Process Tool

LaGuardia Community College
City University of New York
Student Name Louise Margaret Tomas
Date: 09/23/2008
Client’s Initials M.D. LDR #10 Age 25
Sex__F__ Religion Hindu
Occupation Unemployed
Cultural/Ethnic Background Indian
Admitting Date 09/23/2008
Reason for Admission: Premature onset of
Admitting Diagnosis_Contractions
Secondary Diagnosis None
.Surgical Procedure Possible Cesarean
Health History G3P2002. GA 31weeks 4
days. LMP unknown. EDD 11-21-2008.
Previous gynecological history is unknown. No
known drug allergy.
Need Data - Label S for Subjective, O for Objective
Activity at home prior to admission: Pt reported
her pregnancy to be uneventful. (S)
Present level of activity: Pt currently on prescribed
bedrest for the remainder of her labor and delivery;
especially since she was pre-term, with cervical
dilation of 4.5cm and 80% effacement. (O)
Degree of mobility – restrictive devices, e.g.
monitoring, IV, note any hyperreflexia: Pt has a
fetal heart rate monitor and a tocodynamometer
attached. She was receiving 125mL/hr in her left
forearm. No hyperreflexia observed. (O)
Sleep pattern prior to admission – Did labor
begin at night or during daytime hours?
(compare pre-pregnancy, pregnancy,
labor/delivery): Client was at home when she
started to feel contractions; she went to the
Women’s Health Clinic and was referred to the
Labor and Delivery department. Client requested
alleviation from the contraction pain via medication.
Present pattern of rest during labor – naps,
Data Analysis
Nursing Diagnosis
The client on prescribed bed rest is unable to
ambulate to relieve pressure and pain during
labor. Elevating the head of the bed, back rubs
and frequent changes in position contribute to
comfort and relaxation. A side-lying position is
generally the most advantageous for the laboring
woman. (London p 362)
Electronic monitoring may be done externally
with a device placed against the maternal
abdomen. The portion of the monitoring
equipment called a tocodynamometer, or “toco”,
is positioned against the fundus of the uterus and
held in place with an elastic belt. When the uterus
contracts, the fundus tightens and the change in
pressure against the toco is amplified and
transmitted to the electronic fetal monitor.
(London, p 430-31)
During pregnancy, adequate rest is important for
both physical and emotional family health.
Women need more sleep, particularly in the first
trimesters, when they tire easily. Without enough
rest, pregnant women have less resilience.
(London p 256)
Acute pain r/t uterine
contractions, cervical dilation
and fetal descent, AEB client’s
verbalization of feeling pain
and request for pain
Impaired comfort r/t pain of
labor process AEB pt’s
grimacing and holding breath
during contractions.
Impaired physical mobility
r/t restrictive devices and
position for labor, pain,
swelling, and tissue trauma
AEB pt being hooked up to an
IV and continuous fetal
monitoring, labor pains.
transition: Client was observed resting after she
received Magnesium Sulfate 4% continuous IV, 5
grams/ hour. (O)
Urinary elimination during labor –: She did not
void during the time I was there. The bladder did
not appear distended with visualization; but I was
unable to palpate. (O)
Assistive measures –catheterization or other? No
catheterization or other assistive measures used. (O)
Bowel evacuation during labor – last bowel
movement (compare pre-pregnancy and during
pregnancy): Pt. was not observed having a bowel
movement. I could not ask when her last bowel
movement was since she was being prepped for
delivery. (O)
Assistive measures –enema?: No assistive
measures or enemas were observed. (O)
Physical fatigue often affects adjustments and
functions of the new mother. It can reduce milk
flow, therefore increasing problems with
establishing breastfeeding. Energy is also needed
to adjust to a new infant and to assume new roles.
(London p 472)
Many factors affect the individual’s perception of
and response to pain. Fatigue and sleep
deprivation may also influence response to pain.
The tired woman has less energy and ability to use
such strategies as distraction or imagination to
deal with pain. As a result she may lose her
ability to cope with labor and choose analgesics or
other medications to relieve the discomfort.
(London p 414)
During labor, gastric motility and absorption of
solid food are reduced. Gastric emptying time is
prolonged, and gastric volume (amount of
contents that remain in the stomach) remains
increased, regardless of the time the last meal was
taken. Some narcotics also delay gastric emptying
time and add to the risk of aspiration if general
anesthesia is used. (London p 414)
A woman may be quite thirsty and may drink
large amounts of fluid following childbirth. This
helps to replace fluids lost in labor, in urine and
through perspiration. The bowels tend to be
sluggish following childbirth because of the
lingering effects of progesterone and decreased
abdominal muscle tone. Constipation can result
from refusing or delaying a bowel movement.
(London p 448)
Risk for constipation r/t
decreased motility of the
gastrointestinal tract,
insufficient physical activity
decreased emptying time of
stomach (hormonal changes),
and side effects of medication.
Degree of anxiety and attitude towards
pregnancy: Pt was anxious and her anxiety level
increased as the contractions progressed in intensity
and duration. She also became very anxious
because she did not know if her baby was “going to
make it”(O + S)
Stage of growth and development: achievement
of developmental tasks: The pt is in Erikson’s
intimacy versus isolation stage. She is listed as
Single in her registration and no next of kin was
present or listed in her chart. The involvement of the
FOB (father of baby) is unknown. (O + S)
Preparation for labor and delivery – classes
(Lamaze or other), literature: Client received
prenatal care from East New York Clinic but did not
attend labor or child preparation classes. (S)
Significant other/support person present at
labor: No support person/ significant other was
present while I was there. (O)
Ability to communicate –appropriateness,
language problems
Cultural/Ethnic/ Religious influences:
Client spoke English, so no language barrier was
Client listed Hindu as her religion but did not
mention if she had any spiritual/ religious
preferences for her labor and delivery.
Developing maternal confidence is a major
component of childbirth education. The Council
of Childbirth Education Specialists encourages
education that focuses on the interconnectedness
of the mind and spirit. Once that is understood,
coping strategies, stress reduction, and relaxation
techniques are taught. Childbirth preparation
programs typically have an education component
aimed at eliminating fear and teaching coping
techniques. The programs teach relaxation
techniques, conditioning exercises, and breathing
patterns to use during labor. (London p 191)
The nurse and clients of different cultural and
ethnic backgrounds have additional barriers to
overcome in the teaching-learning process. These
barriers include language and communication
problems, differing concepts of time, conflicting
cultural healing practices, and beliefs that may
positively or negatively influence compliance
with health teaching. (Kozier p 464)
Praise for breathing, relaxation, and pushing
efforts not only encourages repetition of the
behavior but also decreases anxiety about the
ability to cope with labor. (London p 459)
Knowledge of values, customs, and practices of
different cultures is as important during labor as it
is in the prenatal period. Without this knowledge a
nurse is less likely to understand a family’s
behavior and may attempt to impose personal
values and beliefs on them. (London p 454)
The manner in which a woman chooses to deal
with the discomfort of labor varies widely. Some
Risk for powerlessness r/t
premature labor process .
Risk for anxiety r/t medical
interventions .
women turn inward and remain very quiet during
the whole process. Others may be very vocal, with
behaviors such as counting or shouting. It is
important to be aware of these cultural differences
and support the laboring woman in whichever
way she chooses to deal with her pain as long as it
is not harmful to the fetus (London p 360)
Relaxation during labor allows the woman to
conserve energy and the uterine muscles to work
more efficiently. Without practice it is difficult to
relax the whole body in the midst of intense
uterine contractions. (London p 191)
The laboring woman's support system may
influence the course of labor and birth. The
presence of the father and significant others
(especially the nurse) tends to have a positive
effect. A labor partner's presence at the bedside
provides a means to enhance communication and
to demonstrate feelings of love. Enhancement of
the birthing experience is beneficial to the
mother-baby connection. Presence of the father
during birth also can enhance father-baby
bonding. (London, p 318-19)
It is important to support a woman’s individual
expression, whatever it may be (as long as harm is
not done to another), in order to enhance the
birthing experience for mother, baby, and family.
(London p 455)
Indicators of positive resolution in Erikson’s stage
of intimacy versus isolation include an intimate
relationship with another person and commitment
to work and relationships. Indicators of negative
resolution include impersonal relationships,
avoidance of relationships, career, and lifestyle
commitments. (Kozier p 357 and 958)
Past obstetrical history –TPAL, concurrent
medical problems e.g. diabetes, herpes, AIDS:
Pt is G3P2002. She has no known gynecological
problems and no known diseases at present. She has
no known drug allergies.
Present obstetrical history-gestation, fetal
presentation (if you are present at birth APGAR
Gestation is 31 weeks and 4 days.
LMP is unknown.
EDD 11-21-2008.
She is Rubella IgG immune.
HIV (ELISA) is nonreactive.
GBS is unknown (usually done at 36 weeks
Chlamydia trachomatis is negative.
Fetal presentation is suspected as cephalic. (O)
Immediate environment for comfort; Birthing
room is clean and well lit. Her sheets are clean. The
midwife placed a large plastic bag under pt’s
buttocks in order to maintain a clean environment
and to catch all secretions and waste. (O)
Level of awareness –latent, active or transitional
labor: Pt is A Ox3. (O)
Visual disturbances – blurred vision: Client
denied any visual disturbances and does not use any
visual aids. (S + O)
T= number of term infants born—that is, the
number of infants born after 37 weeks’ gestation
or more.
P= number of preterm infants born—that is, the
number of infants born after 20 weeks’ gestation
but before the completion of 37 weeks’ gestation.
A= number of pregnancies ending in either
spontaneous or therapeutic abortion.
L=number of currently living children.
(London p 214)
GBS is a bacterial infection found in the lower
gastrointestinal or urogenital tracts. Women may
transmit GBS to their fetus in utero during
childbirth. Newborns become infected in one of
two ways: by vertical transmission from the
mother during birth or by horizontal transmission
from colonized nursing personnel or colonized
infants. GBS causes severe, invasive disease in
infants. Intrapartum antibiotic therapy is
recommended. (London p 369)
Pain during labor is caused by a number of
factors. They include dilation of the cervix
(primary source of pain), stretching of the lower
uterine segment, pressure on the adjacent
structures, hypoxia of uterine muscle cells during
contractions. The areas of pain include the lower
abdominal wall and areas over the lower lumbar
region and upper sacrum. (London p 414)
Risk for injury r/t physiologic
changes that have occurred
during labor and delivery.
Risk for infection r/t invasive
procedure i.e. IV insertion,
multiple vaginal examinations.
Number of hours in labor, pain management
(anesthesia and implications):
Medications (actions and implications: side
1. Penicillin G Potassium IV bolus 2.5 million units
in 50 mL of NS once only for four hours.
2. Fentanyl Citrate 0.05 mg/mL IV bolus 25 mcg
once only.
3. Lactated Ringers IV continuous100 mL/hour.
4. Penicillin G Benzathine 2.5 million units/mL
IVPB once.
Fluid balance –IV administration, edema
(location, pitting): Pt is receiving Lactated Ringers
IV continuous 100 mL/ hour. There is no edema
Delivery: NSVD. Forceps or C/S (indications),
type of incision (C/S or episiotomy),
implications/potential complications):
Pt did not deliver while I was present. (O)
Vaginal discharge- amniotic (test done, i.e.
ferning, nitrazine) or other (color, quantity,
odor), bleeding: Not Applicable.(O)
Lab results –Urinalysis (protein, glucose, blood),
VDRL, BUN, sonogram, amniocentesis, estriol
A urine dipstick was done while client was in triage
but the findings were not documented yet. (O)
Latent Phase: The woman is talkative and smiling
and is eager to talk about herself and answer
questions. Excitement is high, and her partner or
other support person is often as elated as she is.
Active Phase: When a woman enters this phase
her anxiety tends to increase as she senses the
intensification of contractions and pain. She
begins to fear a loss of control and may use a
variety of coping mechanisms.
Transition Phase: Anxiety increase significantly,
she may become restless, frequently changing
positions, and afraid of being left alone. Women
ability to cope with labor may decrease and
become apprehensive, irritable, and withdrawn.
(London p 407-8)
Vital signs:
BP 105/52,
P 90,
RR 20,
T 97.8 F
Skin color and temperature: Skin was pink and
warm to the touch with good turgor. (O)
Fetal heart tones –rate, strength, regularity,
decelerations, internal or external monitor:
External fetal monitor and external tocometer was
used. FHR stayed within normal limits of 120-160.
There was good variability and no decelerations or
accelerations were noted. (O)
Fetal activity level (note if changes in NST or
OCT results): Pt reported normal fetal movements.
Newborn initial assessment (Apgar etc.): Not
Breathing pattern –diaphragmatic, rapid,
shallow, costal, patterned breathing (Lamaze):
Pt held her breath for approximately 3-4 seconds
during contractions. (O)
Assistive measures- oxygen: Client was given
Oxygen 8L/ min. (O)
Breathing techniques may help the laboring
woman. Used correctly they increase the woman’s
pain threshold, permit relaxation, enhance the
woman’s ability to cope with the uterine
contractions, and allow the uterus to function
more efficiently. (London p 461)
Lab results –Blood type and Rh, CBC, platelet
count, NSTs, OCTs, Fetal scalp samples:
Maternal Blood Type A positive. (O)
A more natural approach that lets the mother wait
to bear down until she feels an urge to push may
shorten the pushing phase, reducing the incidence
Ineffective breathing pattern
r/t pain AEB observation of pt
holding breath at times during
of physiologic stress in the mother and acidosis in
the newborn. This technique may also decrease
the incidence of instrument births and damage to
maternal perineal tissue. (London p 465)
Applying cool cloths to the face and forehead may
help cool the woman involved in the intense
physical exertion of pushing. (London p 465)
General appearance: Pt is small in stature (5 feet)
and appears well nourished with no obvious signs of
dehydration. (O)
Weight gain since conception (compare with prepregnancy)
Client’s pre-natal chart was not present; client
stated: “I didn’t expect to be in labor”. (O+S)
Last food intake since beginning of labor:
Last food intake of chicken and rice was at 18:30 on
09/22/2008. (O)
Vomiting or nausea:
No complaints of nausea or vomiting. (S)
The recommended weight gain for women of
normal weight before pregnancy is 25to 35lb
(11.4 to 15.9kg). Underweight women are
advised to gain the weight needed to reach their
ideal weight plus 25 to 35lb (11.4 to 15.9). The
average pattern of weight gain is 3.5 to 5lb (1.6 to
2.3 kg) during the first trimester and 12 to 15lb
(5.5 to 6.8) during each of the last two trimesters.
Adequate nutrition and weight gain are important
during pregnancy. (London p 200)
Risk for nutritional
knowledge deficit r/t client’s
Lab results – Urinalysis- presence of blood,
sugar, or protein:
Urinalysis was done but not documented. (O)
Priority Diagnosis # 1: Ineffective breathing pattern ineffective r/t pain AEB observation of pt holding breath at times during
contractions and pushing.
Expected Outcomes
Client will demonstrate a breathing pattern that supports blood gas results within the client’s normal parameters within 30
Client will report ability to breathe comfortably within 30 minutes.
Client will be knowledgeable about when contractions are starting and will take cleansing breaths in and out through the mouth
within 30 minutes.
Assess V/S q15 min for first hr and q2hr thereafter
Monitor rate, depth and ease of respirations q15 min for first hr and q2hr thereafter.
Teach proper breathing techniques, and offer reassurance when done correctly.
Monitor client’s oxygen saturation.
Continue to administer O2 .
(Ackley and Ladwig, p 221-26)
Priority Diagnosis # 2: Acute Pain r/t uterine contractions, cervical dilation and fetal descent, AEB client’s verbalization of feeling
pain and request for pain medication.
Expected Outcomes
Client will use pain-rating scale to identify current pain intensity and determine comfort goal in 1 hour.
Client will identify how unrelieved pain will be managed in 30 minutes.
Client will state ability to obtain sufficient amounts of rest and sleep in 1 day.
Client will understand when to take analgesics for pain in 30 minutes.
Client will perform activities of recovery with reported acceptable level of pain in 12 hours.
Client will be reasonably comfortable and learn pain relief methods in 1 hour.
Administer pain medication as prescribed.
Teach client non-pharmaceutical methods of dealing with pain such as distraction, or watching TV.
Provide backrubs and frequent changes in position to ease the level pain and provide comfort and relaxation.
Teach breathing techniques that can help increase the client’s pain threshold.
(Ackley and Ladwig, p 710-18)