SY 2020-2021

COLLEGE OF
NURSING
Silliman University
Dumaguete City

NURSING CARE PLAN

Submitted to:

Asst. Prof. Maria Theresa C. Belci​ña

Submitted by:
Arbas, Joanne Therese
Gonzaga, Kenneth John
Jacinto, Jhelan Vienne
Lagusad, Gwynnein Anne
Mozol, Marr Miguel

Level II - D1
 Silliman University
College of Nursing
Dumaguete City

NURSING CARE PLAN

Gwynnein Anne Real Lagusad

CUES/EVIDENCES NURSING OBJECTIVES INTERVENTIONS RATIONALE EVALUATION

DIAGNOSIS

Objective Ineffective coping After my care of the INDEPENDENT: After my care of the
related to mother in the 2nd patient in the labor
● 28 year combination of stage of labor, she ● Establish ● To gain the and delivery room
primipara on anxiety and stress will cope with the rapport patient’s during active labor,
2nd stage of process without cooperation the patient has less
labor, fully complications and anxiety experience
dilated and experience less ● Asses ● Provides as evidenced by:
100% anxiety and stress experience baseline
effaced as evidenced by: of anxiety information Vital signs: Temp:
● Profuse and what on the 36 °C tympanic,
sweating STO: triggers the outcome PR:85 beats/min
● Vital signs: feelings identification bounding and
Temp: 36 Vital signs are and regular, RR: 25
°C within normal planning of cycles/min, quiet
tympanic, intervention and regular, BP:
PR:85 Decrease s 120/85mmHg
beats/min emotional and ● Encourage ● Conserves
bounding psychological pain client to rest strength Exhibited proper
and regular, from 10/10 to 7/10 between needed for breathing
RR: 25 contractions pushing, techniques
 cycles/min, Relieve the anxiety with eyes thereby throughout delivery
quiet and and stress and closed. facilitating
regular, BP: promote comfort the coping
120/85mmH process. “​Dakong salamat
g . ninyo maam nga
● Rated pain LTO: nakaya rajd nako
is 10/10, 0 After she gets birth ● Goal is bsag galabaw ako
as the and onwards, the ● Teach maximum kahadlok sa
lowest and patient will go back mother the control of proseso.”, as
10 as the to her normal level effects of the anxiety verbalized by the
highest of functioning anxiety experience patient
experienced to divert
on the focus on
Subjective: process of successful
“mahadlok ko nars, labor and delivery and
murag di jd nako delivery birth of the
kaya.” as fetus.
verbalized by the
patient

DEPENDENT:
● There are
● Administerin necessary
g or certain
medications safe
if possible anti-anxiety
medications
that the
physician
will
 prescribe.

COLLABORATIVE
: ● To know the
● Refer to the current
physician status of the
about the patient and
patient’s plan on
status what
during labor intervention
after nursing s should be
intervention applied next
s are done.
 Kenneth John A. Gonzaga
NCM 33 - D1

CUES/EVIDENCES NURSING OBJECTIVES INTERVENTIONS RATIONALE EVALUATION

DIAGNOSIS

Objective ● ​Risk for fetal ● ​That after Independent: Independent: ● ​After my care
injury related clinical hours of the patient
● A 26 year old to gestational fetal risk will ● Note in the
pregnant diabetes be managed progress of
Emergency
woman who is secondary to and reduced. labor. ● ​Prolonged or
dysfunctional department,
37 weeks of premature or
labor with an the patient will
gestation is stillbirth.
admitted in the extended be relieved
ED for ​Definition: ● ​Vitalsigns ● ​Monitor latent phase from the pain
suspected will be in a baseline can contribute and reduce the
premature ● Vulnerable to normal range FHR to problems degree for
labor. She was physical during the manually of infection, fetal injury.
diagnosed with damage due to delivery of and/or maternal
GDM during environmental the patient. electronicall exhaustion,
her 24th week conditions y. Evaluate severe stress,
of gestation. interacting frequently and ● ​Client will be
She has with per protocol. hemorrhage
● ​Patientwill at ease
complaints of individual’s Note FHR caused by
be relieved variability knowing the
pain radiating adaptive and uterine
defensive from the and periodic atony/rupture, safe child
from her back
resources, radiating pain changes in putting the delivery.
to her
which may coming from response to fetus at
stomach.
compromise the regions of uterine greater risk
health. the abdominal contractions. for hypoxia
● Presence of
● Reference: ● ​The patient
facial grimace.
 ● Doenges, area. and injury. will feel
Moorhouse, comfortable
Murr and at ease
● Vital Signs: *modified by after the care.
Gordon (2012: ● Patient will be ● ​Monitor ● ​Normal

-Temp: 37°C Nurse’s free from FHR during range for fetal
Tympanic Pocket Guide premature or rupture of heart rate is
PR: 78 bpm bounding 14th Edition stillbirth membranes, between
● ​Stillbirth
can
and regular, C&E reassess per 120–160 bpm
protocol, with average be prevented.
RR: 26 cycles/minute, publishing Inc
quiet and regular obtain variability,
BP: 123/81mmHg 30-min EFM accelerating
strip for in response to
record. maternal ● “Wala jud ko
● Subjective:
Evaluate activity, fetal kahibaw unsay
“ Gasakit ug ga
ngol-ngol ako tiyan, periodic movement, nahitabo dong
wa ko kahibaw ngano changes in and uterine pero salamat
or unsay nahitabo, FHR. contractions. kaayo imo gi
hasta sad ako likod, salbar akong
lisod kaayo igimok.” bata sa mga
Verbalized by the lisod na
● ​Monitor ● Changes in
patient. sitwasyon ug
FHR and amniotic fluid
periodic pressure with inyo ko
changes if a rupture, gitabangan sa
problem is and/or sakit sa ako
detected with variable tiyan ug
fetoscopy or decelerations likod.” As
external of FHR after
verbalized by
monitor. rupture, may
the patient.
Note indicate
presence of umbilical
bradycardia/t cord
achycardia compression,
 or sinusoidal which
pattern. decreases
oxygen
transfer to the
fetus
● ​Assess
maternal
perineum for
chlamydial ● ​Any
discharges, decrease in
vaginal baseline FHR
warts, or variability—s
herpetic evere and
lesions. untreatable
variable
decelerations,
recurrent late
● ​Calm decelerations,
client/partner or persistent
, explain the bradycardia—
prolapse and reflects fetal
its decompensati
implications. on, hypoxia,
or acidosis
resulting from
anaerobic
Dependent:
metabolism
● Administer
oxygen via
face mask ● ​STDs can be
acquired by
the fetus
during
● ​Turn off pregnancy;
oxytocin if therefore,
infusing, and cesarean birth
increase may be
plain IV indicated,
solution; especially for
clients with
active herpes
simplex virus
● ​Prepare for type II.
transfer to a
level 2 or 3
hospital
setting as ● ​Helps couple
indicated, if understand
the client is the
at home, or significance
in a of prolapse
free-standing and promotes
birth setting. cooperation
measures

● ​Prepare for
surgical ·​ ​Dependent:
intervention,
as indicated.

● ​Increases
maternal
oxygen
available for
fetal uptake
● ​Promotes
greater
periods of
uterine
relaxation and
increases
uteroplacental
blood flow;
increases
circulating
blood volume
available for
oxygen
transfer
within the
maternal
circulation of
the placenta.

● Compromised
fetal status or
identification
of maternal
conditions
such as STD
requires
closer birth
 setting.

● *​ ​CNS
damage
occurs if fetal
hypoxia or
acidosis
continues for
more than 30
min. To avoid
fetal
compromise,
cesarean birth
is treatment
of choice for
prolapsed
cord prior to
full cervical
dilatation.
 ​SILLIMANUNIVERISTY
COLLEGE OF NURSING
DUMAGUETE CITY
NURSING CARE PLAN: DURING LABOR
Prepared by: Joanne Therese A. Arbas

CUES/EVIDENCES NURSING OBJECTIVES INTERVENTIONS RATIONALE EVALUATION

DIAGNOSIS

An anxious, 20 year Knowledge At the end of my INDEPENDENT: At the end of my

old primipara patient deficit related to care, the patient will care, the objectives
was admitted to the lack of be able to gain - ​Assess the - This will aid in were met as
labor and delivery information knowledge regarding patient’s level of establishing evidenced by:
ward. regarding the the preparation for understanding on learning needs and
progress and labor as evidenced the progress of set priorities. - Patient verbalized
Subjective: proper by: labor and the proper understanding of
preparations for preparations as well physiological
- ​Rates pain as 7 on a labor as - Verbalizing as her expectations. changes in the
scale of 0-10 evidenced by understanding of progress of labor
questions physiological - Discuss concerns - To build a good
- Verbalized changes in the with the patient and rapport and provide - Patient participated
“Mahadlok ko dili progress of labor actively listen individualized care. in the learning
unya nako kaya ang process
kasakit sa pag utong” - Participating in the - Provide and -Active participation
learning process discuss options for of the patient/couple - Patient verbalized
- Stated “Wala koy care during the is important in the understanding of
idea unsay mahitabo - Verbalizing labor process. decision-making conditions,
karon, ni anhi ko kay understanding of process. procedures and
nagsugod na akong conditions, - Provide proper preparations
contractions basin procedures and information about -To assist the for labor.
manganak nako” proper preparations procedures patient in
for labor. (especially fetal maintaining control - Demonstrated the
- Asked “Unsa ako monitoring). during labor, to proper preparation of
buhaton para ma reassure the patient labor and delivery
preparar ko sa pag - Demonstrating the that the procedure
panganak?” proper preparation of is safe for her and
labor and delivery the baby.
Objective:

- Patient’s non-verbal -Provide information - To reassure the

cues showed fear and regarding normal patient that these
worry as evidenced progression of labor are normal signs
by hand tremor, like uterine that labor is
sweating, and contractions and progressing.
panicking cervical dilation

- When in pain,
patient makes facial - Obtain informed -When procedures
grimacing consent of involve the patient's
procedures, body, it is necessary
- Patient shows (ex. episiotomy) and for the patient to
interest in learning explain the have appropriate
more about what she procedures and the information to make
will experience during possible risks informed choices.
labor as evidenced by associated with
asking a lot of labor and delivery.
questions
- Educate the - Unprepared
Vital Signs: patient about couples need to
T: 37.3 C breathing and learn coping
P: 85 bpm, regular, relaxation mechanisms on
strong techniques admission to help
R: 25 bpm shallow appropriate to each reduce stress and
and fast-paced phase of labor; anxiety.
BP: 130/70 mmHg teach and review
pushing positions
for stage II.
 COLLEGE OF NURSING
Silliman University
Dumaguete City
S.Y. 2020 – 2021

NURSING CARE PLAN: DURING LABOR

Prepared by: Jhelan Vienne E. Jacinto

CUES/EVIDENC NURSING OBJECTIVES INTERVENTION RATIONALE EVALUATION

E DIAGNOSIS

Subjective: ● Ineffective After 8 to 10 hours 1. Monitor vital • To detect possible After our 8 to 10
breathing of nursing care the signs. changes in the nursing care, the
● Verbalized, pattern client will achieve health status of the objectives are met
“Dili ko related to respiratory rate as client and report as evidenced by:
makaginhaw pain evidenced by: any possible
a ug tarong secondary to deviation from
labor ● Vital signs normal values.
agi sa ● Vital signs
process within
kasakit sa within
normal
akong tiyan normal
ranges: • To obtain baseline ranges:
diri dapit 2. Assess
ubos sa ako data and monitor
T = 36.5 – 37.5°C respiration and T= 36.8° C
for any alterations
pusod.” per axilla client’s nonverbal per axilla
in normal pattern.
cues.
P = 60-100 bpm P= 85 bpm,
strong, regular strong,
● Claimed, • Calming a client regular
“Wa ko 3. Reassure client
R = 12-20 cpm, with shortness of
that measures are R= 25 cpm
kabalo regular, moderate, breath by telling her
being taken to regular,
 ngano pero effortless. No usage ensure safety. that actions are moderate,
murag of accessory being taken to effortless
gikumot sa muscles. improve the
situation is an BP= 120/90
kasakit.”. mmHg
BP = 120/80 mmHg essential
intervention to
reduce panic and
● Rated pain decrease symptoms
● Rating pain ● ​Rated pain
experienced by the
as 9 in a as 5-6 in a as 5 in a
client.
scale of scale of scale of
0-10. 0 0-10. 0 0-10.
being least being least
painful and 4. Remain calm • Client tends to
painful and panic when she sees
10 being the while applying ● Demonstrate
10 being the nurse panicking
nursing d the proper
most most which can further
intervention. breathing
painful. painful. complicate the
technique
client’s condition
Objective:
● ​Client will
● A be able to
● Minimized
24-year-old demonstrate 5. Teach client • Interventions
restlessness,
primipara, proper controlled breathing focus on slowing
guarding,
who is 39 breathing technique, the breathing
financial
weeks of demonstrate to the pattern and
technique grimacing,
gestation, on client the proper educating the client
without any profuse
the 1​st​ stage way. Ask the client to control response.
difficulty. sweating,
of labor to perform The client in pain
irritability,
breathing could not think
and
● Minimized techniques. Give properly therefore
movement.
movements, direct and concise direct instructions
 ● Vital signs irritability, directions. should be used.
restlessness,
T = 37.2°C per facial
axilla grimacing,
and profuse
P = 86 bpm regular, sweating.
6. Distract client • Relaxation
strong from feeling techniques
anxious and being effectively manage
R = 30 cpm shallow in the state of pain pain by increasing
and fast-paced, with by providing sense of control,
the use of accessory physical measures reducing feelings of
muscles that will aid helplessness and
relaxation: hopelessness,
BP = 130/90 mmHg providing a calming
• Soothing Massage diversion, and
● Irritability disrupting the
• Aromatherapy pain-anxiety-tensio
noted
● Restless n cycle
• Relaxing music
● Presence of entertainment
facial
• Etc.
grimacing
● Profuse
Sweating
7. Allow the chosen • Presence of and
family of the client support from
to be involved in significant others
her care as well as help calm the
giving support. patient thereby
decreasing anxiety
which is one of the
causative factors of
the condition