NURSING CARE PLAN

Assessment Nursing Planning Nursing Evaluation

Diagnosis Interventions
Subjective: Activity Short term: - Asses status of the - After 30 mins of
(I felt a sudden intolerance -After 30 minutes patient and fetus the health teaching,
contraction, I related to of health teaching, - Encourage bed patient will be able
thought I am in muscle or patient will be able rest with patient side to verbalized her
labor) patient cellular to verbalized her lying position. understanding and
verbalized hypersensitivity understanding - Apply external able to use about
Objective: about identified uterine and fetal identified
Continue techniques to monitoring techniques to
uterine enhance activity - Monitor patient’s enhance activity
contraction. intolerance V/S closely, every intolerance.
Facial mask of 15 minutes.
pain. - Instruct patient to
Irritability report any feelings .
of difficulty
of breathing or chest
pain,dizziness,nervo
usness and irregular
heartbeat.
- Monitor uterine
contractions,includin
g frequency and
domain.
Collaborative:
Obtain diagnostic
studies including
complete blood
count,hemoglobin
and hematocrit,
urine,vaginal a
cervical cultures as
ordered.
 NURSING CARE PLAN

Assessment Nursing Planning Nursing Evaluation

Diagnosis Interventions
The nurse on duty Fluid volume Short term: Independent: Short term: After 1
found the fundus deficit related to After 1 hour of * Monitor the V/S of hour of nursing
is boggy and active fluid nursing the patients intervention, the
above the level of volume loss as intervention, the *Asses the patient to patient will be able
the umbilicus her evidenced by patient will be massage the uterus to:
bp reveals 95/55 boggy fundus able to: to help it contract to > Identify risk
and the PR is 116 above the level of Identify risk slow the bleeding factors and
with bounding the umbilicus, factors and *Encourage the appropriate
pulse. and blood clots. appropriate patient to take some interventions
interventions slow deep breaths
and relax as much > Maintain a bp
Maintain a bp as possible. atleast 108/72
atleast *Asses the skin and mmHg
100/60mmHg oral mucus > Maintain a Pulse
Maintai the PR membranes rate between 116
between 116 to * In the case of to102bpm
102 bpm traumatic bleeding,
the site of trauma is
sutured under GOAL MET
general anesthesia
after the placenta
has been expelled.
* Blood transfusion
may be necessary
depending on the
hemoglobin and the
state of the patient.

Dependent:
Administer oxytocin
as ordered.
 Nursing Care Plan

Assessment Nursing Planning Nursing Interventions Evaluation

Diagnosis
Objective: Risk for excess * After 15 to 30 > Educate mother and The fluid level is
>Decrease in fluid volume minutes of nursing family members maintained at
intake of fluid related to intervention, the regarding the same extent
(e.g., inability to excessive /rapid mother will be able importance of proper
intake fluid due replacement of to: nutrition, hydration, The need for
to oral trauma) fluid loss. * Be Assessed and diet modification continous
Hypervolemia about neurological in relation to the monitoring of the
status, observing newborn’s health. newborn’s fluid
for any behavioral intake and output
changes >Monitor and was achieved.
document vital signs
* Be monitor for especially BP and PR.
sign of
hypertensive, >asses skin turgor
Tachycardia, and oral mucuos
observe the sign membranes for signs
of dyspnea. of dehydration

* Be monitor about > Asses alteration in

intake output urine mentation/ sensorium
specific gravity. (confusion, agitation,
slowed responses.)

> Monitor electrolytes

and urine osmotality,
and report abnormal
values.

> Identify the possible

cause of the fluid
disturbance or
imbalance.
 Nursing Care Plan

Assessment Nursing Planning Nursing Interventions Evaluation

Diagnosis
Subjectives : Anxiety related to After 8 hours, > Maintain a calm, non >After 8 hours. The
Will be my fetal safety (as client will be able-- threatening manner while patient was able to
baby okay? As evidenced by to verbalize working with the client verbalize and
verbalized by verbalization of decrease in express her feelings
the mother doubt and fear anxiety-to appear > Monitor maternal/fetal throughout the entire
due to the relaxed and vital signs.Use presence, shift which helped
understanding of comfortable-to us touch or verbalization to her to relieve her
risk from green communication encourage expressions or anxiety.-patient
amniotic fluid) and relaxation clarifications of needs, verbalized, “I am
techniques in order concerns, unknowns, and able to fully
to alleviate the questions understand the
anxiousness situation,
> Remain with the client at
all times when levels of
anxiety are high (severe or
panic); reassure client of
his or her safety and
security.Establish a
therapeutic relationship,
conveying empathy and
unconditional positive
regard.

> Encourage verbalization

of fears and concerns.
Encourage use of
relaxation techniques such
as deep breathing
exercises and music
therapy
 Nursing Care Plan

Assessment Nursing Planning Nursing Evaluation

Diagnosis Interventions
Subjective: Risk for Short term: - Teaching the - After 30 mins of
I have been altered -After 30 minutes importance of the health
diagnoses in nutrition less of health teaching, regularity of teaching, patient
Gestational than body patient will be able meals and snacks will be able to
Diabetes in requirements. to verbalized her when taking verbalized her
last 7 months understanding insulin understanding
when I’m about gestational about gestational
pregnant. As diabetes. - Teach and diabetes.
verbalize by demonstrate
the patient. client to monitor
sugar using a
Objective” finger-stick
> Patient is at method.
diet as
moderated -Discuss the type
because of her of insulin dosage
glucose level and schedule
> dry mouth
- Referred to a
registered
dietician to
individualized diet
and counsel
regarding dietary
questions.