Nursing Care Plan

BSN 2C Team 2

Case Overview: Karla arrived with her husband at SPDC hospital at midnight. Karla believes she is in labor. Karla, after 5 hours, complained of
severe pain and anxiety. Later Karla feels a gush of fluids and puts on her call light.

Nursing
Date Assessment Needs Planning Intervention Evaluation
Diagnosis
12 AM Subjective:
Cooping Anxiety related to After an 4 hours of 1. Use presence, touch (with After an 4 hours of
stress of labor nursing intervention, permission), verbalization, nursing intervention, the
“complain of the client will be able and demeanor to remind client will be able to:
severe pain and to: patients that they are not
anxiety”
Rationale: alone and to encourage
Enumerate the expression or clarification of
different relaxation Client states she feels
needs, concerns, unknowns, in control of her
Objective data: techniques to relieve
Patient stated and questions. situation; she and her
anxiety
about her severe support person express
pain and anxiety Understands the
Undergoing 1 confidence in
information to reduce Rationale:
stage labor own anxiety level themselves and in
Being supportive and health care personnel.
Communicate and approachable promotes
Rationale: express feelings communication.
about anxiety
Patient feels a
gush of fluid 2. Reinforce patient’s personal
reaction to or expression of
pain, discomfort, or threats to
well-being

Rationale:
Talking or otherwise expressing
feelings sometimes reduces
anxiety.
3. Use empathy to encourage
patient to interpret the anxiety
symptoms as normal.

Rationale:
Anxiety is a normal response to
actual or perceived danger.

4. Provide massage and

backrubs for patient to reduce
anxiety.

Rationale:
This aids in reduction in anxiety.

5. Provide patients with a means

to listen to music of their
choice.

Rationale:
Music is a simple, inexpensive,
esthetically pleasing means of
alleviating anxiety.

6. Teach patient to visualize or

fantasize about the absence
of anxiety or pain, successful
experience of the situation,
resolution of conflict, or
 outcome of procedure.

Rationale:
Use of guided imagery is very
useful for reducing anxiety.