Assessment/Cues Nursing Diagnosis Background Goals and Nursing Evaluation

Knowledge Objectives Interventions and

Subjective Acute pain related Labor pain is After 30 minutes Independent After 30 minutes
to uterine generated by of nursing of nursing
contractions contractions of the interventions, the interventions, the
Patient states that she uterus's muscles and patient will be Educate the client patient,
has a bad stomach pressure on the able to: on pain distractions
ache cervix. This like deep breathing,
discomfort manifests
as severe abdominal
pain visual imagery, and
relaxation
 Verbalize
d
Objective cramps, groin pain,
and back pain, as
contrpti techniques reduction
of pain
 These non-

Guarding behaviour
well as an achy
sensation. ons pharmacolo
gic comfort
(pain
scale of
2/10)
(+) Facial grimace
she measures
work by
 Appears
to be
Restlessness providing
Diaphoresis
would diversion
relaxed
between
uterine
Increased HR (102 like te Provide massage contractio
ns
bpm) and/or counter
 Verbalize Was able
Pain scale of 9/10 pressure and/or
reduction to use
of pain assist patient to find
appropriat
 Appear position of
e
relaxed maximum comfort
technique
and be able  Changing s to
to rest positions enhance
 between and using comfort
uterine counter and
contraction pressure maintain
s may help control of
 Will be alleviate labor
able to use discomfort process
appropriate caused by
(Focused
techniques pressure of
breathing,
to enhance presenting
comfort parts on Visualizat
and bony ion,
maintain structures, Guided
control of ligaments, imagery,
labor or tissue. and
process Massage Change in
helps positions.
relieve Relaxatio
muscle n through
tension. music)

Provide positive
reinforcement and
encouragement to
patient
 Gives sense
of control
and self-
confidence

Dependent
Provide
information about
available
analgesics, usual
responses/side
effects (client and
fetal), and duration
of analgesic effect
in light of current
situation.
 Providing
information
allows the
patient to
make
informed
decisions
regarding
pain control

Administer pain
medications as
ordered (Fentanyl)
 Fentanyl
stimulates
mu-opioid
receptors in
the central
nervous
system
(CNS),
altering the
body's
response to
pain.