Nursing care plan

Of The Mother
 Nursing Care Plan of the mother

Prenatal Assessment

Cues/Evidence Nursing Diagnosis Objective

Intervention Rationale Evaluation

SUBJECTIVE DATA: Disturbed sleep Within our 1. Assess vital

signs Elevated blood Within our care,
Patient verbalized that pattern r/t shortness care, the especially her
blood pressure is usually the client had
she easily wakes up of breath and urinary client will pressure level
observed in sleep improved sleeping
whenever she hears frequency improve sleep
disturbed client pattern as
noise. Furthermore, pattern as
evidenced by:
she reported frequent evidenced by: 2. Encourage the
Voiding before
awakenings during the mother to void
before bedtime may limit Absence of dark
night to go bathroom Absence of sleeping
the sleep circles under
due increased urge to dark circles
disturbance eyelids and
urinate which under eyelids
brought about by frequent yawning
happened around and frequent
urinary frequency as observed
5times.She also added yawning,
that she finds it improved face 3. Provide a quiet
A quiet Decrease urinary
difficult to sleep expression environment
conducive environment frequency from 5
sometimes because for sleeping
promotes times each night
she felt slight pain on Verbalized
continuation of to 3 times
the area near her understanding
sleep without
buttocks due to the on the cause
disturbances Report of rested
pressure she feels on of sleep 4. Promote use of
and more relaxed
her chest which disturbance bedtime rituals
such as
affects her breathing. drinking a glass
of milk Promotes
She also said that she Report before sleeping,
taking relaxation and OBJECTIVES FULLY
sleeps with a pillow increased a bath, reading a
book readiness for MET
and a blanket. (We sense of well –
sleep
failed to inquire about being and 5. Teach client to
her having nightmares feeling of elevate head by
using
or sleepwalking). She rested more pillows
during
takes a nap when she sleep or have her
on Elevating the head
feels like taking a nap Report an side – lying
position promotes lung
but only for a short increased
expansion, being
time. number of
in a side – lying
hours of sleep
position decrease

the pressure on
OBJECTIVE DATA:
the chest wall and
Sleepy eyed noted
vena cava by the

gravid uterus
Dark circles under
eyelid
observed

Frequent yawning
noted

Vital signs:
T=37˚C
RR=14 cpm
BP= 138/74 mmHg
PR= 72 bpm

SUBJECTIVE DATA: Disturbed Body mage Within our 1. Assess readiness

to Give patient sense Within our care,
Client verbalized that related to change of care, client accept changes in
of control over client had
she feels sad about appearance shall accept body image
situation accepted her body
her physique and associated with body image
image as
body image. pregnancy as manifested 2. Employ a calm,
Improves nurse- evidenced by:
by: caring, confident,
and client relationship.
non-judgmental
Expressed positive
OBJECTIVE DATA: Express approach.
feeling towards
Physiologic changes: positive
Creates a sense of self and others.
feeling 3. Discuss with
mother trust at the same
Contour of the towards self physiologic changes
time educate Verbalized
abdomen changes and others during pregnancy
mother about acceptance of

changes during body image:

Presence of linea nigra Verbalize
pregnancy “Ok na man ako
on the abdomen acceptance of
pagkita sa ako
body image 4. Allow pt to
express To create a kaugalingon”
feelings towards her
positive outlet of
Perceived pregnancy
emotions Perceived
pregnancy in
pregnancy in a
a positive
positive light and
light 5. Teach pt coping
claimed she is
strategies:
Help overcome excited to see her
• Preparing for
maladaptive baby.
upcoming
delivery behaviors
• Provide literary
articles about
OBJECTIVES FULLY
pregnancy
MET

1st stage of labor

Cues/ Evidence Nursing Diagnosis Objectives Interventions

Rationale Evaluation
SUBJECTIVE Altered comfort: Within our care, Independent
Within our care, the
DATA: pain related to client shall 1. Monitor vital
To obtain baseline client was able to:
Client verbalized increased uterine experience signs every 15
data.
excruciating pain on contractions and increased comfort minutes for 2
hours Maintained v/s
the abdomen and pressure on as evidenced by: and 30 minutes
within normal
further stated that pelvic structures V/S within normal until stable.
range:
the intensity of pain range:
is increasing. T: 36.5-37.5 2. Assess
This is to monitor T: 37.4C
PR: 60-100bpm contraction
the progress of PR: 66bpm
RR: 12-20cpm patterns, bloody
labor and the RR: 16cpm
OBJECTIVE DATA: BP: 110-140/60- show
condition of both BP: 110/70mmhg
Rated pain as 9 in a 90mmHg and the degree of
the mother and the
scale of 1 to 10; 10 pain and its
baby. Helps to Verbalize pain
being most painful Verbalization pain characteristics,
identify areas of within tolerable
while 1 being least within tolerable location,
severity, chief concern, limits.
painful. limits throughout duration, and
providing baseline
the duration of frequency.
for future Verbalize discomfort
Facial grimacing labor
interventions. as controlled with
noted
non-pharmacologic
Verbalize
Left lateral position methods
Abdominal guarding discomfort as 3. Provide comfort
increases venous
noted controlled with non- measures:
return and Rated pain as 8 in a
pharmacologic • Encourage
enhances placental scale of 1 – 10
Restlessness noted methods comfortable
circulation.
especially during positioning.
Position changes Groaning, and facial
exacerbation of Rates pain as < 8 • Position the
promote comfort , grimacing not
contractions. in a scale of 1-10, client in a
reduce muscle noted.
10 as the highest left side
lying tension, relieve
and 1 is the lowest. position.
pressure and Was observed to be
 • Encourage promote fetal restless when
Absence of client to descent. contractions
occur.
expressive assume
behaviors such as different
restlessness, positions and Responded to
moaning, sighing, change them questions and
irritability, and regularly. instructions
facial grimacing. Proper breathing appropriately.
4. Teach proper technique can
Verbalize desire to breathing technique prevent exhaustion,
participate in labor therefore OBJECTIVES
as tolerated preventing PARTIALLY MET
prolonged delivery
Responds to of the fetus and
questions and prolonged pain.
instructions 5. Inspect the
appropriately client’s suprapubic A full bladder
area and palpate for contributes to
Identifies need for bladder distention. discomfort and
additional pain Encourage the impedes fetal
relief measures as client to void. descent.
tolerated.
6. Provide
information and Helps alleviate any
update client on anxiety and fears
labor progress that may
exacerbate pain.
Dependent

7. Administer
 analgesia as
Mechanism of
ordered
action is to reduce
Collaborative
pain.

8. Refer to
physician any
To provide
abnormalities that
immediate medical
may be observed.
intervention.

SUBJECTIVE Anxiety related to Within our care, Independent

At the end of our
DATA: hospitalization client will manage 1. Monitor Vital
To obtain baseline care, the client was
Client verbalized and upcoming anxiety with Signs
data. able to:
concern about delivery process positive coping
upcoming delivery mechanisms as 2. Assess level of
Identify areas of Maintained v/s
and expresses evidenced by: anxiety through
concern that might within normal
worries about her verbal and non-
interfere with the range:
child inside her V/S within normal verbal cues.
normal progress of
womb. range:
labor. T: 37.4C
T: 36.5-37.5
PR: 66bpm
PR: 60-100bpm
Enhances nurse- RR: 16cpm
OBJECTIVE DATA: RR: 12-20cpm 3. Employ a calm,
client relationship. BP: 110/70mmhg
Exhibit poor eye BP: 110-140/60- caring, confident,
contact 90mmHg and non-judgmental
Claimed that she’s
approach.
Provides a healthy worried about the
Facial tension Acknowledge and
outlet of emotions condition of her
observed discuss fears, 4. Allow client to
and relieves baby.
recognizing healthy express fears and
anxiety.
Impaired attention vs. unhealthy fears feelings of anxiety
Verbalized that she
noted appropriately.
Adequate is capable of
 Absence of facial explanation helps
delivering the baby.
Appears tension and 5. Acknowledge reduce anxiety,
preoccupied; improved attention normalcy of fear soothe fears, and
Claimed excited to
decreased span. and provide provides
assurance. see her baby.
perceptual field. opportunity for
Verbalizes control of questions and
She claimed that
the situation answer honestly
she trusts the
within client’s level Provides feeling
or nurses in the
Verbalizes desire to of understanding. sense of security
hospital.
participate in labor and trust between
process as tolerated 6. Offer support by the nurse and the
staying with the patient.
OBJECTIVES
Expresses patient, pating her
PARTIALLY MET
confidence in arms, and brushing
herself, her support a whisp of hair off
person, and the her forehead, and
healthcare provide a cool cloth
personnel. on her forehead as
needed. Mechanism of
Acquires knowledge action is to
relieve
about childbirth and anxiety.
is better prepared Dependent
to cope with future 1. Administer anti-
births anxiety medication
as ordered by the Provides ongoing
physician. and timely
support.

Collaborative
1. Refer to support
groups as needed.
SUBJECTIVE Risk for fluid Within our care, our Independent:
Within our care, the
DATA: volume deficit client will maintain 1. Assess
patient’s To obtain baseline client was able to
Client requested for related to adequate fluid hydration status:
data.
a glass of water prolonged lack of volume and • Monitor V/S
Determine Maintained v/s
since she feels oral intake and electrolyte balance • Do PA (skin
alterations in fluid within normal
thirsty as reported. diaphoresis as evidenced by: turgor,
mucous volume and range:
membranes,
electrolyte
OBJECTIVE DATA: V/S within normal and
capillary imbalance. T: 37.4C
Vital signs: range: refill).
PR: 66bpm
T=37˚C T: 36.5-37.5 • Observe
RR: 16cpm
RR=14 cpm PR: 60-100bpm urinary
output, BP: 110/70mmhg
BP= 138/74 mmHg RR: 12-20cpm color,
measure
PR= 72 bpm BP: 110-140/60- amount, and
Exhibited moist
90mmHg specific
mucous membrane;
Received D5LR at gravity.
has good skin
right metacarpal Adequate urinary • Review lab
turgor, and prompt
vein flowing at 33 output with normal
capillary refill.
data
(Hb/hct,
gtts/min specific gravity
serum

electrolytes).
Exhibit moist
To maintain skin OBJECTIVES
mucous membrane,
integrity, prevent PARTIALLY MET
2. Provide
frequent
good skin trugor,
dehydration and
oral and skin
care.
and prompt
preserve kidney
capillary refill.
function.

Verbalize
To prevent
3. Discuss
 understanding of importance of aspiration which
withholding food withholding food can lead to
and fluids during and water during respiratory
distress.
labor the entire labor
course.
Demonstrate To prevent
behaviors to 4. Identify means to dehydration and
monitor and prevent dehydration preserve kidney
prevent dehydration such as providing function.
as indicated. ice chips or saturate
OS with water to be
sipped by the pt.

Dependent:
5. Assist in IV To prevent
infusion as ordered. dehydration and
preserve kidney
function

2nd stage of labor

 Cues/ Evidence Nursing Diagnosis Objectives
Interventions Rationale Evaluation

SUBJECTIVE Anxiety related to Within our care, our Independent:

Within our care, the
DATA: lack of knowledge client will manage 1. Assess
level of Identify areas of client was able to:
Client verbalized about labor anxiety with anxiety
through concern that might
she is worried about experience positive coping verbal and
non- interfere with the Verbalized desire to
the delivery of the mechanisms as verbal cues.
normal progress of participate actively
baby because this evidenced by:
labor. through effective
will be her first time
pushing
to do so. Verbalize awareness 2. Employ a calm,
Enhances nurse-
of feelings of caring,
confident, client relationship.
anxiety and non-
judgmental OBJECTIVES
OBJECTIVE DATA: approach.
PARTIALLY MET
Exhibit poor eye Verbalize
Provides a healthy
contact willingness to 3. Allow client
to outlet of emotions
cooperate and express fears
and and relieves
Facial tension and follow instructions feelings of
anxiety anxiety.
grimacing observed carefully during the appropriately.
entire course of
Adequate
Impaired attention labor 4. Acknowledge
explanation helps
noted normalcy of
fear reduce anxiety,
Manifest positive and provide
soothe fears, and
Appears attitude towards opportunity for
provides assurance.
preoccupied; healthcare questions and
decreased personnel and answer honestly
perceptual field. support persons. within client’s
level
of
understanding This position aids in
Verbalizes control of
the easy expulsion
the situation 5. Assist pt.
in of the fetus, thus
 proper
positioning – reducing stress and
Verbalize desire to Lithotomy
position anxiety from
participate actively
prolonged labor
during the course of
labor
6. Promote
effective
Acquires knowledge second-stage
about childbirth and pushing by
is better prepared instructing
client to
to cope with future push with each
births contractions
and
rest between
them

SUBJECTIVE Altered comfort: Within our care, our Independent:

Within our care, the
DATA: Pain related to client shall actively 1. Assess the
Provide baseline client was able to:
Client was bearing down participate in labor degree of pain
and data for future
frequently shouting efforts and and cope with the its
characteristics, interventions
and moaning. distention of the discomfort location,
severity, Claimed that she
Reported slight perineum effectively as duration, and
can deliver the
difficulty in bearing evidenced by: frequency.
baby.
down.
Verbalize pain 2. Employ a
calm, Gives pt a sense of Perceived labor
OBJECTIVE DATA: within tolerable caring,
confident, trust and Improves experience in a
Sighing and limits. and non-
judgmental nurse-client positive light and
moaning observed approach.
relationship. comply with the
Verbalize desire to
instructions of the
Facial tension and continue with the 3. Accept
patient’s Pain is a subjective physician
grimacing noted labor process. description of
pain experience and effectively.

cannot be felt by
Restlessness Perceive labor others.
Demonstrated
observed experience in a 4. Support pt. pain-
proper breathing
positive light and coping activities: Provides feeling
or techniques
Profuse sweating comply with the Offer support by sense of security
noted instructions of the staying with the and trust between
physician patient, pating her the nurse and the
OBJECTIVES
effectively. arms, and brushing patient.
PARTIALLY MET
a whisp of hair off
Demonstrate use of her forehead, and
relaxation and provide a cool cloth
diversional on her forehead as
activities as needed.
indicated (Guided-
imagery, Deep- 5. Instruct patient Proper breathing
breathing). to do proper technique can
breathing technique prevent
exhaustion,
Demonstrate proper (panting). therefore
breathing preventing
techniques prolonged delivery
of the fetus and
prolonged pain.
Collaborative:
6. Participate in the
delivery process To minimize
with other health workload,
therefore
care team members saving time and
(Doctor/Midwife, making the
delivery
Handle, Assist, IC, of the fetus
faster.
and Circulating)
SUBJECTIVE Ineffective Within our care, the Independent:
Within our care, the
DATA: breathing pattern client will improve 1. Assess for
Pain can limit client was able to:
Client reported related to breathing pattern concomitant pain/
respiratory effort
difficulty in inadequate lung as manifested by: discomfort
Was free from
breathing and cried expansion
cyanosis and other
for help. secondary to RR will be within the 2. Encourage deep
Facilitates alveolar signs of hypoxia
immobility normal range (16- breathing exercise
lung expansion thus
20cpm).
improving gas Participated actively
OBJECTIVE DATA:
exchange in the labor process
Hyperventilation Establish a normal/ 3. Maintain calm
through effective
noted effective respiratory attitude while
To limit level of pushing
pattern dealing with
client anxiety
RR= 31cpm
Demonstrated
Be free from 4. Encourage pt.
to appropriate coping
Appears restless cyanosis and other assume various
behavior to promote
signs of hypoxia position during
Various positions proper breathing
Profuse sweating active labor (ex.
facilitates lung such as using deep
noted Participate actively Squatting
position) expansion and easy breathing
in the labor process
expulsion of the technique.
Encourage rest
fetus.
Demonstrate period between
appropriate coping bearing down
To limit fatigue OBJECTIVES
behavior to
PARTIALLY MET
promote proper
breathing
3rd stage of labor

Cues/ Evidence Nursing Diagnosis Objectives

Interventions Rationale Evaluation

SUBJECTIVE Risk for Fluid Within our care, our

Independent: Within our care, the
DATA: Volume Deficit client will maintain 1. Assess
patient’s To obtain baseline client was able to:
Claimed that she’s related to adequate fluid hydration
status: data. Determine
not allowed to drink hypovolemia volume and • Monitor
V/S alterations in fluid Maintained v/s
or eat since she secondary to electrolyte balance (Check
BP volume and within normal
entered the delivery excessive blood as evidenced by: right
after electrolyte range:
room. loss
expulsion of imbalance.
V/S within normal
placenta) T: 37.4C
range: • Do PA
(skin PR: 66bpm
OBJECTIVE DATA: T: 36.5-37.5
turgor, mucous RR: 16cpm
Placenta delivered PR: 60-100bpm
membranes, BP: 110/70mmhg
at: 12:12 pm RR: 12-20cpm and
capillary
BP: 110-140/60-
refill). Exhibited moist
Gush of blood is present 90mmHg • Observe
mucous membrane,
during the delivery of the
urinary output, good skin trugor,
newborn and placenta Adequate urinary color,
measure and prompt
output with normal
amount, and capillary refill.
Vital signs: specific gravity
specific
T = 37˚C
gravity.
PR = 72 bpm Exhibit moist
OBJECTIVES
• Review
lab
RR= 14 cpm mucous membrane,
PARTIALLY MET
data
(Hb/hct,
BP = 138/74 mmHg good skin trugor,
To preserve skin
serum
and prompt
integrity, prevent

electrolytes).
 capillary refill.
dehydration and

preserve kidney
2. Provide
frequent
 oral and skin
care. function.

Prevent dehydration

and preserve kidney

Dependent:
function.
3. Assist in IV
infusion as
ordered. Promotes uterine

contraction which

prevents uterine
4. Administration
of atony or bleeding
methergin as
ordered

SUBJECTIVE Altered Comfort: Within our care, the 1. Assess the

level Assessing the pain Within our care, the
DATA: Pain related to client will: of pain experience
level experienced client:
Claimed to feel tissue trauma by the client and
by the client
slight pain during secondary to Report pain her ability to
determines her Reported pain
episiorrhaphy medial reduction, from a perform
capability to comply perception as
episiorrhaphy scale of 7 to 5 normal task such
with other having a numeric
as
eating, interventions value of 3
OBJECTIVE DATA: Demonstrate use of breastfeeding and
Weak and relaxation skills and dressing
Able to perform
exhausted diversional
breathing exercise
activities 2. Check vital
Serves as
Facial grimacing is signs
comparison from Able to exhibit
evident Exhibit absence of
previous minimal pain
facial grimacing
measurements thus gramacing
Eyes are closed as
determine any
observed Manifest normal RR
improvement or RR= 18 cpm
 ( 12-20 cpm)
further
Moaning and crying
deterioration of the Verbalized “ Mo
can be heard from Verbalize method
client’s condition inom ko og tambal
the patient but that provide relief 3. Review client’s
kung sakitan na jud
didn’t screamed or previous
Identify possible ko kaayo pareha
gave any experiences with
ways on how to anang mag sakit
verbalizations pain and methods
handle the pain akong pus-on kung
found helpful for
experiences by the reglahon ko.”
Narrowed focus is pain control in
the client
evident (reduced past
interaction with
OBJECTIVES
people) 4. Provide comfort
PARTIALLY MET
measures
To provide
Rated pain as 4 in a ( backrub,
nonpharmacologic
scale of 1-10, 1 as therapeutic touch)
pain management
the lowest and 10
as the highest 5. Encourage the
May help decrease
use of relaxation
pain perception by
technique such as
interrupting the
deep breathing and
conduction of
imagery
nerve pain impulse

4th stage of labor

Cues/ Evidence Nursing Diagnosis Objectives Interventions

Rationale Evaluation
SUBJECTIVE Risk for infection Within our care, the 1. Monitor vital
A slight elevation in Within our care, the
DATA: r/t impaired skin client will: signs especially
temperature client:
Client verbalized: integrity temperature
suggests fever.
“naa pay mga secondary to Not exhibit any
To assess if Did not manifest the
nanggawas nga medial signs and 2. Note signs/
infection is signs of infection
dugo sa akong episiotomy symptoms of symptoms of
fever, occurring (fever and chilling)
kinatawo” infection such as pallor and chills
T = 37.4C
fever and chilling
To prevent infection
“ sakit pa e lihok 3. Perform
surgical to the area and Listened upon
ang sa akong paa Identify handwashing
before inhibit cross explanation on the a
dapit” interventions to and after doing
contamination factor ( impaired
prevent/ reduce risk perineal care on
the skin integrity ) of
of infection site of
episiotomy developing infection

Give the client the

OBJECTIVE DATA: Verbalized 4. Explain why
and idea on the Was not able to
Method of delivery: understanding of how infection is
causative factors on verbalize an
NSVD with thick individual risk likely to happen
infections formation understanding of
meconium staining factors
the risk factors
5. o perineal
care Perineal area should
Episiotomy area is and teach the
be cleansed well to
Swollen and reddish mother on the
prevent the growth OBJECTIVES
in color. importance of
of microorganisms PARTIALLY MET
proper perineal
cleaning
SUBJECTIVE Impaired skin Within our care, 1. Inspect status
of Detect signs and Within of our care,
DATA: integrity r/t client will have the perineum
symptoms of client had improved
Client verbalized, episiotomy improved skin
possible infection skin integrity as
“naa pay mga secondary to integrity as
evidenced by:
nanggawas nga vaginal delivery evidenced by: 2. Check clients
Any deviation may
dugo sa akong medical record and
suggest blood Episiotomy healed
kinatawo” Episiotomy will heal lab findings
clotting/coagulation without infection
in due time without especially platelet
is impaired and
“ sakit pa e lihok infection count, bleeding
healing will be Regained skin
ang sa akong paa time, clotting time
affected. integrity
dapit” Identify signs and
symptoms of
Identified s/s that
infection that can 3. Instruct and
Sitz bath aids in suggest infection
OBJECTIVE DATA: further impair skin assist the pt. In
the healing process by have occurred.
Method of delivery: integrity use of sitz bath
increasing
NSVD with
circulation to the
meconium staining Verbalized
perineum and OBJECTIVES FULLY
understanding of
prevent edema. MET
Episiotomy area is individual risk
Swollen and reddish factors 4. Teach pt. How to
Provide knowledge
in color. apply and remove
on how to apply and
Verbalize maternity perineal
remove pads that
understanding on pad
can help maintain
the need to
skin integrity.
maintain proper
personal hygeine
Suggests infection
5. Instruct pt. To
has occurred and
watch for s/s of
immediate
infection such as:
intervention is
fever, foul odor on
required.