NCM 107.

1 – OBSTETRICS

Instruction: Make a Nursing Care Plan (NCP) with a minimum of three Nursing Diagnosis. Prioritization of
Nursing Diagnosis should be observed.

PATIENT’S DATA
Name: Patient X
Date of Birth: January 3, 1993
Place of Birth: Naga City, Camarines Sur
Address: Francia, Naga City
Age: 28 years old
Civil Status: Single
Religion: Roman Catholic
Patient Medical History: With controlled HPN & DM
Chief Complaint: Labor pain, EDC was 2 weeks ago.

VITAL SIGNS
T- 37.7
R- 21
P- 82
BP- 140/100

Patient X presents at the health facility accompanied by her partner with complaints of labor pain and
contractions every 15 minutes. Upon assessment of the mother, the following were observed:
• the patient has controlled HPN and DM,
• GP TPAL Score of G1P1 (0001)
• NCD Risk Assessment – Patient is a heavy cigarette smoker and alcohol drinker
• Large than the usual abdomen (r/o Oligohydramnios);

Assessment of the fetus reveals: station or presenting part has descended into the maternal pelvis; fetal
heart rate increased toe every 15 minutes, then slowing of FHT as labor progresses.

The patient also verbalized that she did not seek for medical advice and pre-natal checkup throughout the
duration of the pregnancy, and this is the only time she was seen by a health professional.
 NURSING CARE PLAN
ACTUAL DIAGNOSIS

DATE ASSESSMENT DIAGNOSIS BACKGROUN PLANNING INTERVENTIO RATIONALE EVALUATION

D N
KNOWLEDGE
Novembe OBJECTIVE SUBJECTIVE Acute pain Laboring SHORT TERM Independent Independent SHORT TERM
r 28, related to happens GOAL: nursing nursing GOAL: Goal
2021 • Vital • Chief laboring as when After 8 interventio intervention fully met
Signs Complain evidenced by there are hours of ns: s: After 8
T- 37.7 t: Labor
R- 21 pain,
chief frequent nursing • Monito • This hours of
complaint of contracti interventi r the helps nursing
P- 82 EDC was the patient ons of ons, interventi
BP- 140/100 2 weeks uterin to
and frequent uterus patient e know ons,
• the ago contraction for the will verbalizes
activi the
patient • With s. cervix to verbalize that the
ty progre
has complain dilate. reduced every ss and pain is
controll ts of This is pain. contra identi already
ed HPN labor painful ction. fy if reduced
and DM pain and and there and
• GP TPAL contract happens 2 LONG TERM are manageable
Score of ions weeks GOAL: .
any
G1P1 every 15 before of After 5 abnorm
(0001) minutes. after days, alitie
• NCD Risk • The EDD. patient s in LONG TERM
Assessme patient will contra GOAL: Goal
nt – also participat ctions fully met
Patient verbaliz e in . After 5
is a ed that activities • Monito • High days,
heavy she did to r and blood patient
cigarett not seek diminish record pressu already
e smoker for pain and the re may participat
and medical to enhance patien be a es in
alcohol advice comfort. t`s cause activities
drinker and pre- vital of her that may
• Large natal signs HPN enhance
than the checkup and and DM her
usual througho the which comfort.
abdomen ut the FHR. may
(r/o duration affect
Oligohyd of the the
ramnios) pregnanc FHR of
y, and
• Presenti this is the
ng part the only fetus.
has time she • Give • This
descende was seen the keeps
d into by a patien them
the health t/coup inform
maternal professi le ed why
pelvis. onal. inform the
• Fetal ation delive
heart on the ry is
rate progre nearin
increase ss of g.
d to labor
every 15 as
minutes, well
then as the
slowing FHR.
of FHT • Provid • This
as labor e the will
progress patien help
es. t the the
• Patient comfor patien
Medical t that t have
History: they a
With need. comfor
controll table
ed HPN & feelin
DM. g as
she
goes
on
with
her
labor.
• Encour • It
age reduce
patien s the
t to feelin
change g of
positi pain
on and
from
 time discom
to fort.
time
or
have
some
time
to
walk.
• Encour • Drinki
age ng
the water
patien will
t to help
stay in
hydrat improv
ed. ing
oligoh
ydramn
ios.
This
increa
ses
the
level
of
amniot
ic
fluids
.
Dependent Dependent
Nursing Nursing
Interventio Intervention
ns: s:
• Provid • These
e medica
medica tions
tions are
as needed
prescr to
ibed reduce
by the pain.
 physic Howeve
ian. r, we
must
not
overlo
ok the
advers
e
effect
s of
theses
medica
tions
as it
may
also
affect
the
baby.
• As • If the
instru result
cted s show
by the little
physic amount
ian, of
conduc amniot
t ic
severa fluid,
l lab the
tests fetus
for must
the be
patien delive
t. red
immedi
ately
to
preven
t risk
of
miscar
riage
or
 stillb
irth.

NURSING CARE PLAN

ACTUAL DIAGNOSIS

DATE ASSESSMENT DIAGNOSIS BACKGROUN PLANNING INTERVENTIO RATIONALE EVALUATION

D N
KNOWLEDGE
Novembe OBJECTIVE SUBJECTIVE Ineffective As a SHORT TERM Independent Independent SHORT TERM
r 28, health pregnant GOAL: nursing nursing GOAL: Goal
2021 • Vital • The maintenance woman, it After 8 interventio intervention fully met
Signs patient related to is hours of ns: s: After 8
T- 37.7 also unhealthy important nursing hours of
R- 21 • Ask • This
verbaliz lifestyle to engage interventi nursing
P- 82 the is
ed that choices such yourself ons, interventi
BP- 140/100 patien import
she did as smoking in a patient ons,
t on ant to
• the not seek and drinking healthy will her know patient
patient for alcohol as lifestyle verbalize already
percep if the
has medical evidenced by so that her verbalizes
tion patien
controll advice no interest the fetus understand her
on her t is
ed HPN and pre- in health in you ing on the understand
health willin
and DM natal improvement carry importance ing on the
status g to
• GP TPAL checkup and will be of healthy importance
. change
Score of througho verbalized healthy. lifestyle of healthy
her
G1P1 ut the that she Having since lifestyle
lifest
(0001) duration hadn`t bad habit she`s since
yle
• NCD Risk of the visited the would pregnant. she`s
especi
Assessme pregnanc physician also pregnant.
ally
nt – y, and for pre- danger her
Patient this is natal check- your LONG TERM baby
is a the only up. child and GOAL: LONG TERM
is in
heavy time she may lead After 5 GOAL: Goal
danger
cigarett was seen to worst days, fully met
.
e smoker by a case patient After 5
health • Ask • Bad
and scenario. will the habit days,
alcohol professi participat patient
onal. patien may
drinker e physical t greatl already
• Large • Chief activities participat
about y
than the Complain to help es in
her affect
usual t: Labor her physical
habits her
pain,
 abdomen EDC was improve in the lifest activities
(r/o 2 weeks her health past yle and
Oligohyd ago status. and in and improved
ramnios) • With the the her health
• Presenti complain presen lifest status.
ng part ts of t. yle of
has labor her
descende pain and baby.
d into contract The
the ions nurse
maternal every 15 must
pelvis. minutes. help
• Fetal her to
heart break
rate these
increase habits
d to , so
every 15 it
minutes, won't
then lead
slowing to
of FHT unwant
as labor ed
progress conseq
es. uences
.
• Patient
• Educat • This
Medical
e the is to
History:
patien know
With
t on if the
controll
the baby
ed HPN &
import is
DM.
ance doing
of well
check- or
ups have
during some
pregna abnorm
ncy. alitie
s
during
pregna
ncy
 since
the
mother
doesn`
t
practi
ce a
health
living
.
• Encour • Being
age a
patien smoker
t to and
practi alcoho
ce lic
health drinke
living r may
. harm
the
baby`s
health
and
HPN
may
attack
again.
• Encour • Suppor
age t is
the very
partne import
r to ant to
fully a
suppor pregna
t her nt
wife woman
as she becaus
goes e it
on helps
with her to
her lessen
er
 pregna stress
ncy. and
anxiet
y.
Dependent Dependent
nursing nursing
interventio intervention
ns: s:
• As • This
prescr is to
ibed treat
by the alcoho
physic l
ian, depend
admini ance
ster and
phenob alcoho
arbita l
l. withdr
awal.

Collaborati Collaborativ
ve nursing e nursing
interventio intervention
ns: s:
• Encour • These
age are
the suppor
patien t
t to system
join s that
self- will
help help
groups her
. promot
e
abstin
ence
from
alcoho
l and
 cigare
ttes.
• She • A meal
may plan
also or
consul diet
t a therap
nutrit y may
ionist also
or help
dietit her to
ian. start
health
living
for
her
and
for
her
baby.
 NURSING CARE PLAN
POTENTIAL DIAGNOSIS

DATE ASSESSMENT DIAGNOSIS BACKGROUN PLANNING INTERVENTIO RATIONALE EVALUATION

D N
KNOWLEDGE
Novembe OBJECTIVE SUBJECTIVE Risk for Smoking SHORT TERM Independent Independent SHORT TERM
r 28, fetal injury and GOAL: nursing nursing GOAL: Goal
2021 • Vital • The related to drinking After 8 interventio intervention fully met
Signs patient unhealthy during hours of ns: s: After 8
T- 37.7 also
R- 21
lifestyle pregnancy nursing • Freque • To hours of
verbaliz choices such may interventi nursing
P- 82 ntly identi
ed that as smoking increase ons, the interventi
BP- 140/100 monito fy if
she did and drinking the risk fetus will ons, the
r the there
• the not seek alcohol. for maintain a FHR of are fetus
patient for injury in normal FHR shows
the any
has medical the and the normal
fetus. abnorm
controll advice baby`s mother FHR, and
alitie
ed HPN and pre- health. will have the mother
s seen
and DM natal This can normal achieved
in the
• GP TPAL checkup cause vital the normal
fetus.
Score of througho danger to signs. vital
ut the • Monito • Since
G1P1 the baby r the the signs such
(0001) duration as the as
of the vital mother
• NCD Risk mother signs has temperatur
Assessme pregnanc goes e and BP.
y, and of the fever
nt – along mother and
Patient this is with her
the only , high
is a pregnancy especi blood
heavy time she .
was seen ally pressu
cigarett her re,
e smoker by a
health BP. the
and nurse
alcohol professi
onal. must
drinker monito
• Large • Chief
r it
than the Complain
freque
usual t: Labor
ntly
abdomen pain,
as it
(r/o EDC was
may
Oligohyd 2 weeks
affect
ramnios) ago
the
• Presenti • With placen
ng part complain tal
has ts of perfus
descende labor ion.
d into pain and • Educat • This
the contract e the will
maternal ions patien help
pelvis. every 15 t on her
• Fetal minutes. how realiz
heart smokin e as
rate g and soon
increase drinki as
d to ng possib
every 15 affect le
minutes, s the that
then baby`s smokin
slowing health g and
of FHT . drinki
as labor ng may
progress cause
es. an
injury
• Patient
to the
Medical
baby.
History:
With • Patien • Even
controll t though
ed HPN & educat her
DM. ion on HPN
HPN and DM
and DM are
and contro
its lled,
effect nurses
s on must
fetal still
growth educat
. e the
patien
t on
the
effect
s of
 HPN
and DM
so
that
she
will
know
what
to do
and
not
do.
• Encour • Patien
age t must
the unders
patien tand
t to the
start need
health to
lifest practi
yle. ce
health
living
not
just
for
her
but
for
the
baby
also.

Dependent Dependent
nursing nursing
interventio intervention
ns: s:
• As • These
prescr medica
ibed tions
by the will
physic improv
 ian, e the
admini BP of
ster the
medica patien
tions. t and
her
body
temper
ature.

Collaborati Collaborativ
ve nursing e nursing
interventio intervention
ns: s:
• Encour • Consul
age tation
the with a
mother nutrit
to ionist
consul is
t a also
nutrit import
ionist ant
becaus
e they
will
know
what
plan
or
regime
n is
suited
for
your
lifest
yle.
This
may
not
only
help
you,
 but
also
the
baby.
• Visit • OB-
an OB- GYNEs
GYBE are
the
one`s
who
will
instru
ct you
with
the
things
you
need
to do
and
not to
do.
They
are
also
the
one`s
who
perfor
ms
ultras
ound
to
know
the
fetal
presen
tation
.