NURSING CARE PLAN

NURSING GOALS/OBJECTIVES
ASSESSMENT INTERVENTION RATIONALE EVALUATION
DIAGNOSIS (PLANNING)
 To identify if - Goal was met;
 Monitor Vital Signs of there is a The patient
the patient and the baby. progress in displayed a
Subjective: vital signs. normal state of
“Patients report she’s vital signs.
feeling contractions
every 2 minutes and  Provide some comfort  To give and - Goal was met;
think her water may measures such as provide Patient was able
After 1 hour of nursing
have broken.” repositioning, and comfort to the to managed and
interventions, the patient
indulging gentle touch patient. controlled pain
will be able to:
Labor pain or massage in the back contractions.
Objective: related to uterine  Carry out proper or leg.
contractions and techniques for
Positive amniotic fluid - Goal was met;
cervix dilation relaxation such as  Teach the patient to use  To relax the
Cervix is 7 cm dilated evidenced by breathing exercises. patient and Patient was able
breathing exercises or
Contractions 1 minute alterations in  Displayed a normal relaxation techniques. improve the to performed
vital signs. state of vital signs; patient relaxation
apart
respiratory rate, response to techniques.
V/S: RR – 30 bpm heart rate, and pain.
HR – 125 bpm blood pressure.
 To observe if - Goal was met;
BP – 110/67 mmHg  Monitoring uterine Patient was able
contractions and there’s any
Fetal HR - 133 bpm complications to deliver the
cervical dilation. baby normally
or abnormal
state in terms without any
of contractions complications.
and dilations.
 NURSING GOALS/OBJECTIVES
ASSESSMENT INTERVENTION RATIONALE EVALUATION
DIAGNOSIS (PLANNING)

 Monitor the  To detect if there - Goal was met;

respiratory rate, is any possible The newborn
depth, and illnesses may was monitored
effort, as well as occur or related and relieved
nasal flaring and to. respiratory
abnormal distress.
Subjective: After nursing breathing
“Upon delivery of the interventions the patterns.
baby, APGAR scoring newborn will be able to:  APGAR scoring
Risk for impaired gas  Determine the
has made and routine exchange  Free from any help to - Goal was met;
done to the baby, then to signs of APGAR score in determine if the Newborn
the nursery for further respiratory the first and fifth newborn need an condition was
management.” distress. oxygen based on well.
minutes of life
the score
and keep track of written.
it to see if
oxygen
resuscitation is
required.