N C P : 2 N D S TA G E O F L A B O R

CUES/EVIDENCES

NURSING
DIAGNOSIS

NURSING
INTERVENTIONS

Subjective:
-Verbalized: sakit na kaau, lami na
iutong
-Verbalized: dili na nako
maagwanta ang kasakit.
-Rated pain as 10 (in a scale of 1-10
with 10 as the most painful and 0 as
the least)
Objective:
-Vital signs
T= 36.5 C
PR= 74 bpm regular, and bounding
RR= 20 cpm, regular and effortless
BP= 110/80 mmHg weeks

Altered comfort: Acute pain related to

the birth process

Independent:
1. Monitor V/S

OBJECTIVES:
Within our care during the delivery
process, the client shall have reduced
perception of pain as evidenced by:

2. Stay with client and provide support.

-LMP: July 24, 2010

-EDC: May 1, 2010
-AOG: 38 4/7
-Facial grimacing noted
-Loud moaning
-Frequent complains of pain
-Sweating noted
-Holds tightly to the side portion or
the side rail of the bed
-Diaphoresis
-Panting
-Constantly moving or unable to be
still

3. Minimal facial grimaces

CUES /
EVIDENCES
Objective:

Vital signs:
T= 36.5 C
PR= 74 bpm regular, and
bounding

1. V/S will remain or be within normal

range (T=36.5-37.5 C; PR=60-100
BPM; RR=12-20 CPM; Bp= 120140/60-90 mmHg)
2. Reduction of sweating

4. Demonstration of proper deep

breathing techniques
5. Demonstration of effective pushing
6. Decreased restlessness
7. Decreased moaning
8. Verbalized no pain during
episiotomy

NURSING
DIAGNOSIS
Risk for infection related to presence of
episiotomy and tissue trauma
OBJECTIVES:
Within our care during delivery process,
the client will have no signs and
symptoms of infection as evidenced by:

3. Encourage relaxation and rest after

contraction
4. Assist client in assuming optimal position
for pushing or bearing down.
5. Use distraction techniques.
6. Provide comfort measures such as
perineal care, cool environment, clean and
dry linens.
7. Inform the patient about the progress of
delivery.
8. Handle nurse performs Ritgens
maneuver.
Collaborative:
9. Administer local anesthesia as prescribed.
(Lidocaine 10cc injected via the perineal
area)

NURSING
INTERVENTIONS
Independent:
1. Assess the condition of episiotomy
site.
2. Monitor amount of swelling,

RATIONALE

1. Heart rate usually increases with pain

2. Having support persons increase the
patients sense of security and safety
during the labor process.
3. Complete relaxation between
contractions promotes rest and
facilitates proper pushing.
4. Proper positioning optimizes bearing
down efforts, facilitates labor progress
and reduces discomforts
5. This heightens ones concentration
upon nonpainful stimuli to decrease
ones awareness and experience of
pain.
6. Promotes psychological and physical
comfort, allowing client to focus on
labor.
7. Letting the client know the progress of
delivery ensures cooperation and
minimizes anxiety thus reducing the
pain perceived.
8. This maneuver prevents further
laceration.
9. Blocks the generation and conduction
of action potentials n sensory nerves
by reducing sodium permeability,
reducing height and rate of rise of the
action potential, increasing excitation
threshold, and slowing conduction
velocity.
RATIONALE

1. To monitor the general integrity of

the skin. A healthy skin can
contribute to the faster healing of
the wound.
2. To determine the status of the

EVALUATION

At the end of our care

during the delivery
process, our goal was
partially met as evidenced
by:
1. Vital signs were
not taken prior to the
third stage of labor
2. Sweat was still
present
3. Facial grimacing
was still noticed
4. Demonstrated
proper deep breathing
techniques.
5. Demonstrated
effective pushing but
was still not enough. A
nurse did fundal push.
6. Decreased
restlessness
7. Had minimal
moaning
8. Did not verbalized
pain during episiotomy

EVALUATION
At the end of our care during
delivery process, the goal
was partially met as
evidenced by:
1. Vital signs were not taken

RR= 20 cpm, regular and

effortless
BP= 110/80 mmHg weeks

1.
V/S will remain or be
within normal range (T=36.5-37.5 C;
PR=60-100 BPM; RR=12-20 CPM;
Bp= 120-140/60-90 mmHg

redness and pain in the

episiotomy.
3. Observe the principles of surgical
asepsis during episiorraphy

Midline episiotomy done

2.
Episiorrhaphy done
without any signs of infection

3rd degree laceration

3.

4. Instruct client to avoid movements

and to remain in lithotomy position
during episiorrhaphy.
5. Assist physician in suturing the
episiotomy

Primigravida

Presence of bulging,
swelling, edematous perineum
due to pressure of presenting
part of the fetus

Intact suture

4.
Minimal swelling and
redness in the perineum

episiotomy.
3. Prevent contamination of the
sterile field this minimizing further
complications.
4. To avoid further injury of the
episiotomy wound.

prior to the third stage of

labor
2. Episiotomy intact without
any signs of infection.
3. Intact suture was made.

5. Assisting in episiotomy repair

helps the physician for easy
manipulation and smooth flow of
the procedure, by this time you
can also assess the condition of
the episiotomy.

4. Minimal swelling and

redness on the perineum
noted after episiotomy
repair.
5. No foul odor noted

The delivery process was

done for almost 2 hours

5.
No foul odor in the
perineum

The operation started at

11:50 am and ended at2 pm

6.

No exudates passes

7.
Remain in lithotomy
position
8.
Observance of sterile
technique by the physician and
student nurses

6. Only blood gushed out

from the perineum
7. Remained in lithotomy
position
8. Persons with direct care
to the patient wore gloves
and observed sterile
techniques