NURSING CARE PLAN (DURING LABOR)

Assessment Diagnosis Planning Implementation Rationale Evaluation

SUBJECTIVE CUES: Labor pain r/t Within 2 hours of 1. Assess the stage of labor, perform vaginal Choice and timing of medication is affected by degree of At the end of 2-hour nursing
“Agay! Sakit kaayo” uterine nursing exam noting nature and amount of vaginal dilation and contractile pattern. intervention, the patient was
contraction, interventions, the show, cervical dilation, effacement, fetal able to participate in decision-
stretching of patient will be able station and fetal descend. making plan for pain
OBJECTIVE CUES: cervix and to participate in management.
 Facial Grimace birth canal, decision-making for 2. Assess pain, noting the location, intensity Provides information to aid in determining choice or
 Labored and fetal pain management (scale of 0-10) duration. effectiveness of interventions
breathing expulsion plan.
 Uncomfortable 3. Coach use of appropriate May block pain impulses within the cerebral cortex
 Rubbing the breathing/relaxation techniques and through conditioned responses and cutaneous
abdomen and abdominal effleurage based on the stage of stimulations and gives client a means of coping with and
back labor controlling the level of discomfort.
 Irritability
 Restlessness 4. Provide comfort measures back rub, helping Reduces bladder distension which can increase
position of comfort. Recommend client to discomfort and prolong labor. Promotes relaxation,
 Diaphoresis
void every 1-2 hour refocuses attention and may enhance coping abilities.
 Narrowed
focus: self-
5. Time and record the frequency, intensity and Information is necessary for choosing appropriate
focus
duration of uterine contractile pattern per interventions and preventing or limiting undesired side
protocol effects of medication

6. Assist client in assuming optimal position for Proper positioning with relaxation of perineal tissue
bearing down (e.g. Squatting) optimizes bearing-down efforts, facilitates labor progress,
reducing discomfort.
 NURSING CARE PLAN (POSTPARTUM METHOD)
Assessment Diagnosis Planning Implementation Rationale Evaluation

1. Assess mother’s knowledge and previous 1. Establish baseline and direction for
SUBJECTIVE CUE:
Readiness for Within 2 hours experience with breastfeeding teaching/planning After 2 hours of nursing intervention
Mother expresses effective of nursing the patient was able to demonstrate
desire to provide breastfeeding intervention, 2. Initiate breastfeeding within the first 2. Early feedings are of great benefits for the mother effective techniques for breastfeeding
breast milk for related to the patient will hour after birth and the infant because oxytocin release is
child’s nutritional Maternal be able to stimulated, helping to expel the placenta and
needs. Confidence demonstrate prevent excessive maternal blood loss; the infant
effective receives the immunological protection of
OBJECTIVE CUES:
techniques for colostrum, peristalsis is stimulated, lactation is
Infant is content breastfeeding accelerated, and maternal-infant bonding is
after feedings enhanced

Mother is able to 3. Observe mother’s return demonstration 3. May require several instruction sessions
position infant at
breast to promote 4. Encourage rooming in and breastfeeding 4. Mothers who room-in with their infants have
successful latch on on-demand greater percentages of exclusive breastfeeding
response when released from the hospital

5. Teach the mother of the importance of 5. For adequate hydration and nutrition for both the
maternal nutrition and fluid intake. mother and infant.

6. Discuss prevention and treatment of 6. Common problems experienced by breastfeeding

common breastfeeding problems such women may be preventable with anticipatory
as nipple pain and or trauma. guidance or successfully managed with prompt
assistance from a health care provider

7. Provide information as needed about 7. Early recognition of infant hunger promotes a

early infant feeding cues versus the late timely/more rewarding feeding experience for the
cues of crying infant and the mother

8. Include the partner and other family 8. Family member’s impressions and ideas about
members in education about breastfeeding influences breastfeeding initiation
breastfeeding. and duration.
 NURSING CARE PLAN (POSTPARTUM METHOD)
Assessment Diagnosis Planning Implementation Rationale Evaluation

1. Assess client’s temperature and provide 1. Fever is usually the first sign of infection. Within 2H of nursing intervention the
SUBJECTIVE CUES:
Risk for Within 2H of information about the normal body temperature. patient was able to state measures to
Patient confirms infection r/t nursing protect and heal the impaired skin area.
presence of episiotomy intervention the 2. Instruct the client to monitor the site of skin 2. Systematic inspection can identify
itchiness in the patient will be impairment for color changes, redness, swelling, impending problems early.
labia. able to state warmth, pain or other signs of infection.
“Oo. Katol siya” measures to
protect and heal 3. Monitor the client’s skin care practices, noting 3. Cleansing should not compromise the
OBJECTIVE CUES:
the impaired type of soap or other cleansing agents used, skin. Harsh cleansing agent, extremely
skin area. temperature of water and frequency of cleansing. friction or force, hot water and too
 Presence of
genital warts frequent cleansing should be avoided.
 Presence of 4. Monitor the client’s continence status and
suture in the minimize exposure of skin impairment to other 4. Moisture from urine and stool may
perineum areas of moisture from perspiration or wound contribute to the development of
 Unpleasant drainage. infection
odor of
discharges 5. Implement a written treatment plan of topical 5. A written plan ensures consistency in care.
treatment to the site of skin impairment.

6. Asses the client’s nutritional status. Refer for a 6. Optimizing nutritional intake including
nutritional consult and/or institute dietary calories, fatty acids, protein is needed to
supplements as necessary. promote wound healing.

7. Instruct the client to avoid massaging the areas of 7. Research suggest that massage may lead
skin impairment. to deep tissue trauma

8. Teach the client skin assessment and ways to
monitor impending skin breakdown
9. Emphasize the need for taking antibiotics as
prescribed by the physician
8. Early assessment and intervention help
prevent the development of skin
problems.
9. To treat or prevent infection
 NURSING CARE PLAN (POSTPARTUM METHOD)
Assessment Diagnosis Planning Implementation Rationale Evaluation
SUBJECTIVE CUES:
Readiness for Within 2H of nursing 1. Assume the facilitator vs. authority 1. Advice giving is counterproductive and Within 2H of nursing intervention the
“Dili ko gusto masundan enhanced intervention the role when engaging with clients instead providing information and couple is able to state different
dayon ang bata.” knowledge r/t couple will be able to encouraging clients to self-generate methods of family planning including
OBJECTIVE CUES:
family planning state different solutions to problems can enhance self- their advantages and disadvantages.
 Eagerness to learn methods of family control and confidence.
about family planning including
2. Consider motivational interviewing 2. Motivational interviewing focus on the
planning methods their advantages and
techniques when focusing on family client as an autonomous decision-maker
disadvantages.
planning related goals, priorities and
preferences.

3. Explain the importance of family 3. To reinforce the importance of proper

planning spacing of children which can also prevent
unexpected pregnancies and reduce
health risk related to pregnancy.

4. Discuss the methods available in the 4. This will inform the patient that there are
market different methods she can consider.

5. Discuss the advantages and 5. Discussion of pros and cons of each

disadvantages of each method method promotes informed choice about
their sexual and reproductive health.

6. Consider the client’s unique cultural 6. Adapting activities that are culturally or
interest, religious beliefs and values religiously relevant were most effective
when promoting family planning for promoting health in some races.

7. Refer to Health Center for 7. This will promote direct patient care and
Department of Health programs and support service within the patient’s
free consultations regarding family community
planning and contraception.