Name: L,M

AP: Dr. Tuazon

Chief Complaint: Labor Pains
Diagnosis: polyhydramious

Room and Bed Number: 338-1

G4 P3 A0 T3 P0 A0 L2

Date &

Cues

Need Nursing

time
Dec.

-Attends regular

Diagnosis
Readiness

After 1 hour span of 1.Evaluate current knowledge

Goal partially met

10,

prenatal visit x5

for

care patient would

and cultural beliefs regarding

For patient

2014

-Seeks

enhance

be able to

normal physiological and

10:00 am

@ 9:30 necessary

child

A. Verbalize

psychological changes in

a. she had not

am

knowledge about

bearing

understanding of

pregnancy, as well as beliefs

verbalized any

her unborn child

process

care requirements

about activities, self-care.

understanding about

as evidence by

to promote health

2.Determine degree of

care requirements

unsa naman

of self and infant

motivation for learning.

b. verbalizes that

ako buhaton pag

R-Client may have difficulty

she is now ready no

gawas niya?

B. Verbalize that

learning unless the need for it is

matter whats her

-Reports

she in now ready

clear.

childs appearance

managing

no matter whats

3.Identify who provides support

is as evidence by

unpleasant

the appearance of

within the clients culture

dawaton nalang

symptoms in

her baby

R- Helps ensure quality and

nako kay blessing

pregnancy

continuity of care because

man and baby,

-Irritable when

C. Demonstrate

support persons may be more

hatag mana sa

asked about her

safety precautions

successful than the healthcare

Ginoo

baby

provider in communicating

c demonstrated

-Constantly

information.

safety precautions

crying

4.Evaluate the clients/couples

as evidence by

-Do not talk

response to pregnancy,

when walking she

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Objectives of care

Nursing intervention

Evaluation

about her baby.

individual and family stressors,

and cultural implications of

pregnancy/childbirth.

R-The ability to adapt positively

depends on support system,

cultural beliefs, resources and

effective coping mechanisms

developed in dealing with past

stressors.
5.Maintain open attitude toward
beliefs of client/couple.
R-Acceptance is important to
developing and maintaining
relationship and supporting
independence.
6.Provide information about
potential teratogens, such as
alcohol, nicotine, illicit drugs, the
STORCH, group of viruses e.g
rubella, and HIV.
R-Helps client make informed
decisions/choices about

45 | P a g e

hold her tummy.

behavior/environment that can

promote healthy offspring.
7.Use various methods for
learning, including pictures, to
discuss fetal development.
R-Visualization enhances reality
of child and strengthens learning
process.
8.Discuss signs of labor onset
how to distinguish between false
and true labor, when to notify
healthcare provider and to leave
for hospital/birth centers, and
stages of labor/delivery.
R-Helps ensure timely arrival
and enhances coping with
labor/delivery process.

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