Problem
Sally Rodgers, a 25-year-old nullip in labor at term who is dilated 3 cm. This is a change from 2 cm over the previous 90 minutes. Sally is having frequent, strong to palpation contractions that are extremely uncomfortable. She is trembling, complaining of nausea, and begging her nurse for pain relief. The patient's primary nurse believes epidural anesthesia would be appropriate and informs the obstetrician (OB) attending. The OB attending states he wants the patient to be dilated 4-5 cm before she receives the epidural. The nurse reiterates to the attending OB that she assesses that the patient is in active labor. Although Sally's cervix has not demonstrated active labor yet, her nurse believes the pain relief and relaxation resulting from an epidural would benefit the patient.
The attending OB agrees to the epidural placement. The patient is fully dilated and begins pushing 3 hours after the placement.
Develop a plan of care for your patient
Medical diagnosis, nursing diagnosis, subjective, objective date, short-term goal, long-term goal, interventions and rationals, and reevaluation outcomes.