CUES Nursing Scientific Planning Intervention Rationale Expected

Diagnosis Explanation Outcome

S=”This is my Deficient The pt. is SHORT >establish rapport >to gain cooperation SHORT
first baby. I Knowledge experiencing the TERM: and trust from client TERM:
really do not regarding latent phase of the After 10-20 After 10-20
know what to procedure, active stage of minutes of NI, >monitor vital signs >to obtain baseline minutes of NI,
do” treatment needs, labor. The client is the pt. will and perform and assess possible the pt. shall
and possible a primi-gravida participate in preliminary areas of immediate have
O=>presence outcomes related and she admits to the learning assessment intervention participated in
of: to lack of not knowing process. the learning
>active queries exposure anything about >identify client’s >to determine level process .
regarding evidenced by what to expect and level of of teaching
procedure questions. what to do. This understanding
>facial has led to >the client may not
expressions deficient >determine client’s be physically,
suggesting fear knowledge. LONG readiness for teaching emotionally, or
>active TERM: mentally capable of LONG TERM:
verbalization of After 2-3 days learning at this time After 2-3 days
the problem of NI, the pt. of NI, the pt.
will regain >be alert for >clients may need to shall have
normal bowel avoidance or experience lack of verbalized
patter acceptance information before understanding
verbalize they decide to accept of procedure,
understanding teachings treatment
of procedure, needs, and
treatment >provides possible
needs, and >determine barriers opportunities to outcomes.
possible towards earning address barriers such
outcomes. as language
differences

>assess fetal heart >determines presence

tone of fetal distress

>determines need for

>assess for progress transfer from labor
of laborcntinuously room to delivery
room

>instruct client on the >clients in the latent

latent phase of labor phase are still capable
of learning as pain is
still tolerable

>motivate clients >enhances

towards learning participation and
compliance

>provide only >To prevent overload

information relevant and address current
to the current issues immediately
situation
>relieves anxiety and
>allow to verbalize tension
feelings
>provides learning
>answer queries and and encourages
encourage to ask attention and
questions compliance towards
new knowledge

>enhances learning
>provide tools for and promotes
learning such as cooperation and
visual aids fascination

>instruct on proper >provides a clear

“pushing” during instruction to the
labor, with pursed proper way of
lips “pushing”
minimizing
 exhaustion and
discomfort

>instruct on deep >allays anxiety,

breathing exercises promotes relaxation,
reduces discomfort.

>instruct that pain >to allay anxiety and

and forceful provide factual
contractions are information as to
normal what the client may
expect

>instruct to refrain >pushing earlier may

from “pushing” until result to fetal distress
instruct to do so
during crowning.

>ask if the mother is >breasfeeding

to breastfeed after promotes nonding
delivery. Encourage and provides
it optimum fetal
nutrition.

>remain as factual as >brings realism to

possible. Maintain light and allows for
veracity realistic expectations

>use short, simple >provides learning

sentences while conserving
time. Clients in labor
may only be taught
during the latent
stage.
>use gestures and
facial expressions if >enhances learning
appropriate using non-verbal cues

>provide written
guidelines if feasible >reinforces learning
and allows client to
proceed at his own
pace.
>begin teaching with
what the client knows >arouses learning and
already limits the sense of
being overwhelmed
>prepare for delivery
>always prepare for
delivery should a
precipitous labor
occur.