ASSESSMENT DIAGNOSIS PLANNING INTERVENTION EVALUATION

SUBJECTIVE DATA: Risk & Diagnosis: Short term: 1. Assess progress in labor SHORT TERM:

- Abdominal Deficient knowledge rt After 2 hours of nursing • uterine contraction pattern After an hour of nursing
cramps misinterpretation of intervention the patient • cervical dilation intervention, the client
- Pain scale is information aeb request of will verbalize • fetal position and station was able to:
6/10 information, statement of understanding of Rationale:
- G1P0 concern and first physiological changes and Verbalize Understanding
pregnancy. physiology during Location and intensity of pain about physiological and
OBJECTIVE DATA: pregnancy. varies with phase or stage of psychological changes
Risk for anxiety related to labor during pregnancy
- Cervical situational, interpersonal After 1 hour of nursing
dilation 2-3 transmission. intervention the patient 2. Instruct mother and her Demonstrate breathing
centimeters will demonstrate family on labor process and relaxation techniques
- Station appropriate relaxation proficiently Able to
floating and breathing techniques Rationale: enhance her coping
- Effacement: abilities
20% After 2 hours of nursing The patient has the right to
- Membranes: intervention the patient be informed on what should LONG TERM:
Intact will be able to enhance be done to them during the
her coping abilities. labor process. For them to Appear relaxed
know what are the appropriate to the labor
Long term: appropriate response and situation
support during labor.
After 1 week of nursing After 1 week of NI the
intervention the patient 3. Explain physiology of pain patient has now gained
will demonstrate in labor confidence and positive
increased relaxation thoughts about labor
between contractions, Rationale: process.
and now comfortable
with her pregnancy. To enhance coping abilities After 2 weeks of NI the
of the client and to provide patient has now finally
After 1 week of Nursing information about relaxation gained knowledge and
intervention the patient techniques. having a stress-free
will gain more confidence pregnancy
and positive thoughts 4. Guide and support woman
about labor process. and Her support person in Goal: MET
using self-comforting
After 2 weeks of Nursing techniques
Intervention the patient
will gain more knowledge Rationale:
and a stress-free
pregnancy. Qualitative research has
demonstrated that one of the
most significant aspects of
the experience of labor for
women is the presence of one
or more persons.

Postpartum women report

that one of the things
contributing to a positive
labor experience was the
presence of family member or
friend.

5. Encourage rest and

educate the client about
relaxation and breathing
techniques

Rationale:

Relaxation enhances the

effectiveness of
nonpharmacologic and
pharmacologic pain
management strategies.
Breathing techniques are
used as a distraction during
labor to decrease pain and
promote relaxation.

6. Encourage support to the

mother and family before,
during and after delivery

Rationale:

Continues support can result

in the following:

Decreased anxiety Increased

satisfaction with child birth
experience. Gain more
confidence