Nursing Diagnosis 1: Powerlessness related to painful contractions and duration of labor
Goal: Client will demonstrate that she feels some control over the labor process after 30 minutes.
Evaluation: Client expresses preferences for position and techniques to
control pain; asks questions about her progress and states feelings
about what is happening.
Allow her to be out of bed walking or sitting up in bed.
Assess couple for contributing factors related to feelings of loss of control.
Assist with using controlled breathing exercises and position changes.
Reinforce information learned in childbirth education classes.
Slowly and clearly explain the events and changes occurring with the active stage of labor.
Inform the couple of things that can and cannot be controlled.
Reassure, as appropriate, that labor is proceeding without problems.
Provide continued emotional support throughout labor and provide privacy as appropriate.
Encourage the husband to continue to actively support his wife.
Administer analgesia and anesthesia according to the policies.
Nursing Diagnosis 2: Risk for infection related to early rupture of membranes.
Goal: Client will remain free of signs and symptoms of infection.
Evaluation: Temperature remains below 100.4°F (38°C); pulse,
respirations, and blood pressure remain within acceptable parameters of
client’s baseline values.
Obtain vital signs, at least every 1 to 2 hours and report any temperature above 100.4°F (38°C).
Perform perineal care frequently, especially after each voiding and any bowel movements.
Change bed linens and pads as soon as they become soiled or moist.
Use aseptic techniques when performing pelvic examination.
Administer IV fluids as ordered to maintain fluid balance.
A woman whose membranes have ruptured should lie on her side until a
fetal monitor shows good baseline variability and no variable
decelerations or she has been checked to cofirm the head of the fetus
is well engaged to prevent the umbilical cord prolapse into the vagina
Give the cleansing
Nursing Diagnosis 3: Risk for ineffective breathing pattern related to breathing exercises.
Outcome Identification: Client will not experience hyperventilation when using breathing techniques during labor.
Evaluation: Client’s respiratory rate is within normal limits; skin
pink, cool, and dry. No reports of lightheadedness or tingling/numbness
To halt hyperventilation, the woman should keep a paper bag nearby when
doing breathing exercises. She can ward off symptoms of
hyperventilation by breathing in and out into the paper bag. This
causes her to rebreathe the carbon dioxide she exhales, thus replacing
the carbon dioxide lost.
If a paper bag is unavailable, she can use her cupped hands instead.
Prevent hyperventilation by making certain that when the woman is
breathing rapidly she is not hyperventilating, and that she ends all
breathing sessions with a long cleansing breath to help restore carbon
Nursing Diagnosis 4: Anxiety related to stress of labor.
Goal: Client will manage the stress of situation with positive coping mechanisms.
Outcome Evaluation: Client states that she feels
somewhat in control of her situation; she and her support person
express confidence in themselves and health care personnel.
Help the woman to perceive labor clearly and providing the opportunity
for her partner to provide support as well as being personally
available to provide support to the woman and her partner throughout
the labor process.
Offer Support. There is no substitute for personal touch and contact as a way to provide support during labor.
Patting a woman’s arm while telling her that she is progressing in
labor, brushing a wisp of hair off her forehead, wiping her forehead
with a cool cloth— help to convey concern.
Nursing Diagnosis 5: Risk for fluid volume deficit
related to prolonged lack of oral intake and diaphoresis from the
duration of labor
Goal: Client will not experience fluid volume deficit during labor.
Outcome Evaluation: Client states that she does not feel thirsty; voids at least 30 mL/h every 2 to 4 hours.
Limit the amount of oral fluid or food intake during labor to ice chips
or lollipops to prevent aspiration if, in an emergency, general
anesthesia administration should be necessary.
Provide frequent mouth washes and apply a cream to her lips.
Allow her to suck on hard candy or ice chips relieve this discomfort.
Women in prolonged labor may need additional fluid and caloric intake
to prevent secondary uterine inertia (a cessation of labor
contractions) and generalized dehydration and exhaustion.
If all oral fluids are contraindicated by the birth plan, intra-venous
glucose solutions may be administered to maintain caloric reserve.
هــذا كل اللــي عندي ، وتــرى هذا من جهــدي ، وان شـاء اللهـ اي شي جديد راح انزلهـ ع طوووول
والاهـــم الافــادة للجميــع
دمتــم بحفظ الرحمن