Student Name: Louise Margaret Tomas Client Initials: M.D. Clinical Date: 09/23/2008 Instructor: Prof.

Anne-Marie Emmanuel

LAGUARDIA COMMUNITY COLLEGE Nursing Program NURSING CARE PLAN SCR270

Nursing Diagnosis
# 1 Acute pain r/t uterine contractions, cervical dilation and fetal descent, AEB clients verbalization of feeling pain and request for pain medication.

Expected Outcomes
1. Client will use pain-rating scale to identify current pain intensity and determine comfort goal in 1 hour. Client will identify how unrelieved pain will be managed in 6 hours. Client will state ability to obtaon sufficient amount of rest and sleep in 1 week. Client will understand when to take analgesics for pain in 2 hours. Client will perform activities of recovery with reported acceptable level of pain in 12 hours. Client will be reasonably comfortable and learn pain relief methods in 12 hours.

Nursing Actions/ Implementation

1. Administer pain medication as prescribed. 2. Teach client non-pharmaceutical methods of dealing with pain such as distraction or watching TV. 3. Provide backrubs (if not contraindicated) and frequent changes in position to ease the level of pain and provide comfort and relaxation. 4. Teach breathing techniques that can help increase the clients pain threshold.

Rationale (Cite Specific Sources) Many factors affect the individuals perception of and response to pain. Fatigue and sleep deprivation may also influence response to pain. The tired woman has less energy and ability to use such strategies as distraction or imagination to deal with pain. As a result she may lose her ability to cope with labor and choose analgesics or other medications to relieve the discomfort. (London p 414) Pain during labor is caused by a number of factors. They include dilation of the cervix (primary source of pain), stretching of the lower uterine segment, pressure on the adjacent structures, hypoxia of uterine muscle cells during contractions. The areas of pain include the lower abdominal wall and areas over the lower lumbar region and upper sacrum. (London p 414)

Evaluation
9/23/08: Outcomes met. 1. Client states lowering of level of pain after medication for pain is given after 30 mins.

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#2 Risk for infection r/t

invasive procedure i.e. IV insertion, vaginal examinations.

Client will: 1. remain free from symtoms of infection during hospital stay. 2. state symtoms of infections to which be aware in 2 hours. maintain white blood cell count and differential within normal limits during hospital stay. demonstrate appropriate hygienic measures such as hand washing, oral care and perineal care in 12 hours.

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Observe and report signs of infection such as redness, warmth, discharge and increased body temperature. Assess temperature of neutropenic clients; report a single temperature of greater than (100.5 F) Oral or tympanic thermometers may be used to assess temperature in adults and infants. Encourage fluid intake. Use appropriate hand hygiene

1.Prospective surveillance study for nosocomial infection on hematologyoncology units should include fever of unknown origin as the single most common and clinically important entity (Engelhart et al, 2002). 2.Fever is often the first sign of an infection (NCCN, 2006). 3.The white blood cell count and the automated absolute neutrophil count are better diagnostic tests for adults and most children (Cornbleet, 2002). 4.The skin is the body's first line of defense in protecting the body from infection (NCCN, 2006).

1. Clients skin remains dry and there is no redness around the IV site. 2. Clients temperature is in the normal limits : 97.8 F 3. Client s skin turgor remains normal 4. Clients blood pressure 105/52 in normal limits

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#3. Risk for

constipation r/t decreased motility of the gastrointestinal tract, insufficient physical activity decreased emptying time of stomach (hormonal changes), and side effects of medication; Magnesium Sulfate.

Client will: 1.maintain passage of soft, formed stool every 1 to 3 days without straining 2. be able to identify the signs of constipation; ie: distention; inability to move bowels. 3.identify measures that prevent constipation such as keeping hydrated.

1Assess usual pattern of defecation, including time of day, amount and frequency of stool, consistency of stool; history of bowel habits or laxative use; diet, including fiber and fluid intake; exercise patterns; personal remedies for constipation; obstetrical/gynecological history; surgeries; diseases that affect bowel motility; alterations in perianal sensation; present bowel regimen. 2.Review the client's current medications. 3.If the client is receiving temporary opioids (e.g., for acute postoperative pain), request an order for routine stool softeners from the primary care practitioner, monitor bowel movements, and request a laxative if the client develops constipation. 4.Provide prunes or prune juice daily 5Encourage a fluid intake of 1.5 to 2 L/day (six to eight glasses of liquids per day), unless contraindicated because of renal insufficiency

1.There are usually a lot of reasons for constipation .The first step is assessment of usual bowel pattern. 2.Many medications are associated with chronic constipation including opiates, antidepressant ,antispasmodics, diuretics, anticonvulsants and antacids containing aluminum(Talley et al 2003) 3.Opiods lead to constipation because they decrease propulsive movement in the colon and enhance sphincter tone, making it difficult to defecate.(Robinson et al 2000) 4.The laxative effect of prunes and prune juice is widely accepted because of conventional wisdom and common experience(Stacewicz-Sepuntzakis et al 2001) 5.Cereal fibers such as wheat bran add additional bulk by attracting water to the fiber so adequate fluid intake is essential. Increasing fluid intake to 1.52.0 L per day while maintaining a fiber intake of 25 g can significantly increase the frequency of stools in clients with constipation(Weeks,Hubbartt& Michaels 2000)

1. Clients abdomen soft upon touch 2. Bowel sounds preset in all four quadrants

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1. #4 Risk for 1. Client will: 1. identify factors that are uncontrollable in 30 minutes. 2. state feelings of powerlessness and other feelings related to powerlessness (e.g., anger sadness, hopelessness) during labor process and while in recovery room. 3. ask questions about care and treatment in 30 minutes. 2.

powerlessness r/t premature labor process.

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Observe for factors contributing to powerlessness. Establish a therapeutic relationship with the client by spending oneon-one time with her. 2.

The essence of ill health is powerlessness, involving the senese of being imprisoned by cisumstances (because of limited choices and abilities) and emotional suffering. (Strandmark, 2004)

1. Not able to asses.

Clients reported as empowering the support the family members, friends, and healthcare providers (Bolse et al, 2005) and believed they had to seek out nursing care as a means of alleviating powerlessness (Shatell, 2005)

#65 Risk for anxiety r/t

medical interventions .

Client will: 1. identify and verbalize symptoms of anxiety within 15- 30 minutes. 2. identify, verbalize and demonstrate techniques to control anxiety within 15-30 minutes.. 3. demonstrate some ability to reassure self within 30-45 minutes.

1. Assess cleints level of anxiety and physicial reaction to anxiety (e.g. tachycardia, tachypnea, nonverbal expressions of anxiety. Consider using The Face Anxiety Scale. 2. If the situational response is rational, use empathy to encourage the client to interpret the anxiety symptoms as normal. 3. Explain all activities, procedures, and issues that involve the client; use nonmedical terms and calm, slow speech. Do this in advance of procedures when possible, and validate the clients understanding.

1. It is an easy to use and accurate way to measure anxiety. (Gustad, Chaboyer & Wallis, 2005) 2. The way a nurse interacts with a client influences his/ hers quality of life. Enhancing self-esteem and providing information and psychological support promotes the clients well-being and his or her quality of life. (Alasad & Ahmad, 2005)

1. Client performed deep breathing exercises and stated she felt a little bit calmer.

3. Triad communication or talking to another staff or family member in front of the client is a way to provide addtionial information to assist in understanding (Davidhizar & Dowd, 2003)

References: London, M. L., Ladewig, P. W., Ball, J. W. & Bindler, R. C. (2007). Maternal & Child Nursing Care (2nd Ed.). New Jersey: Pearson Education, Inc.