Mindanao State University – Iligan Institute of Technology
Student: Chamelli Ann E. Robin
Identified Problem: insufficient knowledge
Nursing Diagnosis: Deficient knowledge related to progress of labor and delivery
CUES
Subjective:
“I’m in labor. Tell me what I’m
supposed to do.” as verbalized by
the patient
Objective:
Fundal Height- 35cm
Cervix dilatation- 6cm dilated
FHR- 150 beats/min
Group: __________
Maternal and Child Nursing
OBJECTIVES
Short Term Objectives:
After 8 hours of nursing
intervention, patient would be able
to:
 Verbalize understanding
of care requirements to
promote health of self
and fetus
Long Term Objectives:
After 16 hours of nursing
intervention, patient would be able
to:
 Engage in activities to
prepare for birth process
 Experience complication-
free labor and childbirth
NURSING CARE PLAN
INTERVENTIONS
Independent:
 Observe and note existing misconceptions
regarding material to be taught.
 Identify cultural influences on health teaching
 Provide an atmosphere of respect, openness,
trust, and collaboration..
 Begin with information the client already knows
and move to what the client does not know,
progressing to simple to complex
 Ascertain the client’s understanding and
expectations of the labor process
 Demonstrate or review behaviors and techniques
(e.g., breathing focused imagery, music, other
distractions; aromatherapy; abdominal effleurage,
back or leg rubs, sacral pressure, repositioning,
and back rest; oral and perineal care and linen
changes; and shower/ hot tub use)
 Discuss available analgesics, usual responses
and side effects (client and fetal), and duration of
analgesic effect in light of current situation
 Provide information about additional learning
resources
Inclusive Dates of Duty: ______________________________
Patient: __________________________ Room No.: _______
RATIONALE EVALUATION
Short Term:
 Assessment provides an important After 8 hours of nursing intervention,
starting point in education. the patient was able to verbalize
Knowledge serves to correct faulty understanding of care requirements
ideas. to promote health of self and fetus
 Interventions need to be specific to
each patient considering their
individual differences and
backgrounds. Long Term:
 Conveying respect is especially After 16 hours of nursing intervention,
important when providing the patient was able to perform
education to patients with different activities and techniques that assisted
values and beliefs about health with pain control and relaxation and
and illness. has demonstrated behaviors and
 This can arouse interest / limit techniques for a complication-free
sense of being overwhelmed labor and childbirth.
 To establish content to be included
 To assist with pain control and
relaxation
 This allows client to make an
informed choice about the means
of pain control; thid can allay the
client’s fears and anxieties about
medication use
 This may assist with further
learning and promote learning at
his or her own pace.