of effective pushing techniques. The nursing interventions include instructing the patient on effective pushing positions and techniques. The objective is that after 30 minutes of instruction, the patient will be able to push effectively. Observation of the perineum during pushing is also included to ensure safety of the mother and baby.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    72 views2 pages

    DR NCP 2

    Uploaded by

    Wenn Joyrenz Maneclang
    The nursing care plan is for a patient in labor named M.Q.M. The patient is complaining of difficulty relaxing between contractions and lower back pain. The nursing diagnosis is deficient knowledge of effective pushing techniques. The nursing interventions include instructing the patient on effective pushing positions and techniques. The objective is that after 30 minutes of instruction, the patient will be able to push effectively. Observation of the perineum during pushing is also included to ensure safety of the mother and baby.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    of 2

    PATIENT M.Q.M.

    PATIENT DATA RECORD NURSING CARE PLAN

    CUES/ CLUES

    NURSING DIAGNOSIS

    SUBJECTIVE

    OBJECTIVE

    Deficient knowledge: SHORT TERM:


    Effective pushing
    Patient verbalized having
    After 30 min of
    techniques
    difficulty relaxing between
    nursing instruction in
    contractions and is
    more effective
    complaining of lower back
    pushing techniques,
    pain. She cries and says she
    patient will be able to
    cant take it anymore,
    do effective pushing
    properly and will do it
    whenever there are
    contractions
    OBJECTIVE
    VS taken as follows
    BP: 110/70
    HR 79/min,
    RR 18/min,
    Temp: 37.0
    Contractions occur every
    1 min and 40 sec and
    last for 70 sec and strong
    in intensity
    7-8 cm/90%/C/R/ station

    NURSING INTERVENTION

    RATIONALE

    INDEPENDENT

    SHORT TERM:

    Teach patient how to


    effectively push:
    - Instruct patient to do a
    dorsal recumbent position
    - Instruct patient to breathe
    deeply, stop breathing and
    push for 10 secs and to
    slowly gasp air
    - Instruct her to look at her
    stomach while pushing

    Observe patients perineum for


    fetal crowning with each push.

    Dont talk to Cathy


    unnecessarily in between
    contractions

    EVALUATION

    Effective pushing will help After 30 min of


    nursing instruction
    the baby to descend
    in more effective
    easily
    pushing
    techniques,
    patient could do
    effective pushing
    properly and did it
    whenever there
    are contractions

    Observation permits the


    nurse to maintain the
    safety of both the mother
    and the baby.
    Silence allows her to
    conserve her energy for
    pushing efforts that are
    progressing well.

    Page 2 of 2
    Maneclang, Wenn Joyrenz U. RLE 6.3 (2NUR-6)

    CUES/ CLUES
    SUBJECTIVE

    NURSING DIAGNOSIS
    Pain r/t effects of
    uterine contractions

    Patient verbalized having


    difficulty relaxing between
    contractions and is
    complaining of lower back
    pain

    OBJECTIVE
    VS taken as follows
    BP: 120/70
    HR 82/min,
    RR 19/min,
    Temp: 37.0
    Contractions every 3
    min for 60 sec and
    strong in intensity
    5 cm/50%/C/I/ station 2

    OBJECTIVE

    NURSING INTERVENTION

    SHORT TERM:
    INDEPENDENT
    After 1 hr of nursing
    intervention, patient
    will express
    Encourage patient to try
    assurance that she
    positions such as sidecan manage labor
    lying, or leaning at the
    pain satisfactorily
    back of the bed and
    remind her to change
    positions about every 30
    minutes or when she
    feels the need for a
    change.

    RATIONALE

    SHORT TERM:
    After 1 hr of nursing

    Teach patient simple


    breathing and relaxation
    techniques

    Observe patients suprapubic


    area and palpate for a full
    bladder at least every 2
    hours. Remind her to void if
    she has not done recently

    Tell Cathy about her


    progress in labor.
    Explain that she will
    probably begin to dilate
    faster now that she has
    entered active phase of
    labor.

    EVALUATION

    These positions shift the


    weight of the fetus away
    from the sacral
    promontory, reducing
    back pain. Alternating
    positions relieves strain
    and constant pressure
    and helps the fetus adapt
    to the pelvis.
    Breathing techniques
    provide distraction from
    pain and enhances
    normal labor process

    A full bladder contributes


    to discomfort and can
    prolong labor by
    obstructing fetal descent

    Encouragement and the


    knowledge that her
    efforts having the desired
    results increase a
    womans willingness to
    continue

    intervention, patient
    expressed assurance
    that she can manage
    labor pain
    satisfactorily

    Page 1 of 2
    Maneclang, Wenn Joyrenz U. RLE 6.3 (2NUR-6)

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