- Acute Pain related to muscle contractions as evidenced by moaning, crying, wincing and
verbalization of pain - Anxiety related to perceived threat to baby and fear of unexpected outcomes as evidenced by increased tension and feelings of inadequacy
- Risk for Decreased Cardiac Output related to complications from labor and delivery and decreased fluid volume as evidenced by signs and symptoms
| Assessment | Nursing Diagnosis | Planning/Outcomes | Intervention | Evaluation |
| Subjective Data: -Verbal reports from the patient -Expressions of pain, such as crying -Unpleasant feeling (such as a prick, burn, or ache) Objective Data: -Significant changes in vital signs -Changes in appetite or eating patterns -Changes in sleep patterns -Guarding or protective behaviors | Acute Pain related to muscle contractions as evidenced by moaning, crying, wincing and verbalization of pain | Patient will verbalize a decrease in pain. Patient will show signs of being at ease and comfort, as evidenced by resting and breathing even and unlabored. Patient will demonstrate and utilize practices that will help reduce the pain, such as relaxation and breathing techniques and changes in body positioning. | 1. Establish a rapport with the patient and their significant other. Entertaining any questions they may have will reduce barriers in communication, ultimately easing any fears and promoting trust and relaxation. 2. Instruct the patient on breathing techniques. Breathing can help distract from pain. The nurse can instruct on breathing techniques such as belly breathing or pant-pant-blow breathing through contractions. 3. Discuss pain relief options. The mother should be in charge of her labor plan. The nurse can discuss and explain options for pain relief and help the mother decide what is best for them. 4. Assist the patient in positioning. Adjusting the body’s positioning will help limit fatigue and enhance circulation. Allow the mother to decide which positions relieve pain, such as side-lying, leaning, or on all fours. 5. Provide comfort measures. Back rubs, pillows for better positioning, and ice cubes can provide short-term relief. 6. Administer analgesics if ordered. An epidural can be placed to block pain below the waist. The nurse assists the anesthesiologist with positioning and preparing the site for epidural insertion in the lower back. | Patient reported relief of pain. Patient rated the pain scale lower than the initial rate at a level that is acceptable to them or 0/10. Patient manifested vital signs within normal limits. Patient verbalized regaining appetite and sleep. |
| Subjective Data: -Feeling nervous -Verbalizing a sense of impending danger -Difficulty controlling one’s worrying Objective Data: -Restlessness and tense appearance -Tachycardia -Tachypnea -Hyperventilation -Diaphoresis -Trembling/tremors -Weakness or tiredness -Difficulty concentrating -Difficulty sleeping GI distress | Anxiety related to perceived threat to baby and fear of unexpected outcomes as evidenced by increased tension and feelings of inadequacy | Patient will verbalize ease of worries and stress. Patient will express feelings of concern and anxiety. Patient will utilize support systems effectively. | 1. Acknowledge the patient’s feelings and verbalizations that may indicate guilt. Knowing how the patient feels towards the process will help gauge how they understand why interventions can sometimes be required during labor and delivery and that these choices are available because they may be medically necessary and not because they are lacking personally. 2. Acknowledge and include their support system. Keeping the significant other/s involved during the process, as well as praising them for any progress, will help establish rapport and trust, leading to a more relaxed environment during childbirth. 3. Maintain a calm demeanor, giving clear and concise explanations. During emergency deliveries, anxiety may occur due to the process not meeting their expectations. The nurse should remain calm and assertive to maintain control of the situation. 4. Encourage relaxation techniques. To keep the abdominal wall from becoming tense, the patient needs to be instructed in proper relaxation techniques such as deep-breathing exercises, effleurage (light, rhythmic, circular strokes on the abdomen), and gentle massages of the shoulders and limbs. This will allow the uterus to rise with contractions without pressing against the hard abdominal wall. 5. Provide a calm environment. Labor can be a long process. When appropriate, keep lighting dim and noises and interruptions to a minimum to allow for rest. | Relieved the following: -Restlessness and tense appearance -Tachycardia -Tachypnea -Hyperventilation -Diaphoresis -Trembling/tremors -Weakness or tiredness -Difficulty concentrating -Difficulty sleeping -GI distress |
| Subjective Data: -Verbalizes Increased thirst -Dizziness Objective Data: -Dehydration -Fluid and electrolyte imbalance -Decreased fluid volume -Hypertension -Hypotension -Cardiac conditions -Childbirth process | Risk for Decreased Cardiac Output Related to complications from labor and delivery and decreased fluid volume as evidenced by signs and symptoms | Patient will remain free from any signs of decreased cardiac output, like arrhythmias, shortness of breath, and alterations in vital signs. The fetal heart rate will remain within normal limits. | 1. Instruct the patient to lie in the left lateral side-lying position. Lateral positioning on the left side increases stroke volume and venous return, ensuring adequate blood circulation throughout the body. 2. Monitor for any signs of bleeding. Pregnant women are prone to bleeding during labor and delivery. Heavy vaginal bleeding and a significant decrease in blood pressure must be monitored during labor and delivery, as this can further complicate cardiac output. 3. Administer supplemental oxygenation as needed. Oxygenation may be compromised in patients who are in labor. Providing supplemental oxygenation can help ensure adequate circulating oxygen and uteroplacental perfusion. 4. Monitor vital signs after anesthesia. Spinal anesthesia is used in the event of C-section delivery and carries the risk of cardiovascular effects like hypotension with compensatory tachycardia and increased stroke volume. 5. Perform fetal heart monitoring. The fetal heart rate is monitored during labor and delivery and should be between 110-160 beats per minute. Late decelerations are caused by decreased blood flow to the placenta from maternal dehydration, hypotension from epidural, anemia, and hypoxia. | Patient remained free from any signs of decreased cardiac output, like arrhythmias, shortness of breath, and alterations in vital signs. The fetal heart rate remained within normal limits. |