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):
- 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.
- 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.)
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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 ?) |
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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. |
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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.
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(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/