CUES S=This is my first baby.

I really do not know what to do O=>presence of: >active queries regarding procedure >facial expressions suggesting fear >active verbalization of the problem

Nursing Diagnosis Deficient Knowledge regarding procedure, treatment needs, and possible outcomes related to lack of exposure evidenced by questions.

Scientific Explanation The pt. is experiencing the latent phase of the active stage of labor. The client is a primi-gravida and she admits to not knowing anything about what to expect and what to do. This has led to deficient knowledge.

Planning SHORT TERM: After 10-20 minutes of NI, the pt. will participate in the learning process.

Intervention >establish rapport

Rationale >to gain cooperation and trust from client >to obtain baseline and assess possible areas of immediate intervention >to determine level of teaching >the client may not be physically, emotionally, or mentally capable of learning at this time >clients may need to experience lack of information before they decide to accept teachings >provides opportunities to address barriers such as language differences >determines presence of fetal distress >determines need for transfer from labor room to delivery room

Expected Outcome SHORT TERM: After 10-20 minutes of NI, the pt. shall have participated in the learning process .

>monitor vital signs and perform preliminary assessment >identify clients level of understanding >determine clients readiness for teaching

LONG TERM: After 2-3 days of NI, the pt. will regain normal bowel patter verbalize understanding of procedure, treatment needs, and possible outcomes.

>be alert for avoidance or acceptance

LONG TERM: After 2-3 days of NI, the pt. shall have verbalized understanding of procedure, treatment needs, and possible outcomes.

>determine barriers towards earning

>assess fetal heart tone

>assess for progress of laborcntinuously

>instruct client on the latent phase of labor

>clients in the latent phase are still capable of learning as pain is still tolerable

>motivate clients towards learning

>enhances participation and compliance

>provide only information relevant to the current situation >allow to verbalize feelings >answer queries and encourage to ask questions

>To prevent overload and address current issues immediately >relieves anxiety and tension >provides learning and encourages attention and compliance towards new knowledge >enhances learning and promotes cooperation and fascination >provides a clear instruction to the proper way of pushing minimizing exhaustion and discomfort >allays anxiety, promotes relaxation, reduces discomfort.

>provide tools for learning such as visual aids >instruct on proper pushing during labor, with pursed lips

>instruct on deep breathing exercises

>instruct that pain and forceful contractions are normal

>to allay anxiety and provide factual information as to what the client may expect >pushing earlier may result to fetal distress

>instruct to refrain from pushing until instruct to do so during crowning. >breasfeeding promotes nonding and provides optimum fetal nutrition. >ask if the mother is to breastfeed after delivery. Encourage it >brings realism to light and allows for realistic expectations >provides learning while conserving time. Clients in labor may only be taught during the latent stage. >enhances learning using non-verbal cues

>remain as factual as possible. Maintain veracity >use short, simple sentences

>use gestures and facial expressions if appropriate >provide written guidelines if feasible

>reinforces learning and allows client to proceed at his own pace. >arouses learning and limits the sense of being overwhelmed >always prepare for delivery should a precipitous labor occur.

>begin teaching with what the client knows already >prepare for delivery