ISABELA STATE UNIVERSITY

City of Ilagan Campus

COLLEGE OF NURSING
NURSING CARE PLAN
ASSESSMENT DIAGNOSIS PLANNING IMPLEMENTATION/ RATIONALE EVALUATION
INTERVENTION
Subjective data: Decreased cardiac Short term: INDEPENDENT After an hour of
output r/t decrease -Lay down the patient in a -To ensure that safeness nursing
The client pre-load, decrease After 30 minutes/ 1 hour of comfortable and safe position of the patient and to ease interventions goal
verbalized that she contractility as nursing intervention the the discomfort she is met. The patients
felt no fetal evidence by fetal client will be able to: experiencing will be able to
movement in her distress restore her
womb -Maintain blood pressure wholeness and
Impaired gas as indicated by calm -Let the patient rest in a well- -Well ventilated area will demonstrate
Objective data: exchange r/t altered heartbeat at normal rate ventilated area and away from the count the patient and free normal daily
 Low oxygen supply, object that might fall from danger causes by activity, show no
maternal inability to -The fetus inside the womb falling object sign of pain and
blood transport oxygen as will be able to acquired discomfort in he’s
pressure or evidence by enough source of oxygen body.
hypotensio compromise source to avoid further fetal
n of oxygen distress -To quantify and asses
 Fetal -Assess the patient and monitor the status of the client
distress -Reduce the feel of patient’s vital signs
causing discomfort and anxiety
hypoxia to -This is to facilitate the
the fetus. Long term: pain experience by the
-Demonstrate changes I -Investigates reports of pain and patient if any
lifestyle pattern to prevent discomfort in the patient
the worsening of her
current condition
DEPENDENT
-The patient will be able to
create an efficient maternal -Provide anti-hypotensive drug as -It will help to normalize
 ISABELA STATE UNIVERSITY
City of Ilagan Campus
COLLEGE OF NURSING
activity to address her needed and appropriate
sensitive pregnancy
-Induce actovegin solution with
glucose and vitamin c if prescribe or
ordered by the physician
COLLABORATIVE
-For a client who experience fetal
distress create a team composing of
rehabilitation nurse, obstetrician and
psychologist
the decrease of patients’
blood pressure
-This will help to treat
the fetal hypoxia
experience by the baby
-The team can assist the
patient to identify what
are the preventive
measurement as well as
to assess what is the
safest way to deliver the
baby

ASSESSMENT
Subjective data:
The client verbalized that she felt contractions,
uterine contraction and perineal
pressure.
The client verbalize that she
experienced alteration in urinary verbalization of
functioning and sleep pattern.
Objective data:
 Alteration in blood
pressure/heart
rate/respiratory rate
 Distraction/expressive
behavior; protective
behavior; positioning to
ease pain.
 Alteration in muscle
tension; diaphoresis.
 Alteration in
neuroendocrine
functioning.
 Narrowed focus; self-
focused; pupil dilation
 Facial expression of pain.
ISABELA STATE UNIVERSITY
City of Ilagan Campus
COLLEGE OF NURSING
DIAGNOSIS PLANNING IMPLEMENTATION/ RATIONALE EVALUATION
INTERVENTION
Labor Pain r/t Short term: Nursing Priority No. 1. After an hour of
uterine nursing
After 1hour / 2 hours To determine client’s individual interventions.
needs: Response to
stretching of of nursing
actions and
cervix and birth intervention the client interventions are
- Identify stage and phase of - Choice and timing of
canal as evidenced will be able to: performed.
labor; perform vaginal medications are
by client affected by degree of Progress toward
examination noting nature and
- -Report pain at dilation and contractile desired outcomes
amount of vaginal show, are attained. The
pain in pelvic area. manageable level. pattern.
cervical dilation, effacement, patients will be
anxiety
fetal station, and fetal descent. able to restore her
wholeness and
Long term: demonstrate
- Note timing of initiation of
- Economic, emotional,
prenatal care and participation normal daily
- Participate in and cultural concerns activity, show no
in childbirth education classes. can limit the mother’s
decision-making for sign of pain and
access or involvement discomfort in he’s
pain management plan
in preparation for labor, body.
to include personal
increasing her need for
preferences and information and
cultural beliefs. support.
- Engage in non-
- Evaluate degree of discomfort - Attitudes and
pharmacologic
through verbal and nonverbal reactions to pain are
measures to reduce
cues; note cultural influences on individual and based
discomfort/ pain.
pain response. on past experiences,
understanding of
- Participate in labor
physiological
process providing
 ISABELA STATE UNIVERSITY
City of Ilagan Campus
COLLEGE OF NURSING
Rate pain as 9 out of 10. client’s desired level changes, and
In which 1 is mild pain of support. familial/cultural
and 10 is severe pain. Nursing Priority No. 2. expectations.

To engage client in non-

pharmacologic pain
management techniques:

- Provide/encourage use of
- Promotes relaxation
comfort measures (e.g., back/
and hygiene, which
leg rubs, sacral pressure, back
enhance feeling of
rest, mouth care, repositioning;
well-being and may
shower/hot tub use; cool, moist
reduce the need for
cloths to face and neck; hot
analgesia or
compresses to perineum,
anesthesia. Position
abdomen; perineal care, linen
changes can also
changes).
enhance circulation,
reduce muscle
tension.
- Recommend client void every
1–2 hr. - Reduces bladder
distention, which can
increase discomfort
and prolong labor.

- Provide for a quiet

environment that is adequately - Non-distracting
ventilated, dimly lit, and free of environment provides
unnecessary personnel. optimal opportunity
ISABELA STATE UNIVERSITY
City of Ilagan Campus
COLLEGE OF NURSING
Nursing Priority No. 3.
To provide more intensive pain
management measures:
- Time and record the
frequency, intensity, and
duration of uterine contractile
pattern per protocol.
- Administer analgesic, such as
butorphanol tartrate (Stadol) or
meperidine hydrochloride
(Demerol), by IV during
contractions or deep
intramuscular (IM) if indicated
during active phase of stage I
labor.
for rest and relaxation
between contractions.
- Information
necessary for
choosing appropriate
interventions and
preventing or limiting
undesired side effects
of medication.
- IV route provides
more rapid and equal
absorption of
analgesic, and IM
route may require up
to 45 min to reach
adequate plasma
levels. Administering
IV drug during
uterine contraction
decreases amount of
medication that
ISABELA STATE UNIVERSITY
City of Ilagan Campus
COLLEGE OF NURSING
- Monitor maternal vital signs
and fetal heart rate (FHR)
variability after drug
administration. Note drug’s
effective- ness and the
physiological response.
- Prepare for/assist with
neuraxial anesthesia (i.e.,
epidural or caudal block
anesthesia) using an indwelling
catheter.
Nursing Priority No. 4.
To support delivery process:
immediately reaches
fetus.
- Narcotics can have
a depressant effect on
fetus, particularly
when administered 2–
3 hrs before delivery.
- Provides relief once
active labor is
established. Note:
Use of ultra–low dose
epidural is being
promoted to achieve
pain control without
negative effect on
client’s ability to
sense contractions
and push effectively.
ISABELA STATE UNIVERSITY
City of Ilagan Campus
COLLEGE OF NURSING
- Note perineal bulging or
vaginal show.
- Discomfort levels
increase as cervix
dilates, fetus
descends, and small
blood vessels rupture.

- Assist client in assuming

optimal position for bearing
down (e.g., squatting or lateral
recumbent).
- Proper positioning
with relaxation of
perineal tissue
optimizes bearing-
down efforts,
facilitates labor
progress, and reduces
discomfort.

- Assist with reinforcement of

medication via indwelling - Reduces
lumbar epidural catheter when discomfort associated
caput is visible. with episiotomy,
forceps application if
needed, and fetal
expulsion.
- Assist as needed with
administration of local - Anesthetizes
anesthetic just before perineum tissue for
episiotomy, if performed. incision/repair
purposes.
ISABELA STATE UNIVERSITY
City of Ilagan Campus
COLLEGE OF NURSING