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Nursing Care Plan Form

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Nursing Care Plan Form

Nursing Care Plan Form

Student Name:                                                           Date:  

Patient Identifier:  L.D.                                        Patient Medical Diagnosis: Labor Stage IA: Latent Phase           

Nursing Diagnosis (use PES/PE format):

  1. Deficient knowledge related to information misinterpretation and lack of exposure or recall as evidenced by following through instructions inaccurately, asking a lot of questions, and misconception statements.

(Nursing Care Plan Form)

  1. Risk of ineffective coping related to personal vulnerability, situational crisis, severe pain, lack of rest, anxiety and fear as evidenced by client’s inappropriate behavior in maintaining control. (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.)

 Outcome Evaluation & Replanning

(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.

 

 Statement #1

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).
 Outcome #1

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.

 

 

 

 

(Nursing Care Plan Form)

References

Hutchison, J., & Mahdy, H. (2019). Stages of labor. In StatPearls [Internet]. StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK544290/#:~:text=The%20first%20stage%20starts%20when,when%20the%20placenta%20is%20delivered.

Martin, P. (2022, September 9). 45 labor stages, induced and augmented, dystocia, precipitous labor nursing care plans. https://nurseslabs.com/labor-stages-labor-induced-nursing-care-plan/

 

 
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TPP250218 Careplan

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(TPP250218 Careplan)

TPP250218 Careplan

Nursing Care Plan Form

Student Name:                                                           Date:   

Patient Identifier:  L.D.                                        Patient Medical Diagnosis: Labor Stage IA: Latent Phase           

Nursing Diagnosis (use PES/PE format):

  1. The initial nursing diagnosis is deficient knowledge related to misperception of information and inadequate exposure or recollection, which is evidenced by incorrectly following directions, asking frequent questions, and making inaccurate statements.
  2. The risk of ineffectual coping due to patient vulnerability, a crisis situation, intense pain, lack of sleep, worry, and dread, as shown by the client’s improper control-maintaining behavior is the second nursing diagnosis. (TPP250218 Careplan)

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 a rationale for each goal & outcome.)

Rationale

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

 Outcome Evaluation & Replanning

(Was the goal met? How would you revise the plan of care according to the patient’s response to the current plan ?)
  1. The patient reports experiencing contractions and pain same as that experienced during menses.

 

 

  1. The patient reports painful back and thigh.

 

 

 

 

  1. The patient has discharge with blood patches and intermittent vaginal bleeding.

 

 Statement #1

The patient is anxious, fearful, and reluctant to report to the hospital because she has experienced cramping before, but not as intense. The first time she experienced cramping she did not report to the hospital, but managed the condition at home. She thought it was the same this round but the pain worsened with time.

Statement #2

The patient was not expecting the pain to be labor because she is at 36 weeks gestation, indicating insufficient knowledge regarding early labor pain, which impacts the client’s decision-making and coping during early labor and before active labor. This diagnosis is indicated by the client asking frequent questions, not doing as instructed, and uttering inaccurate statements.

 

 

 

 

 

 

Statement #1

Coping allows clients to process emotions and stress during pregnancy and labor.

Statement #2

The patient indicates a risk of ineffective coping related to anxiety and fear, situational crisis, and severe pain.
  1. Evaluate the patient’s foundational understanding of and expectations regarding pregnancy.
  2. Inquire about the patient’s nursing care preferences to manage the situation.

 

  1. Evaluate cultural provisions influencing the patient’s labor experience and coping behavior.

 

 

 

 

 

 

 

  1. Check for cervical dilation, vaginal bleeding, fetal condition and well-being, and patterns of uterine contractions and relaxation.

 

 

 

  1. Use the pain scale to examine patient’s pain levels.

 

  1. Inquire about the patient’s age and a partner’s or support presence.

 

 

 

 

 

 
  1. This intervention will aid in the development of learning needs and the establishment of priorities to assist the patient in making sound decisions about her care (Martin, 2022).

 

  1. Identifying the patient’s nursing care preferences will assist in determining how she would benefit from certain care approaches (Hutchison & Mahdy 2019).

 

  1. Cultural factors influence the patient’s labor experience (Martin, 2022).

 

  1. This strategy will aid in ruling out any possible problems that may be causing the pain or the bloody discharge (Hutchison & Mahdy 2019).
  2. Linking labor pain to common circumstances can aid the patient in gathering her resources and deciding on an effective pain relief intervention (Martin, 2022).

 

  1. Negative coping is linked to increased anxiety, patient request medication very earlier than usual in the labor. Furthermore, stress and uneasiness are associated with younger patients, who have difficulty sustaining control (Martin, 2022).
 Outcome #1

The patient responded as expected to the nursing care and the interventions adopted. The patient showed understanding of early labor signs and symptoms by expressing psychological and physiological changes, engaged in making decisions, and indicated effective breathing and relaxation strategies. To determine the extended client’s reaction to the current plan, ongoing monitoring is required.

 

 

 

 

 

 

 

 

 

 

Outcome #2

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

 

 

 

 

(TPP250218 Careplan)

References

Hutchison, J., & Mahdy, H. (2019). Stages of labor. In StatPearls [Internet]. StatPearls Publishing.

Martin, P. (2022, September 9). 45 labor stages, induced and augmented, dystocia, precipitous labor nursing care plans. https://nurseslabs.com/labor-stages-labor-induced-nursing-care-plan/

 

 
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Use Discount Code "Newclient" for a 15% Discount!