NSG DIAGNOSIS Subjective Cues: Anxiety r/t Is this going to 1. Absence take much of a longer?

Ive done compani everything you on said! as stated. 2. Inability to use breathin g Objective Cues: exercise - Restlessnes effective s ly secondary to - Facial giving birth as Grimace/ evidenced by Tension restlessness - Anger and difficulty - Fidgeting - Extraneous concentrating Movements - Limited ROM - Pain related to giving birth - 3 to 4cm cervical dilatation - Anxiety

ASSESMENT

SCIENTIFIC EXPLANATION Intrapartal stage of giving birth Cervical Dilatation and Effacement Tissue Damage Pain Transmission of Pain perception to the Amygdala Parabrachial nucleus Dorsomedial nucleus of the vagus nerve

PLANNING Discharge outcome: After discharge, the client will be able to appear relaxed and report that anxiety was reduced to a manageable level. Short-Term Outcome: After 8hrs of nursing intervention, the client will be able to: 1. Verbalize that anxiety is decreased from mild to moderate anxiety

IMPLEMENTATI ON Independent: 1. Observe behaviors of the client 2. Monitor maternal vital signs

RATIONALE -

EVALUATION

3. Monitor fetal heart rate 4. Establish a therapeut ic

Discharge this may outcome: point out GOAL PARTIALLY level of MET anxiety or After discharge, any changes the client will be able to appear relaxed and to identify report that physical anxiety was responses reduced to a associated with medical manageable or emotional level .Rec: Continue conditions plan Ref: Handbook Short-Term for MedOutcome: Surg Nsg, Brunner and After 8hrs of nursing Suddarth intervention, the 12th ed, pg. client will be able 76 to: to note if 1. Verbalize anxiety is that affecting the anxiety is childs decreased condition

Level: Moderate

Lateral hypothalamus Anxiety Restlessnes s Facial Grimace Difficulty to concentrat e

2. Demonstra te signs of effectivene ss of comfort measures to relieve pain 3. Demonstra te signs of effectivene ss of anxiety manageme nt

relationsh ip with the patient or support person, convey empathy 5. Encourag e client to express feelings 6. Provide a variety of comfort measures for pain felt - position changes - proper deep breathing provide a calm and quiet environm ent

to assist client in identifying feelings of anxiety

from mild to moderate anxiety GOAL MET Rec: Terminate plan 2. Demonstra te signs of effectivene ss of comfort measures to relieve pain GOAL MET Rec: Terminate plan 4. Demonstra te signs of effectivene ss of anxiety manageme nt GOAL MET

for client to develop selfawareness

Ref: Handbook for Med-Surg Nsg, Brunner and Suddarth 12th ed, pg.469

to promote nonpharmacolo gic pain mgt and help minimize pain felt Ref: Handbook for Med-Surg Nsg, Brunner and Suddarth 12th ed, pg. 77 -

Collaborative: 1. Administe r analgesia as prescribe d by the physician

Rec: Terminate plan pharmacolo gic mgt to reduce pain