NURSING CARE PLAN
Identified Problem: Anxiety
Nursing Diagnosis: Anxiety related to lack of exposure to birth process as evidenced by restlessness, facial tension and patient verbalization, "I'm in labor. Tell me
what I’m supposed to do."
CUES OBJECTIVES
Subjective: Short term objectives:
“I’m in labor. Tell me what I’m Within 30-40 minutes of nursing care,
supposed to do.” as verbalized by patient will be able to:
patient
- actively participate in the
learning process about some
relaxation techniques that can
help lessen anxiety
- verbalize feelings, concerns,
and fears about her
impending labor
Objective:
Long term objectives:
- restlessness
- facial tension Within 2 - 3 hrs of nursing care, patient
- active verbalization of the will be able to:
problem
- Show signs of relaxed and
comfortable behavior
appropriate to the labor
situation
- cooperate with the necessary
preparations for delivery
process during the giving of
preoperative information
- verbalize, “I can now recall
some of my lessons from the
pregnancy classes”
INTERVENTIONS
Dependent:
1. Establish and maintain therapeutic relationship
with the patient by displaying warmth, answering
questions directly, and respecting client’s
personal space
2. Monitor maternal and fetal vital signs
3. Assess level and causes of anxiety,
preparedness for childbirth and cultural
background
4. Determine client’s readiness for teaching
5. Identify client’s level of understanding
6. Encourage the client’s participation while
instructing about relaxation exercises such as
deep breathing, progressive muscle relaxation,
guided imagery, meditation and so forth.
7. Explain all activities, procedures, and issues that
involve the client; such as breathing techniques
and patterns for labor. Use nonmedical terms and
calm, slow speech. Do this in advance of
procedures when possible, and validate the
client’s understanding
8. Encourage client to verbalize feelings, concerns,
and fears.
9. Use presence, touch (with permission),
verbalization, and demeanor
10. Provide an opportunity for conversation to include
choice of infant names, expectations of labor and
perceptions/fears during pregnancy.
RATIONALE
Dependent:
1. Therapeutic skills need to be
directed toward putting the client at
ease, because the nurse who is a
stranger may pose a threat to the
anxious client.
2. To identify physical
responses associated with
both medical and emotional
conditions.
3. Provides baseline information.
Determining the degree and causes
of anxiety can help the nurse avoid
assumptions and devise
interventions to help lessen it
4. The patient may not be physically,
mentally and emotionally capable at
this time
5. To determine the method of teaching
and effectively impart knowledge to
the patient
6. Relaxation exercises are effective
nonchemical ways to reduce anxiety.
7. Preoperative information reduces
the anxiety of clients because they
can anticipate and prepare
themselves on what happens during
the procedure.
8. Allowing the patient to ventilate her
feelings can help alleviate tension
9. To remind the patient that they are
not alone.
10. Presents an opportunity for the client
to verbalize excitement about
herself, the pregnancy, and her
baby. Serves as a diversion to help
pass time during what is commonly
the longest phase of labor.
EVALUATION
Short term:
GOAL MET
After 30-40 minutes of nursing care, patient
was able to:
- actively participate to the
learning process about some
relaxation techniques that can
help lessen anxiety
- verbalize feelings, concerns, and
fears about her impending labor
Long term:
GOAL MET
After 1 - 2 hrs of nursing care, patient was
able to:
- Show signs of relaxed and
comfortable behavior appropriate
to the labor situation, without
facial tension
- cooperate with the necessary
preparations for delivery process
during the giving of preoperative
information
- verbalize, “I recalled some of my
lessons from the pregnancy
classes”
Patient H / Room No. | 1
 Independent: Independent:

1. If the patient's level of anxiety had reached a 1. Elevated level of anxiety can
severe or panic state. Report it to the physician increase the patient’s pain
and ask for any medications that can help lessen perception and affect their coping
anxiety and safe for pregnant women. capabilities and delivery process.

Reference:

https://nurseslabs.com/anxiety/
https://nurseslabs.com/labor-stages-labor-induced-nursing-care-plan/6/#f3
https://www.scribd.com/doc/61898024/Anxiety-NCP
https://www.scribd.com/doc/30761506/Ncp-anxiety-preterm

Patient H / Room No. | 2