Vicente, Karren Mae J.

BSN – 2A

NURSING CARE PLAN

Cues/Evidences Nursing Diagnosis Outcome Criteria Nursing Interventions Rationale Evaluation
Client will be able to:  Assess client’s  This will guide in Client was able to:
Subjective Data: Deficient knowledge baseline knowledge establishing learning
related to lack of  Verbalize and expectations needs and set  Verbalize
“I’m in labor. Tell me exposure. understanding of during pregnancy. priorities. understanding of
what I’m supposed to psychological  Provide information  Prenatal education psychological and
do” as verbalized by the and about procedures can facilitate physiological
client. physiological and normal the labor and changes.
changes. progression of labor. delivery process,
Objective Data:  Participate in
assist the client in
 Participate in decision-making
maintaining control
Height: 5’5 decision-making process.
Weight: 142 lb during labor, help
process.
Temp.: 38 °C promote a positive
 Demonstrate
BP: 112/70 mmHg  Demonstrate  Obtain informed attitude, and may appropriate breathing
RR: 20 bpm appropriate consent for decrease reliance and relaxation
HR: 70 bpm breathing and procedures, e.g., on medication. techniques.
FH: 35 cm relaxation forceps delivery,  When procedures
FHR: 150 bpm techniques. episiotomy. Explain involve client’s
the procedures and body, it is necessary
the possible risks for client to have
associated with labor appropriate
and delivery. information to make
 Educate the client informed choices.
about breathing and
relaxation
techniques  Unprepared couples
appropriate to each need to learn coping
phase of labor; teach mechanisms on
and review pushing admission to help
positions for stage reduce stress and
II. anxiety. Couples
with prior
preparation can
benefit from review
and reinforcement.