NURSING CARE PLAN

Name: Mrs. J Age: Sex: Female

Complaint: Severe Painful Contractions Admitting/Working Diagnosis: Breech presentation

Cues Nursing Planning/ Intervention Rationale Evaluati Discharge Planning

Diagnosis Outcome Criteria on
Risk for Short Term Goal: Independent: Obtain ● Taking the history Goal is Medications:
maternal and then review the of labor, the met-
Subjective Cues: injury Through nursing history of labor, onset, and the Applicati ● Parenteral solutions c
intervention and that has glucose and
Patient Complains of related to duration, and onset of duration will help on of
the delivery monitoring , the patient. identify the proper electrolytes can
having severe painful risk for injury to prevent/make maternal
contractions of the fetus causes and nursing
via breech the patient and Dependent: Assess needed manage and fetal mbalances and
fetus will be Uterine contraction may reduce exhaustion
presentatio intervention for ment for
n. decreased. pattern through the patient. diagnosis for the patient.
palpatation or with of ● Oxytocin: Reduce
external/internal ● Assessing uterine breech
Objective cues: uterine contractions.
monitor. contractions will presenta Induce or maintain
Ultrasound result- fetus help to hinder tion
Dependent: Administer increase of dysfunctional labor as
is in a breech were
narcotics/sedative, for indicated.
presentation. contractions as effectivel
sleep. this will risk the y applied ● cefotaxime: Prevents
Collaborative: assist maternal and fetal and the infections
with preparation for C complications risk of
section as indicated, eg. ● Narcotics as
● Rest will benefit injury
administered for better
malposition, CPD, or patients to relieve and
Bandl’s ring. sleep/rest.
fatigue, stress, other
future Environment-
 maintain energy, complica ● Monitor frequently at
etc. tions are home .
lessened.
● Immediate CS is
indicated for
Bandl’s ring or Treatment
fetal distress due ● Use leopold's
to CPD. maneuvers to assess
malpositioning for fetus.

● Providing comfort
measures.

● Relaxation techniques.

Health teaching

● teach Patient about her

situation

● Encourage client to void

every two hours as it can
interfere with fetal
decent.

● Encourage patient to
exclusively breastfeed
for the next 6 months
Out patient

After discharge- schedule for

follow up appointment.

Spiritual

Patient and parents need to

connect and share their feeling
of the situation and the
connection to their faith/belief
and Have good support system
between family members.
Encourage them to seek
consultation etc.