Vous êtes sur la page 1sur 20

Nursing care plan

Of The Mother
Nursing Care Plan of the mother

Prenatal Assessment

Cues/Evidence Nursing Diagnosis Objective Intervention Rationale Evaluation

SUBJECTIVE DATA: Disturbed sleep Within our 1. Assess vital signs Elevated blood Within our care,
Patient verbalized that pattern r/t shortness care, the especially her blood pressure is usually the client had
she easily wakes up of breath and urinary client will pressure level observed in sleep improved sleeping
whenever she hears frequency improve sleep disturbed client pattern as
noise. Furthermore, pattern as evidenced by:
she reported frequent evidenced by: 2. Encourage the Voiding before
awakenings during the mother to void before bedtime may limit Absence of dark
night to go bathroom Absence of sleeping the sleep circles under
due increased urge to dark circles disturbance eyelids and
urinate which under eyelids brought about by frequent yawning
happened around and frequent urinary frequency as observed
5times.She also added yawning,
that she finds it improved face 3. Provide a quiet A quiet Decrease urinary
difficult to sleep expression environment conducive environment frequency from 5
sometimes because for sleeping promotes times each night
she felt slight pain on Verbalized continuation of to 3 times
the area near her understanding sleep without
buttocks due to the on the cause disturbances Report of rested
pressure she feels on of sleep 4. Promote use of and more relaxed
her chest which disturbance bedtime rituals such as
affects her breathing. drinking a glass of milk Promotes
She also said that she Report before sleeping, taking relaxation and OBJECTIVES FULLY
sleeps with a pillow increased a bath, reading a book readiness for MET
and a blanket. (We sense of well – sleep
failed to inquire about being and 5. Teach client to
her having nightmares feeling of elevate head by using
or sleepwalking). She rested more pillows during
takes a nap when she sleep or have her on Elevating the head
feels like taking a nap Report an side – lying position promotes lung
but only for a short increased expansion, being
time. number of in a side – lying
hours of sleep position decrease
the pressure on
OBJECTIVE DATA: the chest wall and
Sleepy eyed noted vena cava by the
gravid uterus
Dark circles under

Frequent yawning

Vital signs:
RR=14 cpm
BP= 138/74 mmHg
PR= 72 bpm

SUBJECTIVE DATA: Disturbed Body mage Within our 1. Assess readiness to Give patient sense Within our care,
Client verbalized that related to change of care, client accept changes in of control over client had
she feels sad about appearance shall accept body image situation accepted her body
her physique and associated with body image image as
body image. pregnancy as manifested 2. Employ a calm, Improves nurse- evidenced by:
by: caring, confident, and client relationship.
non-judgmental Expressed positive
OBJECTIVE DATA: Express approach. feeling towards
Physiologic changes: positive Creates a sense of self and others.
feeling 3. Discuss with mother trust at the same
Contour of the towards self physiologic changes time educate Verbalized
abdomen changes and others during pregnancy mother about acceptance of
changes during body image:
Presence of linea nigra Verbalize pregnancy “Ok na man ako
on the abdomen acceptance of pagkita sa ako
body image 4. Allow pt to express To create a kaugalingon”
feelings towards her positive outlet of
Perceived pregnancy emotions Perceived
pregnancy in pregnancy in a
a positive positive light and
light 5. Teach pt coping claimed she is
strategies: Help overcome excited to see her
• Preparing for maladaptive baby.
upcoming delivery behaviors
• Provide literary
articles about OBJECTIVES FULLY
pregnancy MET

1st stage of labor

Cues/ Evidence Nursing Diagnosis Objectives Interventions Rationale Evaluation
SUBJECTIVE Altered comfort: Within our care, Independent Within our care, the
DATA: pain related to client shall 1. Monitor vital To obtain baseline client was able to:
Client verbalized increased uterine experience signs every 15 data.
excruciating pain on contractions and increased comfort minutes for 2 hours Maintained v/s
the abdomen and pressure on as evidenced by: and 30 minutes within normal
further stated that pelvic structures V/S within normal until stable. range:
the intensity of pain range:
is increasing. T: 36.5-37.5 2. Assess This is to monitor T: 37.4C
PR: 60-100bpm contraction the progress of PR: 66bpm
RR: 12-20cpm patterns, bloody labor and the RR: 16cpm
OBJECTIVE DATA: BP: 110-140/60- show condition of both BP: 110/70mmhg
Rated pain as 9 in a 90mmHg and the degree of the mother and the
scale of 1 to 10; 10 pain and its baby. Helps to Verbalize pain
being most painful Verbalization pain characteristics, identify areas of within tolerable
while 1 being least within tolerable location, severity, chief concern, limits.
painful. limits throughout duration, and providing baseline
the duration of frequency. for future Verbalize discomfort
Facial grimacing labor interventions. as controlled with
noted non-pharmacologic
Verbalize Left lateral position methods
Abdominal guarding discomfort as 3. Provide comfort increases venous
noted controlled with non- measures: return and Rated pain as 8 in a
pharmacologic • Encourage enhances placental scale of 1 – 10
Restlessness noted methods comfortable circulation.
especially during positioning. Position changes Groaning, and facial
exacerbation of Rates pain as < 8 • Position the promote comfort , grimacing not
contractions. in a scale of 1-10, client in a reduce muscle noted.
10 as the highest left side lying tension, relieve
and 1 is the lowest. position. pressure and Was observed to be
• Encourage promote fetal restless when
Absence of client to descent. contractions occur.
expressive assume
behaviors such as different
restlessness, positions and Responded to
moaning, sighing, change them questions and
irritability, and regularly. instructions
facial grimacing. Proper breathing appropriately.
4. Teach proper technique can
Verbalize desire to breathing technique prevent exhaustion,
participate in labor therefore OBJECTIVES
as tolerated preventing PARTIALLY MET
prolonged delivery
Responds to of the fetus and
questions and prolonged pain.
instructions 5. Inspect the
appropriately client’s suprapubic A full bladder
area and palpate for contributes to
Identifies need for bladder distention. discomfort and
additional pain Encourage the impedes fetal
relief measures as client to void. descent.
6. Provide
information and Helps alleviate any
update client on anxiety and fears
labor progress that may
exacerbate pain.

7. Administer
analgesia as Mechanism of
ordered action is to reduce
Collaborative pain.

8. Refer to
physician any To provide
abnormalities that immediate medical
may be observed. intervention.

SUBJECTIVE Anxiety related to Within our care, Independent At the end of our
DATA: hospitalization client will manage 1. Monitor Vital To obtain baseline care, the client was
Client verbalized and upcoming anxiety with Signs data. able to:
concern about delivery process positive coping
upcoming delivery mechanisms as 2. Assess level of Identify areas of Maintained v/s
and expresses evidenced by: anxiety through concern that might within normal
worries about her verbal and non- interfere with the range:
child inside her V/S within normal verbal cues. normal progress of
womb. range: labor. T: 37.4C
T: 36.5-37.5 PR: 66bpm
PR: 60-100bpm Enhances nurse- RR: 16cpm
OBJECTIVE DATA: RR: 12-20cpm 3. Employ a calm, client relationship. BP: 110/70mmhg
Exhibit poor eye BP: 110-140/60- caring, confident,
contact 90mmHg and non-judgmental Claimed that she’s
approach. Provides a healthy worried about the
Facial tension Acknowledge and outlet of emotions condition of her
observed discuss fears, 4. Allow client to and relieves baby.
recognizing healthy express fears and anxiety.
Impaired attention vs. unhealthy fears feelings of anxiety Verbalized that she
noted appropriately. Adequate is capable of
Absence of facial explanation helps delivering the baby.
Appears tension and 5. Acknowledge reduce anxiety,
preoccupied; improved attention normalcy of fear soothe fears, and Claimed excited to
decreased span. and provide provides assurance. see her baby.
perceptual field. opportunity for
Verbalizes control of questions and She claimed that
the situation answer honestly she trusts the
within client’s level Provides feeling or nurses in the
Verbalizes desire to of understanding. sense of security hospital.
participate in labor and trust between
process as tolerated 6. Offer support by the nurse and the
staying with the patient. OBJECTIVES
Expresses patient, pating her PARTIALLY MET
confidence in arms, and brushing
herself, her support a whisp of hair off
person, and the her forehead, and
healthcare provide a cool cloth
personnel. on her forehead as
needed. Mechanism of
Acquires knowledge action is to relieve
about childbirth and anxiety.
is better prepared Dependent
to cope with future 1. Administer anti-
births anxiety medication
as ordered by the Provides ongoing
physician. and timely support.

1. Refer to support
groups as needed.
SUBJECTIVE Risk for fluid Within our care, our Independent: Within our care, the
DATA: volume deficit client will maintain 1. Assess patient’s To obtain baseline client was able to
Client requested for related to adequate fluid hydration status: data.
a glass of water prolonged lack of volume and • Monitor V/S Determine Maintained v/s
since she feels oral intake and electrolyte balance • Do PA (skin alterations in fluid within normal
thirsty as reported. diaphoresis as evidenced by: turgor, mucous volume and range:
membranes, electrolyte
OBJECTIVE DATA: V/S within normal and capillary imbalance. T: 37.4C
Vital signs: range: refill). PR: 66bpm
T=37˚C T: 36.5-37.5 • Observe RR: 16cpm
RR=14 cpm PR: 60-100bpm urinary output, BP: 110/70mmhg
BP= 138/74 mmHg RR: 12-20cpm color, measure
PR= 72 bpm BP: 110-140/60- amount, and Exhibited moist
90mmHg specific mucous membrane;
Received D5LR at gravity. has good skin
right metacarpal Adequate urinary • Review lab turgor, and prompt
vein flowing at 33 output with normal capillary refill.
data (Hb/hct,
gtts/min specific gravity
Exhibit moist To maintain skin OBJECTIVES
mucous membrane, integrity, prevent PARTIALLY MET
2. Provide frequent
good skin trugor, dehydration and
oral and skin care.
and prompt preserve kidney
capillary refill. function.

Verbalize To prevent
3. Discuss
understanding of importance of aspiration which
withholding food withholding food can lead to
and fluids during and water during respiratory distress.
labor the entire labor
Demonstrate To prevent
behaviors to 4. Identify means to dehydration and
monitor and prevent dehydration preserve kidney
prevent dehydration such as providing function.
as indicated. ice chips or saturate
OS with water to be
sipped by the pt.

5. Assist in IV To prevent
infusion as ordered. dehydration and
preserve kidney

2nd stage of labor
Cues/ Evidence Nursing Diagnosis Objectives Interventions Rationale Evaluation

SUBJECTIVE Anxiety related to Within our care, our Independent: Within our care, the
DATA: lack of knowledge client will manage 1. Assess level of Identify areas of client was able to:
Client verbalized about labor anxiety with anxiety through concern that might
she is worried about experience positive coping verbal and non- interfere with the Verbalized desire to
the delivery of the mechanisms as verbal cues. normal progress of participate actively
baby because this evidenced by: labor. through effective
will be her first time pushing
to do so. Verbalize awareness 2. Employ a calm, Enhances nurse-
of feelings of caring, confident, client relationship.
anxiety and non-judgmental OBJECTIVES
Exhibit poor eye Verbalize Provides a healthy
contact willingness to 3. Allow client to outlet of emotions
cooperate and express fears and and relieves
Facial tension and follow instructions feelings of anxiety anxiety.
grimacing observed carefully during the appropriately.
entire course of Adequate
Impaired attention labor 4. Acknowledge explanation helps
noted normalcy of fear reduce anxiety,
Manifest positive and provide soothe fears, and
Appears attitude towards opportunity for provides assurance.
preoccupied; healthcare questions and
decreased personnel and answer honestly
perceptual field. support persons. within client’s level
of understanding This position aids in
Verbalizes control of the easy expulsion
the situation 5. Assist pt. in of the fetus, thus
proper positioning – reducing stress and
Verbalize desire to Lithotomy position anxiety from
participate actively prolonged labor
during the course of
6. Promote effective
Acquires knowledge second-stage
about childbirth and pushing by
is better prepared instructing client to
to cope with future push with each
births contractions and
rest between them

SUBJECTIVE Altered comfort: Within our care, our Independent: Within our care, the
DATA: Pain related to client shall actively 1. Assess the Provide baseline client was able to:
Client was bearing down participate in labor degree of pain and data for future
frequently shouting efforts and and cope with the its characteristics, interventions
and moaning. distention of the discomfort location, severity, Claimed that she
Reported slight perineum effectively as duration, and can deliver the
difficulty in bearing evidenced by: frequency. baby.
Verbalize pain 2. Employ a calm, Gives pt a sense of Perceived labor
OBJECTIVE DATA: within tolerable caring, confident, trust and Improves experience in a
Sighing and limits. and non-judgmental nurse-client positive light and
moaning observed approach. relationship. comply with the
Verbalize desire to instructions of the
Facial tension and continue with the 3. Accept patient’s Pain is a subjective physician
grimacing noted labor process. description of pain experience and effectively.
cannot be felt by
Restlessness Perceive labor others. Demonstrated
observed experience in a 4. Support pt. pain- proper breathing
positive light and coping activities: Provides feeling or techniques
Profuse sweating comply with the Offer support by sense of security
noted instructions of the staying with the and trust between
physician patient, pating her the nurse and the OBJECTIVES
effectively. arms, and brushing patient. PARTIALLY MET
a whisp of hair off
Demonstrate use of her forehead, and
relaxation and provide a cool cloth
diversional on her forehead as
activities as needed.
indicated (Guided-
imagery, Deep- 5. Instruct patient Proper breathing
breathing). to do proper technique can
breathing technique prevent exhaustion,
Demonstrate proper (panting). therefore
breathing preventing
techniques prolonged delivery
of the fetus and
prolonged pain.
6. Participate in the
delivery process To minimize
with other health workload, therefore
care team members saving time and
(Doctor/Midwife, making the delivery
Handle, Assist, IC, of the fetus faster.
and Circulating)
SUBJECTIVE Ineffective Within our care, the Independent: Within our care, the
DATA: breathing pattern client will improve 1. Assess for Pain can limit client was able to:
Client reported related to breathing pattern concomitant pain/ respiratory effort
difficulty in inadequate lung as manifested by: discomfort Was free from
breathing and cried expansion cyanosis and other
for help. secondary to RR will be within the 2. Encourage deep Facilitates alveolar signs of hypoxia
immobility normal range (16- breathing exercise lung expansion thus
20cpm). improving gas Participated actively
OBJECTIVE DATA: exchange in the labor process
Hyperventilation Establish a normal/ 3. Maintain calm through effective
noted effective respiratory attitude while To limit level of pushing
pattern dealing with client anxiety
RR= 31cpm Demonstrated
Be free from 4. Encourage pt. to appropriate coping
Appears restless cyanosis and other assume various behavior to promote
signs of hypoxia position during Various positions proper breathing
Profuse sweating active labor (ex. facilitates lung such as using deep
noted Participate actively Squatting position) expansion and easy breathing
in the labor process expulsion of the technique.
Encourage rest fetus.
Demonstrate period between
appropriate coping bearing down To limit fatigue OBJECTIVES
behavior to PARTIALLY MET
promote proper
3rd stage of labor

Cues/ Evidence Nursing Diagnosis Objectives Interventions Rationale Evaluation

SUBJECTIVE Risk for Fluid Within our care, our Independent: Within our care, the
DATA: Volume Deficit client will maintain 1. Assess patient’s To obtain baseline client was able to:
Claimed that she’s related to adequate fluid hydration status: data. Determine
not allowed to drink hypovolemia volume and • Monitor V/S alterations in fluid Maintained v/s
or eat since she secondary to electrolyte balance (Check BP volume and within normal
entered the delivery excessive blood as evidenced by: right after electrolyte range:
room. loss expulsion of imbalance.
V/S within normal placenta) T: 37.4C
range: • Do PA (skin PR: 66bpm
OBJECTIVE DATA: T: 36.5-37.5 turgor, mucous RR: 16cpm
Placenta delivered PR: 60-100bpm membranes, BP: 110/70mmhg
at: 12:12 pm RR: 12-20cpm and capillary
BP: 110-140/60- refill). Exhibited moist
Gush of blood is present 90mmHg • Observe mucous membrane,
during the delivery of the urinary output, good skin trugor,
newborn and placenta Adequate urinary color, measure and prompt
output with normal amount, and capillary refill.
Vital signs: specific gravity specific
T = 37˚C gravity.
PR = 72 bpm Exhibit moist OBJECTIVES
• Review lab
RR= 14 cpm mucous membrane, PARTIALLY MET
data (Hb/hct,
BP = 138/74 mmHg good skin trugor, To preserve skin
and prompt integrity, prevent
capillary refill. dehydration and
preserve kidney
2. Provide frequent
oral and skin care. function.

Prevent dehydration
and preserve kidney
Dependent: function.
3. Assist in IV
infusion as ordered. Promotes uterine
contraction which
prevents uterine
4. Administration of atony or bleeding
methergin as

SUBJECTIVE Altered Comfort: Within our care, the 1. Assess the level Assessing the pain Within our care, the
DATA: Pain related to client will: of pain experience level experienced client:
Claimed to feel tissue trauma by the client and by the client
slight pain during secondary to Report pain her ability to determines her Reported pain
episiorrhaphy medial reduction, from a perform capability to comply perception as
episiorrhaphy scale of 7 to 5 normal task such with other having a numeric
as eating, interventions value of 3
OBJECTIVE DATA: Demonstrate use of breastfeeding and
Weak and relaxation skills and dressing Able to perform
exhausted diversional breathing exercise
activities 2. Check vital Serves as
Facial grimacing is signs comparison from Able to exhibit
evident Exhibit absence of previous minimal pain
facial grimacing measurements thus gramacing
Eyes are closed as determine any
observed Manifest normal RR improvement or RR= 18 cpm
( 12-20 cpm) further
Moaning and crying deterioration of the Verbalized “ Mo
can be heard from Verbalize method client’s condition inom ko og tambal
the patient but that provide relief 3. Review client’s kung sakitan na jud
didn’t screamed or previous Identify possible ko kaayo pareha
gave any experiences with ways on how to anang mag sakit
verbalizations pain and methods handle the pain akong pus-on kung
found helpful for experiences by the reglahon ko.”
Narrowed focus is pain control in the client
evident (reduced past
interaction with OBJECTIVES
people) 4. Provide comfort PARTIALLY MET
measures To provide
Rated pain as 4 in a ( backrub, nonpharmacologic
scale of 1-10, 1 as therapeutic touch) pain management
the lowest and 10
as the highest 5. Encourage the May help decrease
use of relaxation pain perception by
technique such as interrupting the
deep breathing and conduction of
imagery nerve pain impulse

4th stage of labor

Cues/ Evidence Nursing Diagnosis Objectives Interventions Rationale Evaluation
SUBJECTIVE Risk for infection Within our care, the 1. Monitor vital A slight elevation in Within our care, the
DATA: r/t impaired skin client will: signs especially temperature client:
Client verbalized: integrity temperature suggests fever.
“naa pay mga secondary to Not exhibit any To assess if Did not manifest the
nanggawas nga medial signs and 2. Note signs/ infection is signs of infection
dugo sa akong episiotomy symptoms of symptoms of fever, occurring (fever and chilling)
kinatawo” infection such as pallor and chills T = 37.4C
fever and chilling To prevent infection
“ sakit pa e lihok 3. Perform surgical to the area and Listened upon
ang sa akong paa Identify handwashing before inhibit cross explanation on the a
dapit” interventions to and after doing contamination factor ( impaired
prevent/ reduce risk perineal care on the skin integrity ) of
of infection site of episiotomy developing infection
Give the client the
OBJECTIVE DATA: Verbalized 4. Explain why and idea on the Was not able to
Method of delivery: understanding of how infection is causative factors on verbalize an
NSVD with thick individual risk likely to happen infections formation understanding of
meconium staining factors the risk factors
5. o perineal care Perineal area should
Episiotomy area is and teach the be cleansed well to
Swollen and reddish mother on the prevent the growth OBJECTIVES
in color. importance of of microorganisms PARTIALLY MET
proper perineal
SUBJECTIVE Impaired skin Within our care, 1. Inspect status of Detect signs and Within of our care,
DATA: integrity r/t client will have the perineum symptoms of client had improved
Client verbalized, episiotomy improved skin possible infection skin integrity as
“naa pay mga secondary to integrity as evidenced by:
nanggawas nga vaginal delivery evidenced by: 2. Check clients Any deviation may
dugo sa akong medical record and suggest blood Episiotomy healed
kinatawo” Episiotomy will heal lab findings clotting/coagulation without infection
in due time without especially platelet is impaired and
“ sakit pa e lihok infection count, bleeding healing will be Regained skin
ang sa akong paa time, clotting time affected. integrity
dapit” Identify signs and
symptoms of Identified s/s that
infection that can 3. Instruct and Sitz bath aids in suggest infection
OBJECTIVE DATA: further impair skin assist the pt. In the healing process by have occurred.
Method of delivery: integrity use of sitz bath increasing
NSVD with circulation to the
meconium staining Verbalized perineum and OBJECTIVES FULLY
understanding of prevent edema. MET
Episiotomy area is individual risk
Swollen and reddish factors 4. Teach pt. How to Provide knowledge
in color. apply and remove on how to apply and
Verbalize maternity perineal remove pads that
understanding on pad can help maintain
the need to skin integrity.
maintain proper
personal hygeine Suggests infection
5. Instruct pt. To has occurred and
watch for s/s of immediate
infection such as: intervention is
fever, foul odor on required.

Centres d'intérêt liés