NURSING CARE PLAN
ASSESSMENT DIAGNOSIS
SUBJECTIVE CUES:
“Nabalaka ko kay first time
nako ma-operahan, basin
pud maunsa si baby,” as
verbalized by the patient.
OBJECTIVE CUES:
 apprehensive
 restless
 preoccupied
 voice quivering
 trembling
 increase in perspiration
 V/S are as follows:
 Temp: 36.9°C
 PR: 110 bpm
 RR: 22 cpm
 BP: 130/90 mmHg
PLANNING
Anxiety related to Within 1 hour of nursing
perceived threat of interventions, the patient
maternal and fetal will be able to:
well-being
1. Verbalize awareness
of feelings of anxiety.
2. Appear relaxed and
comfortable.
3. Identify healthy ways 3. Allow the patient to discuss and - Patient may have twisted
to deal with and elaborate
express anxiety. appropriate.
INTERVENTIONS RATIONALE EVALUATION
1. Monitor vital signs for rapid or - To identify physical responses After 1 hour of nursing
irregular pulse, hyperventilation, associated with both medical and interventions, the patient
changes in blood pressure, emotional conditions. was able to:
diaphoresis, tremors, or restlessness.
1. Verbalize awareness
2. Ascertain whether the procedure is - If the procedure is of feelings of anxiety
planned or not. unplanned, patient usually has no as evidenced by
time for physiological or patient stating that,
psychological preparation. “nabalaka ko kagina
kay wala ko nag-
expect nga i-CS ko ug
expectations, as thoughts or unrealistic perceptions wala pud ko kabalo
of abnormality of cesarean birth gyud unsay
which will increase anxiety. mahitabo.”
4. Let the patient verbalize or express - To help distinguish negative 2. Appear relaxed and
inner thoughts and feelings. feelings and concerns and provide comfortable.
chance to cope with feelings of fear
and uncertainty. 3. Identify healthy ways
to deal with and
5. Remain with the patient and stay - To reduce interpersonal express anxiety.
calm. Speak in a slow manner. Convey transmission anxiety and show
empathy. caring attitude to the patient. GOAL MET
6. Reinforce positive aspects of - To redirect focus on likelihood of
maternal and fetal condition. desirable outcome and help to
bring perceived threat into
perspective.
7. Review coping skills used in the
past. - To determine those that might be
helpful in current circumstances.
8. Assist the client in developing self- - Becoming aware helps client to
awareness of verbal and control these behaviors and begin
nonverbal behaviors. to deal with issues that are
 causing anxiety.

9. Provide comfort measures to - Aids in meeting basic human

patient. need, decreasing sense of isolation,
and assisting client to feel less
anxious.
10. Allot time for privacy.
- To allow patient to internalize
information, organize resources,
and cope effectively.

References:

Doenges, M. E., Moorhouse, M. F., & Murr, A. C. (2018). Nurse's pocket guide: Diagnoses, prioritized interventions, and rationales. FA Davis.

Wayne, G. (2019, June 2). 10 Cesarean Birth Nursing Care Plans. Nurseslabs. Retrieved from https://nurseslabs.com/cesarean-birth-nursing-care-plans/2/