Early stages of labor care plan.

[kynewbie]

Hi all,

I am completing my maternity rotation and am having a hard time coming up with a diagnosis for my last patient. She is a 31 yr old, gravida 3, para 2, admitted because she was in discomfort and has previously had rapid labor once her water has broken. She has been in the hospital overnight and a pitocin drip was started at 0930. She is dilated at 4cm with 50% effacement and remained at that the entire day. She never established a regular contraction pattern and upon questioning the attending nurse, she said she was not in actual labor. The physician checked her while I was there and said he would not rupture her membranes until she had a more regular and stronger contraction pattern. She was only in mild discomfort the whole day. Her husband was there with her and provided great support. Her blood pressure and vitals were stable and withing normal limits. I have already written one care plan for alteration in comfort r/t child birthing process but am stumped as to what else to use. I have had better success writing my care plans since I have been writing them straight from my assessment data, but what do you do if there are no abnormalities? Any help would be greatly appreciated. Thanks so much.

[Esme12, ASN, BSN, RN]

the nursing process

the nursing process is a systematic, problem solving process utilized in nursing to identify and treat the nursing diagnoses (problems) of a client - it involves: adpie

-assessment

collecting information concerning the patient's health status from the patient, family, others, medical record, charts, observation, physical exam.

- diagnosing

information is sorted, clustered and analyzed to identify patient's actual or potential health problems. nursing diagnosis is written and placed in priority.

-planning

patient goals or outcomes are set and nursing actions are identified to prevent, correct or relieve health problems. the plan is specific and individualized to meet the patient's needs.

-implementation

is where the care is delivered and the actions are carried out.

-evaluation

the plan is reviewed to determine if the patient's needs are being met and the goals are being achieved. here the plan can be modified, continued, or discontinued

http://www.childbirths.com/euniversity/nursingprocess.htm grat site care plan example

[teensmom]

Her abnormality is that her labor stalled. Her pitocin was not effective in getting her contractions regular.

[clearblue3]

I haven't done an OB care plan but any anxiety? Or what about risk for ineffective coping r/t fatigue during labor or limited mobility ? or what about her positioning and possible decreased circulation? like risk for decreased cardic output r/t supine hypotension secondary to position? I don't know...just some ideas :-) Good luck! I a working on a care plan too and I can't wait to have it done!! :-)