LORMA COLLEGES

NURSING CARE PLAN

RELATED LEARNING
EXPERIENCE

STUDENT NAME: ROTATION: AREA:

YR LEVEL AND SEC: DATES: CLINICAL INSTRUCTOR:
NURSING
ASSESSMENT DIAGNOSIS PLANNING IMPLEMENTATION RATIONALE EVALUATION
Subjective: Fatigue related Energy conservation
Patient reports feeling to the physical Energy Conservation Techniques: techniques help the
Improve patient's
exhausted and tired. demands of patient conserve energy
energy levels and
Patient complains of labor and Encourage the patient to rest in a and manage fatigue
reduce fatigue.
difficulty sleeping due to delivery, as comfortable position during early during labor.
discomfort. evidenced by labor.
Enhance patient's ability
Patient expresses concerns patient- Teach the patient to conserve Pain management
to cope with labor pains.
about managing labor reported energy by using relaxation interventions reduce
pains. exhaustion, techniques. discomfort and improve
Promote relaxation and
Patient reports feeling decreased Assist with positioning changes to the patient’s ability to
improve sleep quality.
anxious about the activity level, alleviate discomfort. cope with labor pains.
upcoming delivery altered sleep
Provide education on
patterns, and Education and support
Objective: energy conservation
anxiety about empower the patient
techniques.
the labor Pain Management: with knowledge and skills
process. to manage labor and
Administer prescribed pain reduce anxiety.
medications as per the healthcare
provider's orders. Optimizing the
Offer massage or back rubs to environment promotes
 relieve muscle tension. relaxation and enhances
Provide heat packs or cold packs as the quality of rest.
requested by the patient.
Collaboration ensures
Education and Support: comprehensive and
coordinated care for the
Explain the different stages of labor patient’s well-being.
and the expected duration of each
stage.
Discuss breathing techniques and
relaxation methods for managing
pain.
Address any concerns or questions
the patient may have about the
labor process.

Environment Optimization:

Ensure the labor room is calm and

free from unnecessary noise.
Adjust lighting to create a soothing
atmosphere conducive to rest.
Provide privacy for the patient
during rest periods.
 NURSE’S NOTES (FDAR)
PATIENT NAME: AGE: HOSPITAL NO.: PHYSICIAN: SEX: WARD/ROOM:

DATE/TIME FOCUS D - ATA A - ACTION R - RESPONSE NURSE SIGNATURE