PATIENT M.Q.M.

PATIENT DATA RECORD NURSING CARE PLAN

CUES/ CLUES

NURSING DIAGNOSIS

SUBJECTIVE

OBJECTIVE

Deficient knowledge: SHORT TERM:

Effective pushing
Patient verbalized having
After 30 min of
techniques
difficulty relaxing between
nursing instruction in
contractions and is
more effective
complaining of lower back
pushing techniques,
pain. She cries and says she
patient will be able to
cant take it anymore,
do effective pushing
properly and will do it
whenever there are
contractions
OBJECTIVE
VS taken as follows
BP: 110/70
HR 79/min,
RR 18/min,
Temp: 37.0
Contractions occur every
1 min and 40 sec and
last for 70 sec and strong
in intensity
7-8 cm/90%/C/R/ station

NURSING INTERVENTION

RATIONALE

INDEPENDENT

SHORT TERM:

Teach patient how to

effectively push:
- Instruct patient to do a
dorsal recumbent position
- Instruct patient to breathe
deeply, stop breathing and
push for 10 secs and to
slowly gasp air
- Instruct her to look at her
stomach while pushing

Observe patients perineum for

fetal crowning with each push.

Dont talk to Cathy

unnecessarily in between
contractions

EVALUATION

Effective pushing will help After 30 min of

nursing instruction
the baby to descend
in more effective
easily
pushing
techniques,
patient could do
effective pushing
properly and did it
whenever there
are contractions

Observation permits the

nurse to maintain the
safety of both the mother
and the baby.
Silence allows her to
conserve her energy for
pushing efforts that are
progressing well.

Page 2 of 2
Maneclang, Wenn Joyrenz U. RLE 6.3 (2NUR-6)

CUES/ CLUES
SUBJECTIVE

NURSING DIAGNOSIS
Pain r/t effects of
uterine contractions

Patient verbalized having

difficulty relaxing between
contractions and is
complaining of lower back
pain

OBJECTIVE
VS taken as follows
BP: 120/70
HR 82/min,
RR 19/min,
Temp: 37.0
Contractions every 3
min for 60 sec and
strong in intensity
5 cm/50%/C/I/ station 2

OBJECTIVE

NURSING INTERVENTION

SHORT TERM:
INDEPENDENT
After 1 hr of nursing
intervention, patient
will express
Encourage patient to try
assurance that she
positions such as sidecan manage labor
lying, or leaning at the
pain satisfactorily
back of the bed and
remind her to change
positions about every 30
minutes or when she
feels the need for a
change.

RATIONALE

SHORT TERM:
After 1 hr of nursing

Teach patient simple

breathing and relaxation
techniques

Observe patients suprapubic

area and palpate for a full
bladder at least every 2
hours. Remind her to void if
she has not done recently

Tell Cathy about her

progress in labor.
Explain that she will
probably begin to dilate
faster now that she has
entered active phase of
labor.

EVALUATION

These positions shift the

weight of the fetus away
from the sacral
promontory, reducing
back pain. Alternating
positions relieves strain
and constant pressure
and helps the fetus adapt
to the pelvis.
Breathing techniques
provide distraction from
pain and enhances
normal labor process

A full bladder contributes

to discomfort and can
prolong labor by
obstructing fetal descent

Encouragement and the

knowledge that her
efforts having the desired
results increase a
womans willingness to
continue

intervention, patient
expressed assurance
that she can manage
labor pain
satisfactorily

Page 1 of 2
Maneclang, Wenn Joyrenz U. RLE 6.3 (2NUR-6)