St.

Paul University Philippines

Tuguegarao City 3500 Cagayan

School of Nursing and Allied Health Sciences

College of Nursing

Nursing Care Plan

Assessment Diagnosis Planning Intervention Rationale Evaluation

SUBJECTIVE: Knowledge Deficit NOC: NIC:
related to lack of KNOWLEDGE: TEACHING: Goal Met:
The client information FALSE LABOR INFORMATION
verbalized “she had regarding false ON
been having labor. HEALTHCARE
contractions at 7-to-
10-minute intervals GOAL: The
since 4 p.m. They After an hour of client verbalized
lasted 30 seconds”. nursing The nurse To gain the trust of “some of the
She also stated “she intervention, the established rapport the patient awareness
had been having a client will be able with the patient and involved. implications and
lot of false labor to verbalize, “some therapeutic possible
and hoped that this of the perception communication. outcomes of
was the real thing”. consequences and preterm labor”
future outcomes of
preterm.”

OBJECTIVE: The client

The client will gain learned what
-Membranes are knowledge about The nurse To detect any false labor and
intact. monitored and changes or preterm
-Temperature is false labor and recorded the deterioration on pregnancy are.
36.8 C preterm pregnancy. patient’s vital signs. vital signs.
-Pulse rate is 94
b/m
-Respiration is The client will be The client learned
23 c/m able to verbalize Established an To gain patient’s and expressed what
-Blood pressure and express what atmosphere of trust and have a she had learned.
is 124/80 mmHg she had learned. respect, openness, good nurse-patient
-The FHT is 134 trust and relationship
and regular collaboration.
-The baby’s
head is already
at +1 station Examine the To facilitate
-Cervix is 1 cm patient's interest and patients’ interest
(dilated and 80% ability to learn. and have the choice
effaced) of declining
educational
services.

Provided health To provide

teaching regarding adequate
on false labor. knowledge to the
client’s
understanding on
false labor.

Provided teachings To provide

on client about adequate
knowledge to the
preterm pregnancy, client
so understanding on
that therapy can be preterm pregnancy
instituted promptly. and techniques on
therapy.

Assess barriers to To established

learning (e.g., learning situation
perceived change in social interaction
lifestyle, financial patterns, cultural
concerns, cultural norms and values,
patterns, lack of and environmental
acceptance by peers influences.
or coworkers).