nursing care plan

1. Assessment Diagnosis Planning Intervention Rationale Evaluation
Subjective Data:
”Why did I
experience mild pain
similar to the
cramping when I
have a period? Why
did I also experience
back and thigh pain
more frequent? I
also noticed a clear
and blood-streaked
discharge over the
past few days. Why
is that happening to
me?” as verbalized
by the patient.
Knowledge Deficit
r/t lack of exposure
as manifested by
questions
Short term:
- Client will verbalize
understanding of
psychological and
physiological changes.
- Client will participate
in decision-making
process.
- Client will
demonstrate
appropriate breathing
and relaxation
techniques.
Independent:
- Assess client’s baseline
knowledge and
expectations during
pregnancy.
- Review appropriate
activity levels and safety
precautions, whether
client remains in
hospital or returns
home.
- Review roles of staff
members.
- This will guide in
establishing learning
needs and set
priorities.
- Provides guidelines
for client to make
appropriate informed
choices; allows client
to engage in safe
diversional activities
to refocus attention.
- Identifies resources
for specific needs
Short-term goal met:
- Client verbalized
understanding of
psychological and
physiological changes.
- Client participated in
decision-making
process.
- Client demonstrated
appropriate breathing
and relaxation
techniques.
Nursing Care Plan
Lipa City Colleges

2. Objective Data:
- Displays moderate
to high level of
anxiety (anxious
look)
V/S:
Temp: 37. 2 ° C
HR: 80 bpm
RR: 17 bpm
Sp02: 98%
BP: 120/90
Pain Scale: 5/10 as
zero (no pain) to 10
(worst pain)
Long term:
- Patient will have a
deeper understanding
of labor in pregnancy
- Educate the client
about breathing and
relaxation techniques
appropriate to each
phase of labor; teach and
review pushing
positions for stage II.
Dependent:
- Provide and discuss
options for care during
the labor process.
Provide information
about birthing
alternatives, if available
and appropriate.
- Obtain informed
consent for procedures,
e.g., forceps delivery,
episiotomy. Explain the
procedures and the
possible risks associated
with labor and delivery.
Interdependent:
- Provide information
about procedures
(especially fetal monitor
/situations.
- Unprepared couples
need to learn coping
mechanisms on
admission to help
reduce stress and
anxiety. Couples with
prior preparation can
benefit from review
and reinforcement.
- Active participation
of the client/couple is
important in the
decision-making
process.
- When procedures
involve client’s body, it
is necessary for client
to have appropriate
information to make
informed choices.
- Prenatal education
can facilitate the labor
Long-term goal met:
- Patient had now a
deeper understanding
of labor in pregnancy

3. and telemetry) and
normal progression of
labor.
and delivery process,
assist the client in
maintaining control
during labor, help
promote a positive
attitude, and may
decrease reliance on
medication.
Name of Patient: Sanchez, Carmen
Care Plan by: Vincent M. Material, FRN
Date Initiated: January 20, 2021
Affiliating Agency: Lipa City District Hospital
Received by: ___________________________________
Clinical Instructor

4. Assessment Diagnosis Planning Intervention Rationale Evaluation
Subjective Data:
”Put*ngina ayaw ko
na mabuntis” as
verbalized by the
patient.
Objective Data:
- Displays severe
pain through verbal
and non-verbal way
of expression
V/S:
Temp: 37.5 ° C
HR: 110 bpm
RR: 24 bpm
Sp02: 60%
BP: 140/110
Acute pain r/t
muscular tension
and tissue
dilation/stretching
as manifested by
facial mask of pain
and verbalizations
Short term:
- Client will verbalize
perceived or actual
reduction of pain.
- Client will use
appropriate techniques
to enhance comfort and
maintain control of
labor process.
Long term:
- Patient will have a
deeper understanding
of labor in pregnancy
Independent:
- Monitor frequency,
duration, and intensity
of uterine contractions.
- Monitor cervical
dilation. Note perineal
bulging or vaginal show.
- Monitor maternal vital
signs and FHR
variability after drug
administration. Note
drug’s effectiveness and
the physiological
response.
- Detects progress and
screens for an
abnormal uterine
response.
- Discomfort levels
increase as the cervix
dilates, fetus descends,
and small blood
vessels rupture.
- Narcotics can have a
depressant effect on
the fetus, particularly
when administered 2–
3 hr before delivery.
Therefore, use may be
limited or restricted,
or naloxone
Short-term goal met:
- Client verbalized
perceived or actual
reduction of pain.
- Client used
appropriate
techniques to enhance
comfort and
maintain control of
labor process.
Long-term goal met:
- Patient had now a
deeper understanding
of labor in pregnancy

5. Pain Scale: 10/10 as
zero (no pain) to 10
(worst pain)
- Assess degree of
discomfort through
verbal and nonverbal
cues. Assess personal
and cultural implications
of pain.
- Assess client’s need for
physical touch during
contractions.
- Inform client of onset
of contractions, as
appropriate.
hydrochloride
(Narcan) may be
administered to
reverse adverse drug
effects.
- Attitudes toward
pain and reactions to
pain are individual and
based on past
experiences, cultural
background, and self-
concept.
- Touch may serve as a
distraction, provide
supportive
reassurance, and
encouragement, and
may aid in maintaining
control/reducing pain.
- Client may “sleep”
and/or encounter
partial amnesia
between contractions.
This can be a problem
for some clients,
impairing her ability to
recognize contractions
as they begin and thus
have a negative impact
on her sense of

6. - Evaluate client for
tingling of lips, face,
hands, or feet. If present,
have client breathe into
cupped hands or paper
bag.
- Encourage client to
void.
- Assist client and
partner with changing to
more rapid breathing;
(i.e., pant-blow).
- Assist client with
comfort measures,
including sacral/back
rubs, positioning, mouth
care, perineal care,
change of pads/linens,
hot cold compresses,
sponge baths to face and
neck, or bath/whirlpool.
control. For others, the
brief rest may
“energize” them for
the next contraction.
- Discomfort caused by
respiratory alkalosis
can be relieved by
increasing carbon
dioxide levels through
the rebreathing
process.
- May enhance labor
progress and reduce
the risk of trauma to
the bladder.
- Redirects and focuses
attention; helps reduce
the perception of pain
within the cerebral
cortex.
- Such measures
promote hygiene,
relaxation, and
physical comfort. Note:
Individual needs or
preference can change
quickly during
transition; i.e., client
may request sacral

7. - Offer encouragement,
provide information
about labor progress
and provide positive
reinforcement for
client’s/couple’s efforts.
- Provide for a quiet
environment that is
adequately ventilated,
dimly lit, and free of
unnecessary personnel.
Carry out nursing
procedures between
contractions whenever
possible.
Interdependent:
- Administer analgesic as
ordered. Assist
anesthesiologist if
epidural or caudal
anesthetic is to be used.
rub, then the next
moment demand
everyone move away
from her.
- Provides emotional
support, which can
reduce fear, lower
anxiety levels, and
help minimize pain.
- Nondistracting
environment provides
optimal opportunity
for rest and relaxation
between contractions.
- Judicious use of a
pharmacologic agent
assists the client in
coping with
contractions and may
facilitate labor.

8. Assessment Diagnosis Planning Intervention Rationale Evaluation
Subjective Data:
”Are we really
parents now?” as
verbalized by the
patient.
Objective Data:
- Displays
ambivalent
reactions with both
the mother and
father of the baby
V/S:
Temp: 37. 2 ° C
HR: 80 bpm
RR: 17 bpm
Sp02: 98%
BP: 120/90
Risk for Altered
Family Processes r/t
Situational crisis
(change in
roles/responsibilities)
as manifested by
giving birth to a baby
Short term:
- Family will
demonstrate behaviors
indicative of readiness
to actively participate
in the acquaintance
process when both
mother and infant are
physically stable.
Long term:
- Patient will have a
deeper understanding
of the roles and
responsibilities of a
mother
Independent:
- Provide client and
father with the
opportunity to hold
baby immediately after
birth if infant’s condition
is stable.
- Delay installation of
eye prophylaxis
ointments (containing
erythromycin or
tetracycline) until
client/couple and infant
have interacted, and dim
room lights.
- Early physical
contact helps foster
attachment. Fathers
are also more likely to
participate in infant
caretaking activities
and feel stronger
emotional ties if they
are actively involved
with the infant soon
after birth.
- Allows infant to
open eyes fully to
establish eye contact
with parent and
actively participate in
the interaction, free
from the blurred
vision caused by
Short-term goal
met:
- Family will
demonstrate
behaviors indicative
of readiness to
actively participate in
the acquaintance
process when both
mother and infant are
physically stable.
Long-term goal met:
- Patient had a
deeper understanding
of the roles and
responsibilities of a
mother

9. Pain Scale: 5/10 as
zero (no pain) to 10
(worst pain)
Dependent:
- Facilitate interaction
between the
client/couple and the
newborn as soon as
possible after delivery.
medication.
- Fosters the
beginning of lifelong
emotional ties
between family
members. Both
mother and infant
have a critically
sensitive period
during which
interactional
capabilities are
enhanced.