I need help with my nursing care plan for a labor/delivery patient. I am a level one RN student on my first OB clinical rotations and care plans are still very new to me. I must turn in a concept map with supporting data for each of my diagnoses and an intervention sheet with at least 6 interventions and patient responses to each. Minus the patient responses, here is what I have so far:
#1 Nursing Diagnosis
Acute Pain r/t uterine contractions and stretching of cervix and birth canal
External monitoring of contractions, Patient states "I am hurting," noticeable facial grimace, muscle tension, increased RR, Client rates pain as 9/10, diaphoresis
Client will report that pain management regimen relieves pain to satisfactory level
Client will maintain <4 pain on scale of 1-10 during my shift
1. Assess pain level every hour and prn 2. Administer Stadol IV every 4 hrs and prn3. Assist with epidural 4. Provide nonpharmacologic techniques 5. Encourage client to try different positions 6. Teach simple breathing and relaxation techniques 7. Limit visitors as she desires 8. Keep informed about the progress of labor and Baby's condition 9. Prevent pain when possible during procedures
#2 Nursing Diagnosis
Fatigue r/t childbirth
Supporting Data ??????? HELP?????
Patient will verbalize increased energy and improved well-being
Patient will verbalize environment is suitable for satisfactory rest during my shift
. Assess level of fatigue prn 2. Allow client to express what best helps her relax 3. Limit visitors as she requests 4. Prepare the environment to promote rest 5. Administer pain medication to relieve pain and promote rest 6. Limit the number of times she is interrupted Try to administer medication, check VS, or or other actions in one room visit 7.Teach methods to help relax
#3 Nursing Diagnosis
Anxiety r/t fear of unknown and situational crisis
Supporting Data: Facial tension, increased perspiration, increased pulse ?????? This doesn't sound right?????
Patient will have vital signs that reflect baseline and will verbalize decreased anxiety
Patient will have a relaxed facial expression and body posture between contractions
1. Determine the couple's plans for birth and work with them as much as possible 2. Explain all activities, procedures and issues that involve the client 3. Stay with client as much as possible during labor
!!!!!!!!!!NEED MORE INTERVENTIONS!!!!!!!!!!!!!!
#4 Nursing Diagnosis
Risk for Infection r/t multiple vaginal exams and tissue trauma
Supporting Data!!!!!!!!!NEED SUPPORTING DATA!!!!!!!!!!
Patient will remain free from infection
Patient will free from signs of infection as evidenced by normal VS during my shift
Assess and report signs of infection such as Swelling, discharge, increased body temp and warmth 2. Follow Standard Precautions3. Use sterile technique when inserting Foley 4. Use appropriate hand hygiene 5. Teach patient proper perineum care 6. Teach patient the symptoms of infection and when to report to physician 7. Teach patient proper episiotomy care 8. Monitor VS