Assessment/Cues Nursing Diagnosis Plan of Care Interventions Implementations Evaluation

“I'm in labor. Tell me Benita is diagnosed  Maintain airway INDEPENDENT:  Provides After 8 hrs. of nursing
what I’m supposed to as having an upper patency with  Assess vital baseline on interventions on labor,
do." respiratory infection; breath sounds signs maternal blood the patient was able to
she is in active labor. clear/clearing.  Maintain bed loss. successfully give birth,
 Demonstrate rest or chair rest  Systematic rest without any
behaviors to when indicated. is mandatory complications, also
improve airway Provide and important understanding the
clearance, e.g., frequent rest throughout all appropriate actions to
cough periods and phases of be taken after child
effectively and uninterrupted disease and to birth.
expectorate night time reduce fatigue
secretions. sleep. and improve
 Monitor amount strength.
and type of  To promote
bleeding. placental
 Position mother prefusion.
on her left side.  Prevents tearing
 Monitor uterine of placenta
contractions previa is the
and fetal heart cause of
rate by external bleeding.
monitor.  Assess whether
 Maintain labor is present
positive attitude and fetal status
toward fetal and external
outcome. system avoids
cervical trauma.
 Supports mother
DEPENDENT: and child
 Doctor bonding
prescribing  Provide
medication to adequate fetal
 the client. oxygenation
despite of
lowered
COLLABORATIVE: maternal
 Administer circulating
oxygen as volume.
indicated
NURSING CARE PLAN