DATE CUES NEED NURSING OBJECTIVES INTERVENTIONS EVALUATION

& TIME DIAGNOSIS

3/15/22 Subjective: S Anxiety r/t At the end of the 1. Use positive At the end of the
7-3 The patient is E Unanticipated labor phase, the terminology; avoid use labor phase, the
shift slightly L deviation from patient will be able
of terms that indicate patient is able to:
apprehensive, F expectations to: abnormality of
"Nurse, - aeb procedures or 1. accomplish
delikado ba angP Identification of 1. Client will processes. successful
sitwasyon saE specific report labor.
akong anak?R concerns anxiety R: Helps client/couple
Ma deliver ba C diminished accept the situation 2. Client is
kaha nako ug E Rationale: and/or without self- now
normal? P Main causes of managed. recrimination. relaxed and
T maternal anxiety less facial
Objective: I about childbirth 2. Client will 2. Encourage tension
O are due to fear appear verbalization of
profuse N of damage to relaxed. feelings. GOAL MET
sweating - mother and
S baby and lack of 3. Client will R: Client may be
appeared to be E trust to the accomplish frightened or may not
in distress L quality of successful clearly understand the
F maternity care labor. need for inducing labor.
facial tension - and staff A sense of failure at
C commitment. being unable to “labor
O naturally” may occur.
N
3. Encourage
C
use/continuation of
E
breathing techniques
P
and relaxation
T
-
P exercises.
A
T R:Helps to reduce
T anxiety and enables
E client to participate
R actively.
N
4. Respect the need for
focusing during
contractions. Refrain
from intervening with
client during a
contraction.

R: Interrupting client’s
focusing can be
distracting, making the
technique ineffective as
a pain relief measure.

5. Listen to client’s
comments that may
indicate loss of self-
esteem.

R: Client may believe

that any intervention to
aid the labor process is
a negative reflection on
her own abilities.

6. Offer Support.
R: There is no
substitute for personal
touch and contact as a
way to provide support
during labor. Patting a
woman’s arm while
telling her that she is
progressing in labor,
brushing a wisp of hair
off her forehead, wiping
her forehead with a
cool cloth, these are
indispensable methods
of conveying concern.

7. Encourage client to
assume different
positions and to
change them regularly

R: Position changes
promote comfort,
reduce muscle tension,
relieve pressure, and
promote fetal descent.