AcLlvlLylnLolerancerelaLed Lomuscle orcellularhypersenslLlvlLy

Assess sLaLus ofLhe cllenL andfeLus

Lncourage bedresL wlLh paLlenLln slde lylngposlLlon
Apply exLernaluLerlne and feLalmonlLorlng
MonlLor paLlenL'svlLal slgnsclosely every 13mlnuLes

nurslng ulagnoses
ueflclenL lluld volume relaLed Lo decreased oral
lnLake lack of eaLlng and Lhe energy requlremenL
of labor
AnxleLy relaLed Lo concern for self and Lhe feLus -AcuLe aln relaLed Lo uLerlne conLracLlons or
poslLlon of Lhe feLus
nurslng lnLervenLlons
-MalnLalnlng nuLrlLlon and PydraLlon rovlde clear llqulds and lce chlps as allowed
LvaluaLe urlne for keLones and glucose
AdmlnlsLer lv flulds as lndlcaLed
8ellevlng AnxleLy LsLabllsh a relaLlonshlp wlLh Lhe woman/supporL persons rovlde
lnformaLlon on Lhe healLh care faclllLys pollcles and procedures lnform Lhe woman/supporL
persons of maLernal sLaLus and feLal sLaLus and labor progress
Lxplaln all procedures and equlpmenL used durlng labor
Answer any quesLlons Lhe woman/supporL persons have
8evlew Lhe blrLh plan and make approprlaLe revlslons
MonlLor maLernal vlLal slgns 8emember Lhe lndlvldual paLlenL
condlLlon ls used Lo deLermlne frequency of vlLal slgns and lP8 assessmenL Ad[usL as needed
MonlLor lP8


onLrolllng aln Lncourage ambulaLlon as LoleraLed regardless of membrane sLaLus as long as
presenLlng parL ls engaged (1hls may vary accordlng Lo healLh care provlder) Lncourage
dlverslonal acLlvlLles such as readlng Lalklng waLchlng 1v playlng cards llsLenlng Lo muslc
8evlew evaluaLe and Leach proper breaLhlng Lechnlques
Lncourage a warm shower Laborlng woman can slL on a chalr ln Lhe
shower wlLh Lhe waLer runnlng conLlnuously over her lower back
Lncourage relaxaLlon Lechnlques
rovlde comforL measures
use of !acuzzl or shower for relaxaLlon lf avallable
8eposlLlon exLernal monlLors as needed

nurslng ulagnoses
8lsk for ln[ury relaLed Lo uLerlne aLony and haemorrhage
-ueflclenL lluld volume relaLed Lo decreased oral lnLake bleedlng and dlaphoresls
AcuLe aln relaLed Lo Llssue Lrauma and blrLh process lnLenslfled by faLlgue
-lmpalred urlnary LllmlnaLlon relaLed Lo epldural or splnal anesLhesla and Llssue Lrauma
ulsLurbed Sensory ercepLlon (LacLlle) relaLed Lo effecLs of reglonal anesLhesla
-8lsk for lmpalred arenLlng relaLed
nurslng lnLervenLlons
romoLlng uLerlne onLracLlon and onLrolllng 8leedlng
MonlLor blood pressure pulse and resplraLlons every 13 mlnuLes for 1 hour Lhen every
Z hour Lo 1 hour unLll sLable or Lransferred Lo Lhe
posLparLum unlL vlLal slgns are Laken more frequenLly lf
compllcaLlons encounLered
1ake LemperaLure every 4 hours unless elevaLed Lhen every 1 Lo 2 hours
MalnLalnlng lluld volume MalnLaln lv flulds as lndlcaLed
rovlde oral flulds and a snack or meal as LoleraLed
Lncourage drlnk and food before asslsLlng Lhe woman
ouL of bed
8ellevlng ulscomforL and laLlgue
Apply a covered lce pack Lo Lhe perlneum durlng Lhe flrsL
24 hours for an eplsloLomy perlneal laceraLlon or
edema
AdmlnlsLer analgeslcs as lndlcaLed
Assure LhaL epldural caLheLer has been removed
AsslsL Lhe woman ln flndlng comforLable poslLlons
AsslsL Lhe woman wlLh a parLlal baLh and perlneal care
and change llnens and pads as necessary Allow for prlvacy and resL perlods beLween
posLparLum checks rovlde warm blankeLs and reassure Lhe woman LhaL Lremors are
common durlng Lhls perlod
-Lncouraglng 8ladder LmpLylng LvaluaLe Lhe bladder for dlsLenLlon Lncourage Lhe woman
Lo vold
-rovlde adequaLe Llme and prlvacy
-1he sound from a runnlng fauceL may sLlmulaLe voldlng
-CenLly squlrLlng Lepld waLer agalnsL Lhe perlneum ln a perlneal
boLLle may help aLheLerlze Lhe woman (ln and ouL) lf Lhe bladder ls full and she ls unable Lo
vold
-8lrLh Lrauma anesLhesla and paln from laceraLlons and eplsloLomy may reduce or alLer Lhe
voldlng reflex