Nursing Care Plan Form

Assessment Data

(Include at least three-five subjective and/or objective pieces of data that lead to the nursing diagnosis)

Goals & Outcome

(Two statements are required for each nursing diagnosis.  Must be Patient and/or family focused; measurable; time-specific; and reasonable.)

Nursing Interventions

(List at least three nursing or collaborative interventions with rationale for each goal & outcome.)

Rationale

(Provide reason why intervention is indicated/therapeutic; provide references.)

(Was goal met?  How would you revise the plan of care according to the patient’s response to current plan ?)

1. Patient presents with contractions and pain similar to cramping felt during period.

1. Patient experiences back and thigh pain.

1. Patient has blood-streaked discharge and intermittent vaginal bleeding.

Patient is anxious, fearful, and was reluctant to report to the hospital because she has experienced cramping before but not as intense. Patient was not expecting the pain to be labor, indicating deficient knowledge, which is a condition impacting client’s decision-making and coping during early labor and before active labor. This diagnosis is indicated by client asking multiple question, inaccurate following through instructions, and misconception statements.

Statement #2

Coping allows clients to process emotions and stress during pregnancy and labor. Patient indicates risk of ineffective coping related to anxiety and fear, situational crisis, and severe pain.

1. Evaluate the client’s basic knowledge and expectations during pregnancy.

1. Inquire about the client’s preference nursing care in early labor

1. Evaluate cultural aspects influencing the client’s labor experience.

1. Examine uterine contraction- relaxation pattern, vaginal bleeding, fetal status, and cervical dilatation.

1. Examine the client’s labor pain levels.

1. Note the client’s age and a partner’s or support presence.

1. This intervention will help develop learning needs and set priorities to help clients make informed decisions regarding their care (Martin, 2022).

1. Establishing the client’s preference of nursing care will help determine whether she might benefit from specific care approaches (Hutchison & Mahdy 2019).

1. Cultural factors affect the client’s experience with labor (Martin, 2022).

1. This approach will help rule out potential complication that might be causing the pain or the bloody discharge (Hutchison & Mahdy 2019).
2. Linking labor pain with typical circumstances can help client gather her resources and decide a workable pain relief intervention (Martin, 2022).

1. Negative coping is associated with heightened anxiety, and the patient may request medication too early in labor. Stress and discomfort are associated with younger clients, who experience problems maintaining control (Martin, 2022).

The patient responded as expected to the nursing care and the interventions adopted. The patient verbalized psychological and physiological changes understanding, participated in making decisions, and demonstrated appropriate breathing and relaxation mechanisms. Continued monitoring is required to determine extended client’s response to current plan.

Outcome #2

Outcome two was achieved as the client identified her appropriate behavior to maintain control in early labor. The client identified ineffective coping behaviors and resultants and verbalized awareness of her coping ability. The client used the medication appropriately to manage her pain and discomfort in early labor.