N C P : 3 R D S TA G E O F L A B O R

CUES/EVIDENCES
Subjective:
-Verbalized agay sakit.
-Rated pain as 7 in a range of 0 as no
pain and 10 as severe pain.
Objective:
-Vital signs
T= 36.5C
PR= 74 bpm strong, regular
RR= 20 cpm shallow, regular
BP= 110/80 mmHg
-Facial grimacing is evident
-Profuse sweating noted
-Patient raised her buttocks when the
physician removed blood clots in the
uterus
-3rd degree laceration
-Delivered her baby on 12:08 AM
-Primigravida
-Midline episiotomy done

NURSING DIAGNOSIS
Altered comfort: Acute pain related to tissue
trauma secondary to 3rd degree laceration

INTERVENTION

RATIONALE

Independent:
1.Monitor the vital signs

Within our care during the delivery of the

placenta, the client will be have reduced
perception of pain as evidenced by:
1. V/S will remain or within normal range:
T= 36.5-37.5 C
PR= 60-100 bpm
RR= 16-20 cpm
BP= 110-140/60-90 mmHg
2. Absence of facial grimacing
3. Minimal sweating

2.Encourage client to report type, location,

and intensity of pain, rating on a scale of
0-10. Note associated symptoms.
3.Teach and encourage continuing the use
of deep breathing exercises.
4.Encourage client to remain in her position
5.Tell client the progress of her labor and
delivery. Tell client when the placenta is
out.
6.Teach client not bear down anymore.

4. Absence of guarding behaviour

5. Remain in the
lithotomy position

1.Heart rate usually increases

with pain.
2.Pain is perceived, manifested
and tolerated individually.
Severe pain should be
investigated further for
possible complications.
3.Breathing techniques increase
the womans pain threshold,
encourage relaxation,
provide distraction, enhance
the ability to cope with
uterine contractions, and
allow the uterus to function
more efficiently.
4.To gain cooperation from the
client. To prevent sudden
movement during the
ongoing operation.
5.The client will gain increase
pain threshold since she will
have the knowledge that the
ongoing process will end
sooner if she will cooperate.

CUES/EVIDENCES
Subjective:
-Verbalized laylay na akong tiil
Objective:
-Lithotomy position used during the
delivery process
-The patient is exhausted during the
labor and delivery process
-Trembling of the legs felt
-Physician always remind the patient to
remain in her position
-Narrow DR bed

NURSING DIAGNOSIS
Risk for physical injury related
to lithotomy position
OBJECTIVES:
Within our care during the 3rd
stage of labor, our patient will
be free of injury as evidenced
by:
1. Being free from falls.

INTERVENTION

6.To preserve her energy and

focus more on deep
breathing exercises instead
RATIONALE

Independent
1. Note anticipated length of procedure and
customary position. Provide for potential
complications.

1. Lying for longer than 1 hour in a

lithotomy position leads to intense
pelvic congestion because blood flow
to the lower extremities is impeded.
Pelvic congestion may lead to an
increase in thrombophlebitis in the
postpartal period. It may also
contribute to excessive blood loss with

EVALUATION

At the end of our care

during the delivery of the
placenta, the goal was
partially met as evidenced
by:
1.BP = 120/ 70 mmHg
Other vital signs
were not taken after
placenta delivery
2.Facial grimacing was
still observable
3.Sweating was still
present on the
patients forehead
4.Did not guard her
perineum or the
abdomen
5.Lifted her buttocks
during the removal
of blood clots done
by the physician
even if instructed
not to do so

EVALUATION
At the end of our third
stage of labor care, the
goal was partially met as
evidenced by:
1.Free of falls
2.Verbalized laylay
akong tiil
pagkahuman

-Bed doesnt have side rails

-Body has no bruises
-No thrombophlebitis

2. Report resolution of
numbness, tingling, or
changes in sensation related
to positioning within 24-48
hour as appropriate.
3. Absence of bruises or
wounds at areas not included
in the delivery procedure.
4. Absence of cool, clammy
skin in lower extremities.

birth and placental loosening.

2. Review clients history, noting age,

weight/height, nutritional status, physical
limitations/ preexisting conditions that may affect
choice of position and skin/tissue integrity during
surgery.
3. Stabilize DR table

5. Free from cyanotic feet nail

beds.
6. Being free of
thrombophlebitis

4. Teach the client not to move and remain in her

position. Stress out the importance of remaining
still.
5. Position extremities so they may be periodically
checked for safety, circulation, nerve pressure,
and alignment. Monitor peripheral pulses and skin
color/ temperature.
6. Place legs in stirrups simultaneously, adjusting
stirrups height to clients legs, maintaining
symmetrical position.

2. Many conditions can make individual

prone to injury. It is also useful to
modify actions according to the clients
condition.
3. To prevent falls and loss of balance.
Some clients with larger body mass
needs more assistance during
positioning to prevent injury.
4. To gain cooperation from the client. To
prevent sudden movement during the
ongoing operation.
5. To check for the circulation to the lower
extremities. Cyanotic nail beds, cool,
clammy skin may be indications of
poor circulation and to take emergent
actions if it occurs.
6. Prevents muscle strain. Prolonged
positioning in stirrups may lead to
compartment syndrome in calf
muscles.

3.No bruises
observed on the
body parts of the
body
4.Extremities were
warm and not
pale
5.Nail beds appeared
pinkish
6.No signs and
symptoms of
thrombophlebitis