Problem
Case Scenario
Juanita Perez is a 22-year-old married female who is in active labor. Mrs. Perez is a gravida I who was admitted 4 hours ago at 39- and 5/7-weeks gestation. Mrs. Perez has had an uncomplicated, planned pregnancy and is 6 centimeters (cms) dilated. Mrs. Perez's cervix is 100% effaced and the baby is at-1 station. Her uterine contractions are every 3 to 4 minutes lasting 60 to 90 seconds and are of moderate to severe intensity.
Nursing Assessment
Mrs. Perez vital signs are: blood pressure-122/ 74; heart rate-90 beats per minute; respiration rate-24 breaths per minute; temperature-99.2°F. orally. The fetal heart rate is 135 baseline with accelerations with uterine contractions. Mrs. Perez has a moderate bloody show and amniotic fluid leakage appears clear. Mrs. Perez tells you; I really want "to go naturally." "I am trying not to take the epidural anesthesia, but it is really painful." My husband is trying to help me maintain my breathing and concentration with the techniques we learned in class. "I don't know how much longer I can take this!"
Task
A. Identify significant symptoms and group the symptoms that are similar.
B. Select possible nursing diagnoses for this client.
C. Validate the possible nursing diagnoses.
Compare the signs and symptoms (defining characteristics) that you have identified from your client assessment with the defining characteristics for the nursing diagnosis that you have selected. Also read the definition and determine if this diagnosis fits this client.
D. Write/select a nursing diagnostic statement for one of the nursing diagnoses by combining the nursing diagnosis label with the related to (r/t) factors.