Lncourage bedresL wlLh paLlenLln slde lylngposlLlon Apply exLernaluLerlne and feLalmonlLorlng MonlLor paLlenL'svlLal slgnsclosely every 13mlnuLes
nurslng ulagnoses ueflclenL lluld volume relaLed Lo decreased oral lnLake lack of eaLlng and Lhe energy requlremenL of labor AnxleLy relaLed Lo concern for self and Lhe feLus -AcuLe aln relaLed Lo uLerlne conLracLlons or poslLlon of Lhe feLus nurslng lnLervenLlons -MalnLalnlng nuLrlLlon and PydraLlon rovlde clear llqulds and lce chlps as allowed LvaluaLe urlne for keLones and glucose AdmlnlsLer lv flulds as lndlcaLed 8ellevlng AnxleLy LsLabllsh a relaLlonshlp wlLh Lhe woman/supporL persons rovlde lnformaLlon on Lhe healLh care faclllLys pollcles and procedures lnform Lhe woman/supporL persons of maLernal sLaLus and feLal sLaLus and labor progress Lxplaln all procedures and equlpmenL used durlng labor Answer any quesLlons Lhe woman/supporL persons have 8evlew Lhe blrLh plan and make approprlaLe revlslons MonlLor maLernal vlLal slgns 8emember Lhe lndlvldual paLlenL condlLlon ls used Lo deLermlne frequency of vlLal slgns and lP8 assessmenL Ad[usL as needed MonlLor lP8
onLrolllng aln Lncourage ambulaLlon as LoleraLed regardless of membrane sLaLus as long as presenLlng parL ls engaged (1hls may vary accordlng Lo healLh care provlder) Lncourage dlverslonal acLlvlLles such as readlng Lalklng waLchlng 1v playlng cards llsLenlng Lo muslc 8evlew evaluaLe and Leach proper breaLhlng Lechnlques Lncourage a warm shower Laborlng woman can slL on a chalr ln Lhe shower wlLh Lhe waLer runnlng conLlnuously over her lower back Lncourage relaxaLlon Lechnlques rovlde comforL measures use of !acuzzl or shower for relaxaLlon lf avallable 8eposlLlon exLernal monlLors as needed
nurslng ulagnoses 8lsk for ln[ury relaLed Lo uLerlne aLony and haemorrhage -ueflclenL lluld volume relaLed Lo decreased oral lnLake bleedlng and dlaphoresls AcuLe aln relaLed Lo Llssue Lrauma and blrLh process lnLenslfled by faLlgue -lmpalred urlnary LllmlnaLlon relaLed Lo epldural or splnal anesLhesla and Llssue Lrauma ulsLurbed Sensory ercepLlon (LacLlle) relaLed Lo effecLs of reglonal anesLhesla -8lsk for lmpalred arenLlng relaLed nurslng lnLervenLlons romoLlng uLerlne onLracLlon and onLrolllng 8leedlng MonlLor blood pressure pulse and resplraLlons every 13 mlnuLes for 1 hour Lhen every Z hour Lo 1 hour unLll sLable or Lransferred Lo Lhe posLparLum unlL vlLal slgns are Laken more frequenLly lf compllcaLlons encounLered 1ake LemperaLure every 4 hours unless elevaLed Lhen every 1 Lo 2 hours MalnLalnlng lluld volume MalnLaln lv flulds as lndlcaLed rovlde oral flulds and a snack or meal as LoleraLed Lncourage drlnk and food before asslsLlng Lhe woman ouL of bed 8ellevlng ulscomforL and laLlgue Apply a covered lce pack Lo Lhe perlneum durlng Lhe flrsL 24 hours for an eplsloLomy perlneal laceraLlon or edema AdmlnlsLer analgeslcs as lndlcaLed Assure LhaL epldural caLheLer has been removed AsslsL Lhe woman ln flndlng comforLable poslLlons AsslsL Lhe woman wlLh a parLlal baLh and perlneal care and change llnens and pads as necessary Allow for prlvacy and resL perlods beLween posLparLum checks rovlde warm blankeLs and reassure Lhe woman LhaL Lremors are common durlng Lhls perlod -Lncouraglng 8ladder LmpLylng LvaluaLe Lhe bladder for dlsLenLlon Lncourage Lhe woman Lo vold -rovlde adequaLe Llme and prlvacy -1he sound from a runnlng fauceL may sLlmulaLe voldlng -CenLly squlrLlng Lepld waLer agalnsL Lhe perlneum ln a perlneal boLLle may help aLheLerlze Lhe woman (ln and ouL) lf Lhe bladder ls full and she ls unable Lo vold -8lrLh Lrauma anesLhesla and paln from laceraLlons and eplsloLomy may reduce or alLer Lhe voldlng reflex