NURSING CARE PLAN

ASSESSMENT DIAGNOSIS OUTCOME INTERVENTION EVALUATION

SUBJECTIVE Acute pain related to After 2-4 hours of 1. Expedite the After 2 hours of
Chief Complaint: uterine muscle continuous admission process and continuous
Uterine contraction contraction interventions, the initiate bed rest for pt, intervention, the
patient will using lateral patient verbalized a
A few hours PTA Meaning of Dx: verbalize pain rating recumbent position. pain rating of 2 on the
(Prior to Unpleasant sensory of 2/10 on the pain Side-lying position pain rating scale.
Admission) patient and emotional rating scale. improves uterine blood
experienced experience associated flow and may decrease
uterine with actual or potential uterine irritability
contractions. tissue damage or
described in terms such
damage sudden or 2. Teach relaxation
OBJECTIVE slow onset of any technique (e.g., deep
AOG (Age of intensity from mild to breathing exercise,
Gestation): 29 – 30 severe with an visualization, guided
weeks (premature anticipated or imagery). Help client
labor) predictable pain. refocus, attention
decreases muscle tension,
reduces perception of
discomfort and promotes
sense of control.

3. Monitor the patient’s

pain level every 4 hours
using pain scale. Use to
monitor the level of pain
and to assess what
further interventions are
needed.

4. Monitor Vital Signs Q4.

Reflects effectiveness of
intervention.

5. Management of pain
using non-
pharmacological
treatment like re-
patterning unhelpful
thinking through
 meditations. Use to help
patient to clear up their
mind from negative
thoughts expectations
that may exacerbate pain
and result in failure in
pain management.

6. Provide pharmacologic
pain management per
physician’s
instructions. Reduces
pain and bring relief.

ASSESSMENT DIAGNOSIS OUTCOME INTERVENTION EVALUATION

Subjective: Risk for infection as Goals: 1. Perform proper handwashing Patient remained free
evidenced by elevated technique before handling of infection as
 None WBC count  Patient will remain the client. Proper evidenced by body
free of infection handwashing reduces the risk temperature of 36.5C
Objective: Meaning of Dx: throughout her stay of transmission of
Vulnerable to invasion in the hospital microorganisms that could Patient shows no signs
and multiplication of start an infection and symptoms of
Elevated WBC pathogenic organisms, Outcomes: infection throughout
count which may 2. Monitor temperature every her stay in the
compromise health  Patient’s body hour. Body temperature of hospital
temperature will above 37.5 C is a major sign
remain between of infection
36C – 37C
throughout her 3. Monitor perineal area of the
stay in the hospital client every hour. To be able
 No signs (e,g. to detect for complications
redness, heat, pain, and signs of infection
edema, pus (redness, heat, pain, edema,
formation) and pus formation)
symptoms (e,g.
chills and sweats, 4. Clean perineal area as
feeling feverish, needed. Keeping the perineal
cough, sore throat, area clean as much as
nasal congestion, possible will help prevent
and stiff neck) of growth of microorganisms
infection were seen that could lead to infection
throughout her
stay in the hospital 5. Change perineal pad as
needed. Keeping the area
clean is also very important to
prevent microbial growth

6. Monitor patient for

symptoms of infection (e,g.
chills and sweats, feeling
feverish, cough, sore throat,
nasal congestion, and stiff
neck) every hour. These
symptoms could help in early
detection of an infection for
proper intervention

7.Encourage intake of foods rich

in Vitamin C, Protein, and
calories unless
contraindicated (e.g,
hyperacidity). Vitamin C
helps protect the body from
infections, protein helps in cell
build-up process and calories
provide needed energy for the
body to heal itself

8.Conduct health teachings

about infection prevention.
Teach the patient about
importance of maintaining
proper hygiene. Teach about
proper ways of disinfecting
personal items, and proper
handwashing. Remind her
about the importance of
physical distancing and the
proper use of PPEs (face
masks, face shields)

11. Wear personal protective

equipment (PPE) properly.
Wear Gloves, Mask, and a
Gown before giving care to
patient, change PPEs before
coming in contact with another
patient to prevent cross
contamination or follow
agency protocol.
 ASSESSMENT DIAGNOSIS OUTCOME INTERVENTION EVALUATION
SUBJECTIVE Anxiety related to 1.The client will be 1. Monitor the anxiety level of The client discuss
perceived threats to able to discuss the patient, anxiety triggers thoughts such as
OBJECTIVE self and fetus thoughts such as and symptoms by asking feeling of discomfort,
Pulse rate: 106 feeling of open –ended questions. To hopelessness and
bpm discomfort, establish a baseline helplessness after the
Meaning of Dx: hopelessness, observation of the anxiety application of nursing
A feeling of and helplessness level of the patient. Open- intervention
apprehension caused after application ended questions can help
by anticipation of of nursing explore thoughts and
danger. It is an alerting intervention. feelings of the patient
sign that warns of regarding herself and
impending danger and newborn.
enables the individual
to take measures to 2. Promote wellness. Assist
deal with that threat client with identifying new
methods of coping with
anxiety (e.g . Review
happenings, thoughts, and
feelings preceding the
anxiety attack. List helpful
resources and people.
Assist in developing skills
(e.g. awareness of negative
thoughts, saying “Stop”,
and substituting a positive
thought). Strengthening a
mother’s mental health
and promoting resilience to
handling life's stressors not
only reduces the risk of
mental conditions but
contributes to improved
general health, well-being
and productivity.

3. Note physical ability and

interaction with the
healthcare personnel,
families and friends. It
helps determine the
patient’s level of
independence to perform
 activities of daily living and
healthcare procedures. The
manner of interaction is
also important in order to
establish safety of
significant others and
health care personnel.

4. Demonstrate use of
thought-stoppers or
anxiety-interrupters such
breathing control, self-
directions, imagery and
voice alterations that might
be helpful for the patient
when dealing with stressful
events. These techniques
are found to be essential in
managing the fight-or-
flight response of the
autonomic nervous system.

5. If applicable and available,

refer the patient to a
personnel who conducts
“Assertiveness Therapy
Training”. Assertiveness
Therapy Training facilitates
development of positive-
thinking, realistic goal-
setting and learning
limitations.

6. Administer medications as
prescribed. Educate the
patient about each drugs
benefits, side effects,
proper administration, and
details. Taking medicine as
prescribed or medication
adherence is important for
controlling chronic
conditions, treating
temporary conditions, and
overall long-term health
and well-being.

7. Provide comfort measures

 (e.g. quiet environment or
back rub). - comfort
measures help patient to
calm and relax

8. Provide accurate
information about the
situation. - this help the
client identify what is
reality based and provide
assurance

ASSESSMENT DIAGNOSIS OUTCOME INTERVENTION EVALUATION

Subjective: Risk for fetal injury as Goals: 1. Establish rapport. To gain Patient gave birth to a
evidenced by preterm  Patient will give client’s trust and have baby with an APGAR
 Uterine labor birth to a healthy cooperation with score of 8 at 1 minute
contractions baby interventions and 9 at 5 minutes,
and the baby weighs
Objective: 2. Assess for maternal 1.3 kgs
Meaning of dx: Outcomes: conditions that would
Possible  Patient gave birth to contraindicate steroid
AOG : 29-30 weeks harm/complication a baby with an therapy to facilitate fetal
foreseen to the fetus APGAR score of 7-9 lung maturity. Steroids can
at 1 minute and an possibly aggravate
APGAR score of 7- hypertension, it can also
10 at 5 minutes mask signs of infection. In
patients with Diabetes,
Patient gave birth to steroid therapy can
a baby weighing increase blood glucose
more than 500 levels
grams
3. Monitor fetal heart rate
every 15 minutes. Helps
detect presence of fetal
distress in order to
immediately provide
interventions such as
positioning the mother in a
left side-lying position.

4. Assist as needed with

analysis of amniotic fluid
from amniocentesis or
vaginal pool specimen. L/S
 ration test helps rule out
the need for tocolytic and
antenatal steroid therapy
because it determines fetal
lung maturity

5. Administer the doctor’s

ordered medications
(Terbutaline and
Dexamethasone).
Terbutaline is a tocolytic
that is used to delay labor
for up to 48 hours to give
time for the antenatal
steroid dexamethasone to
do it’s job of maturing the
baby’s lungs faster.

6. Provide client with

information on how the
medications work and why
they were given. Helps
clear out any
misunderstandings the
client may have

ASSESSMENT DIAGNOSIS OUTCOME INTERVENTION EVALUATION

Subjective: Activity intolerance After 2 hours of 1. Provide comfort measure After 2 hours of
 Uterine related to muscular nursing intervention such as back rub and nursing intervention
contraction hypersensitivity as patient will use changing positions. patient used
evidenced by relaxation - Decrease muscle relaxation techniques
continued uterine techniques to tension. to enhance activity
Objective: contraction enhance activity intolerance.
Pulse rate- 106 intolerance. 2. Teach client relaxation
beats/min Meaning of Dx: techniques such as
Insufficient breathing exercise, guided
Physiological or imagery and visualization.
psychological energy to - Breathing exercise After 2 hours of
endure or complete After 2 hours of promotes relaxation nursing intervention,
desired daily activities nursing and help to reduce and the patient’s
intervention, the promote sense of contractions are now
patient’s control by diverting the 20 minutes apart and
 attention of the
contractions will be patient. not 10 minutes apart
20 minutes apart
and not 10 minutes 3. Plan care to carefully balance
apart rest periods with activities.
- to reduce fatigue

4. Instruct the patient to

report any feeling of
difficulty of breathing,
dizziness, and irregular
heartbeat.
- To recognized possible
adverse effect allows
for prompt
intervention.
5. Monitor uterine
contraction, including
frequency and domain.
- Monitoring uterine
contraction provides
evidence of
effectiveness of
intervention.

ASSESSMENT DIAGNOSIS OUTCOME INTERVENTION EVALUATION

Subjective: Risk for maternal injury Goals: 1. Create a list of people the Patient gave birth to a
related to altered  Patient will remain patient trusts and would like baby with an APGAR
 none mobility as evidenced free of injury until to be her guardian for the score of 8 at 1 minute
by cesarean delivery throughout her stay time being. The client needs and 9 at 5 minutes,
Objective: in the hospital extra monitoring and to have and the baby weighs
someone the patient can 1.3 kgs
 Outcomes: easily ask help for simple
 Cesarean  Patient was things like getting a cup of
section delivery discharged water, passing the remote
Meaning of dx: without any injury control, walking to the toilet
Possible harm/hazard upon inspection would be appreciated.
to mother due to  Patient will be
cesarean delivery assisted by a 2. Monitor the cleanliness of
wounds relative, a trusted the penatit’s room. If the
someone, or by a room looks unruly, it could
nurse whenever become a source of hazard
she wishes to for the mother.
ambulate.
 Patient’s room will 3. Bring the most commonly
remain clean and and frequently used items by
be free of any the mother near her bed,
potential hazard within her reach (e,g.
(e,g. slippery cellphone, purse, remote
doormats, slippery control, tissues) this allows
floors ) for more independence for
the woman and concerves
the time of nurses.

4. Allow client to assume a

comfortable position,
facilitates relaxation and not
wanting to go outide

5. Teach patient on emergency

exits and building ways.
Every patient has the right
to know the location of
these exits