St.

Paul University Philippines 

Tuguegarao City, Cagayan 3500 
School of Nursing and Allied Health Sciences 
COLLEGE OF NURSING 

NURSING CARE PLAN

Assessment Diagnosis Planning Intervention Rationale Evaluation

Subjective: Risk for injury Short Term The goals were
Ø related to cord Goal:  Talk to the  Not talking to met as evidenced
prolapse After 1 hour of client and the client or by:
Objective: nursing family member. family creates an
- Multiple gestation intervention the intense scary Short Term
- Breech patient (baby) will situation or even Goal:
presentation of be able to: worse. After 1 hour of
baby A nursing
- Umbilical cord  Improve  Immediately ask  For the other intervention the
presenting from fetal for help, but team member patient (baby) was
the vagina perfusion. never leave the (Obstetrician, able to:
- decreased fetal patient. Pediatrician,
heart rate Anesthesiologist,  Improve
and OR staff) to fetal
be notified and perfusion.
prepare the
delivery room,  Safely
because the only delivered.
safe way to
deliver the fetus Long Term Goal:
is through After 4 hours of
cesarean birth. nursing
 With a gloved intervention the
hand, insert 2  To relieve the patient’s oxygen
fingers on pressure of the is at normal level.
opposite sides presenting part
 of the cord and and to prevent
attempt to apply complete cut off
upward pressure of oxygen
to the supply.
presenting part.

 Position the
patient into a  We can use
knee-chest gravity to relieve
position or the pressure,
Trendelenburg. causing the fetal
head to fall back
from the cord.
 Apply gauze
soaked in warm  If the cord is
sterile saline extruded out of
solution to the the vagina and is
umbilical cord. exposed to air, it
gets dry and
starts to contract,
these will make
it even more
 Immediate difficult for the
delivery oxygen to flow.
 Administer
oxygen to the  This will help to
patient. improve
oxygenation to
the fetus.
 Initiate IV fluid.
 These helps to
increase blood
flow that will
help supply
 more oxygen to
the fetus.
 Collaborate
with the doctor  Tocolytic will
if tocolytic will slow or stop the
be administered. contraction to
prevent the
problem where
the presenting
part is putting
pressure on the
cord.
 Prepare for
neonatal
 The fetus hasn’t
resuscitation.
acquired enough
oxygen during
the duration of
umbilical cord
Long Term Goal:
prolapse and the
After 4 hours of
C-section
nursing
process.
intervention the
 Monitor the
patient will show
patients
normal level of
breathing  These is to
oxygen.
pattern, assess if the
respiratory rate, baby is receiving
heart rate, enough oxygen.
appearance
(cyanosis).