NURSING CARE PLAN

Patient’s Initials: _____________ Chief Complaint: “I feel exhausted and I Name of Student Nurse:
am sweating heavily.”
Age & Gender: 23 years old, female Jeanette Leigh S. Bravo
Birthdate: Admitting Level/Block/Group: AU-FA1-
____________________________________ Diagnosis:_________________________ BSN2-2
Address: __________________________________ Hospital/Area: Emergency
____________________________________ Maternal and Child Health Care
Hospital
____________________________________ Date of Confinement: Clinical Instructor:
______________________________
Anna Lorraine Reyes
Date: _______

ASSESSMENT NURSING PLANNING INTERVENTIONS RATIONALE EVALUATION

ANALYSIS

SUBJECTIVE: ● Risk for ● Patient ● Review the ● Helpful in ● The patient

Maternal will history of identifying accomplished
“I feel exhausted and I
Injury r/t accom labor, possible cervix
am sweating heavily.”
maternal plish onset, and causes, dilation.
As verbalized by the
fatigue and cervix duration. needed ● The patient
patient.
obstruction dilation ● Assess diagnostic improves her
OBJECTIVE: to fetal at least uterine studies, and labor pattern
descent. 1.2 contractile appropriate and the
● Nulliparous ● Risk for cm/hr pattern interventions. identified risk
● Asthmatic Fetal Injury for manually Uterine factors are
● 35th weeks r/t prolonged primipa (palpation) dysfunction reduced.
 AOG labor, fetal ra, 1.5 or may be ● The patient
● 7-8 cm dilated malpresentat cm/hr electronical caused by an displays FHR
● Ruptured ion, and for ly via atonic or within normal
membrane cephalopelvi multipa external or hypertonic limits, with
c ra in internal state. Uterine good
disproportion active monitor atony is variability, no
Vital signs: . phase, with classified as late
● Risk for fluid with internal primary when decelerations
BP: 130/90 mmHg volume fetal uterine it occurs noted.
T: 35.9/axilla deficit due to descen pressure before the ● The patient
profuse t at catheter onset of maintains
HR: 110 bpm diaphoresis. least 1 (IUPC). labor (latent fluid balance,
cm/hr ● Investigate phase) or as evidenced
SaO2: 97% on R/a
for reports of secondary by moist
FHR: 156 bpm primipa severe when it mucous
ra, 2 abdominal occurs after membranes,
cm/hr pain. Note well- appropriate
for signs of established urine output,
multipa fetal labor (active and palpable
ra. distress, phase). pulses.
● Patient cessation ● Dysfunctional ● The patient
will of contractions and her baby
particip contraction lengthen are free of
ate in s, presence labor complications
interve of vaginal increasing ..
ntions bleeding. the risk of
to ● Assess maternal/feta
improv FHR l
e labor manually or complication
pattern electronical s.
and/or ly. ● May indicate
reduce ● Note developing
identifi frequency uterine
ed risk of uterine tear/acute
 factors. contraction rupture
● Patient s. Notify necessitating
will physician if emergency
display the surgery.
FHR frequency ● Detects
within is 2 min or abnormal
normal less. responses,
limits, ● Monitor such as
with fetal exaggerated
good descent in variability,
variabil birth canal bradycardia,
ity, no in relation and
late to ischial tachycardia,
deceler spines. which may
ations ● Administer be caused by
noted. antibiotic to stress,
● Patient client, as hypoxia,
will indicated. acidosis, or
maintai ● Monitor sepsis.
n fluid vital signs. ● Contractions
balanc Note occurring
e, as reports of every 2 min
eviden dizziness or less do not
ced by with allow for
moist change of adequate
mucou position. oxygenation
s ● Assess lips of intervillous
membr and oral spaces.
anes, mucous ● Descent that
approp membrane is less than 1
riate s and cm/hr for a
urine degree of primipara, or
output, salivation less than 2
and cm/hr for a
 palpabl ● Administer multipara,
e fluids may indicate
pulses. intravenous CPD or
● Patient ly.. malposition.
will be ● Prevents/
free of treats
compli ascending
cations infection and
. will protect
fetus as well.
● Increased
pulse rate
and
temperature,
and
orthostatic
BP changes
may indicate
decrease in
circulating
volume.
● Dry oral
mucous
membranes/li
ps and
decreased
salivation are
further
indicators of
dehydration.
● Parenteral
solutions
containing
electrolytes
and glucose
can correct
or prevent
maternal and
fetal
imbalances
and may
reduce
maternal
exhaustion.