ccc248c5-bb20-4462-b3f3-665bfa871b56.jpeg

Help in filling up the following ,giving ,objective and subjective data on assessment , followed by five nursing diagnosing ,to complete the table

Asking for Preferences

Its for a mother in labour

Reading File

Finding Sources

Reading File

I have enough foundational knowledge to now compile a complete, clinically accurate nursing care plan for a mother in labour. Let me produce the full table.

Nursing Care Plan - Mother in Labour

Tharaka-Ithi County Government - Marmanti Level IV Hospital

ASSESSMENT DATA

Subjective Data (What the patient says):

"I am having very painful contractions"
"The pain comes and goes and is getting stronger"
"I feel a lot of pressure in my lower back and pelvis"
"I feel anxious and scared about the delivery"
"I have not eaten or drunk anything for the past few hours"
"I feel the urge to push"
"I am very tired"

Objective Data (What the nurse observes/measures):

Uterine contractions: regular, increasing in frequency, duration, and intensity
Cervical dilation: (e.g. 5 cm - active phase)
Effacement: (e.g. 80%)
Fetal presentation: vertex/cephalic (confirm by examination)
Fetal heart rate (FHR): (e.g. 140 bpm - auscultated/CTG)
Vital signs: BP, Pulse, RR, Temperature recorded
Diaphoresis (sweating) noted
Facial grimacing during contractions
Guarding and tensing of abdomen during contractions
Membranes: intact or ruptured (note color/amount of liquor)
Perineum: bulging or not
Bladder: may be distended
IV access established (if applicable)
Partograph initiated and being monitored

FIVE NURSING DIAGNOSES WITH FULL CARE PLAN

NURSING DIAGNOSIS 1

Column	Content
Date & Time	(fill)
Assessment Data	S: Patient reports severe, cramping lower abdominal and back pain rated 8/10. States "the pain comes in waves and is unbearable." O: Facial grimacing, diaphoresis, guarding of abdomen, uterine contractions every 3-4 minutes lasting 50-60 seconds, strong on palpation.
Nursing Diagnosis	Acute Pain related to uterine contractions and cervical dilation as evidenced by verbal reports of pain (8/10), facial grimacing, and diaphoresis.
Goal/Expected Outcome	Patient will report pain reduced to a manageable level (≤4/10) within 30 minutes of interventions and demonstrate effective use of non-pharmacological coping techniques throughout labour.
Plan of Action / Nursing Intervention	1. Assess pain using a 0-10 numeric pain scale every 30 minutes and with each contraction change. 2. Encourage and teach breathing/relaxation techniques (slow deep breathing during contractions). 3. Provide back massage/counterpressure over sacral area during contractions. 4. Assist patient to assume a comfortable position (lateral, upright, or on all fours). 5. Encourage ambulation if membranes intact and fetal head engaged. 6. Apply warm compresses to lower back. 7. Administer prescribed analgesia (e.g. pethidine/tramadol) as ordered. 8. Ensure continuous emotional support and presence.
Rationale for Nursing Intervention	1. Regular assessment allows timely detection of changes and guides management. 2. Breathing techniques activate the parasympathetic system, reducing pain perception. 3. Counterpressure relieves pressure on sacral nerves. 4. Position changes reduce discomfort and may promote fetal descent. 5. Ambulation uses gravity to assist labour progress. 6. Heat promotes muscle relaxation and reduces pain. 7. Pharmacological analgesia acts centrally to reduce pain. 8. Emotional support reduces anxiety, which lowers pain perception.
Nursing Implementation	Assessed pain every 30 minutes. Taught and supervised breathing techniques. Provided sacral massage during contractions. Positioned patient in left lateral position. Administered prescribed analgesia as ordered. Documented all interventions and patient responses on partograph.
Evaluation (include date & time)	Patient reports pain reduced to 4/10. Breathing techniques used effectively during contractions. Patient states "it is more manageable now." Goal partially/fully met - continue monitoring. (Date/Time: _____)
Name & Sign	(Nurse's name and signature)

NURSING DIAGNOSIS 2

Column	Content
Date & Time	(fill)
Assessment Data	S: Patient states "I am so scared, I don't know what to expect" and "What if something goes wrong?" O: Restlessness, trembling hands, increased respiratory rate, tearful, asking repeated questions about her progress and the baby's condition.
Nursing Diagnosis	Anxiety related to unfamiliar labour process, uncertainty about outcome, and pain as evidenced by verbalization of fear, restlessness, and tearfulness.
Goal/Expected Outcome	Patient will verbalize reduced anxiety, demonstrate calm breathing, and actively participate in labour management within 1 hour of nursing interventions.
Plan of Action / Nursing Intervention	1. Establish therapeutic relationship - introduce self and maintain continuous presence. 2. Explain all procedures and progress to the patient in simple language. 3. Involve and encourage support person (husband/birth companion) at bedside. 4. Reassure patient about fetal well-being by sharing FHR findings. 5. Teach and guide slow, controlled breathing exercises. 6. Answer all questions honestly and promptly. 7. Create a calm, quiet, and reassuring environment. 8. Administer prescribed anxiolytics if ordered.
Rationale for Nursing Intervention	1. Therapeutic presence builds trust and reduces fear of the unknown. 2. Information reduces anxiety caused by uncertainty. 3. Social support is proven to reduce labour anxiety and duration (doula effect). 4. Hearing normal FHR provides reassurance about the baby. 5. Controlled breathing stimulates vagal tone and reduces sympathetic arousal. 6. Unanswered questions escalate anxiety. 7. Sensory stimulation reduction lowers anxiety levels. 8. Pharmacological intervention is used when non-pharmacological methods are insufficient.
Nursing Implementation	Introduced self to patient and maintained bedside presence. Explained labour progress every 30 minutes. Informed patient that FHR is normal. Taught breathing exercises. Involved husband in care. Reduced environmental stimuli.
Evaluation (include date & time)	Patient reports feeling "less scared." Restlessness reduced. Patient using breathing techniques independently. Goal met/partially met - continue support. (Date/Time: _____)
Name & Sign	(Nurse's name and signature)

NURSING DIAGNOSIS 3

Column	Content
Date & Time	(fill)
Assessment Data	S: Patient states "I have not eaten or drunk anything since this morning." O: Dry mucous membranes, concentrated urine (if voided), tachycardia (HR >100 bpm), reports dizziness on standing. Prolonged labour with restricted oral intake.
Nursing Diagnosis	Risk for Deficient Fluid Volume related to restricted oral intake during labour, diaphoresis, and increased metabolic demands as evidenced by dry mucous membranes, concentrated urine, and tachycardia.
Goal/Expected Outcome	Patient will maintain adequate hydration as evidenced by moist mucous membranes, urine output ≥30 mL/hr, stable vital signs, and absence of dizziness throughout labour.
Plan of Action / Nursing Intervention	1. Monitor vital signs (BP, HR, RR) every 30-60 minutes or as per hospital protocol. 2. Maintain IV line and administer IV fluids (e.g. Normal Saline or Ringer's Lactate) as prescribed. 3. Monitor and record fluid intake and urine output. 4. Encourage sips of clear fluids or ice chips if allowed per protocol. 5. Assess mucous membranes and skin turgor every 2 hours. 6. Monitor urine concentration and colour. 7. Weigh patient if possible. 8. Report signs of dehydration or fluid imbalance to the obstetrician promptly.
Rationale for Nursing Intervention	1. Vital signs changes are early indicators of hypovolemia. 2. IV fluids maintain circulating volume and prevent dehydration during restricted oral intake. 3. Monitoring intake/output identifies deficits early. 4. Small sips maintain mucosal hydration without risking aspiration. 5. Dry membranes and decreased skin turgor indicate dehydration. 6. Dark concentrated urine indicates inadequate hydration. 7. Weight changes reflect acute fluid shifts. 8. Early reporting enables prompt medical management.
Nursing Implementation	IV fluid (Normal Saline 500mL) commenced as prescribed. Vital signs monitored and charted every 30 minutes. Urinary output monitored via voiding or catheter. Mucous membranes assessed and found moist after fluid administration. Intake/output chart maintained.
Evaluation (include date & time)	Urine output adequate at ≥30 mL/hr. Mucous membranes moist. Vital signs stable. Goal met - continue IV fluids and monitoring. (Date/Time: _____)
Name & Sign	(Nurse's name and signature)

NURSING DIAGNOSIS 4

Column	Content
Date & Time	(fill)
Assessment Data	S: Patient states "I feel very weak and exhausted." O: Prolonged labour (>8 hours active phase), diaphoresis, facial pallor, reduced cooperation during contractions, slow fetal descent on partograph, frequent position changes.
Nursing Diagnosis	Fatigue related to prolonged labour, pain, and increased physical and emotional demands as evidenced by patient's verbalization of exhaustion, pallor, and reduced participation during pushing.
Goal/Expected Outcome	Patient will report reduced fatigue and demonstrate adequate energy to participate actively in pushing efforts during the second stage of labour.
Plan of Action / Nursing Intervention	1. Encourage rest between contractions - minimize unnecessary interruptions. 2. Provide a comfortable, well-supported position (semi-recumbent or lateral). 3. Administer oxygen via face mask (4-6 L/min) if required. 4. Ensure adequate hydration and IV glucose (as prescribed) to support energy demands. 5. Provide encouraging verbal support and coaching during pushing. 6. Inform and involve patient in progress - small achievable goals ("you're doing great, baby is nearly there"). 7. Minimize unnecessary vaginal examinations. 8. Monitor FHR closely for signs of fetal distress due to maternal fatigue.
Rationale for Nursing Intervention	1. Rest between contractions conserves energy for pushing efforts. 2. Supportive positioning reduces muscle strain and conserves energy. 3. Supplemental oxygen increases oxygen delivery to fatigued muscles and the fetus. 4. IV glucose provides immediate energy substrate. 5. Coaching optimizes pushing effectiveness, reducing total pushing time. 6. Positive reinforcement maintains patient motivation. 7. Minimizing examinations reduces discomfort and energy expenditure. 8. Maternal fatigue can cause fetal compromise; early detection allows timely action.
Nursing Implementation	Patient encouraged to rest between contractions. Position adjusted to semi-recumbent. Verbal coaching provided during second stage. IV fluids maintained. Fetal heart rate monitored every 15 minutes. Progress explained to patient at each assessment.
Evaluation (include date & time)	Patient reports feeling "stronger and ready to push." Successfully participated in directed pushing. Goal met - continue support and monitoring. (Date/Time: _____)
Name & Sign	(Nurse's name and signature)

NURSING DIAGNOSIS 5

Column	Content
Date & Time	(fill)
Assessment Data	S: Patient states "Is my baby okay? I can't feel it moving as much." O: Rupture of membranes noted (if applicable), meconium-stained liquor (if present), FHR irregularities on auscultation/CTG, prolonged deceleration noted, maternal pyrexia (Temp >38°C), uterine tachysystole (>5 contractions/10 min).
Nursing Diagnosis	Risk for Impaired Fetal Gas Exchange related to uterine contractions, cord compression, placental insufficiency, and/or maternal hypoxia as evidenced by prolonged decelerations on FHR monitoring and maternal pyrexia.
Goal/Expected Outcome	Fetal heart rate will remain within normal range (110-160 bpm) with no prolonged decelerations, and delivery of a live baby with Apgar score ≥7 at 1 and 5 minutes.
Plan of Action / Nursing Intervention	1. Monitor FHR every 15-30 minutes in active labour and every 5 minutes in second stage (or continuous CTG if available). 2. Position mother in left lateral position to relieve aortocaval compression. 3. Administer oxygen to mother (4-6 L/min via mask) if FHR abnormalities noted. 4. Ensure adequate maternal hydration to maintain placental perfusion. 5. Discontinue oxytocin infusion if uterine tachysystole present. 6. Prepare for emergency delivery (assisted delivery/caesarean section) if FHR remains non-reassuring. 7. Notify obstetrician immediately of any FHR abnormalities. 8. Prepare resuscitation equipment and neonatal team for delivery.
Rationale for Nursing Intervention	1. Regular FHR monitoring detects fetal distress early, enabling timely intervention. 2. Left lateral position improves venous return and uterine perfusion, increasing fetal oxygenation. 3. Maternal oxygen supplementation increases the partial pressure of oxygen available for placental transfer. 4. Adequate hydration maintains uteroplacental blood flow. 5. Reducing contraction frequency allows fetal recovery between contractions. 6. Timely delivery prevents fetal hypoxia and acidosis. 7. Obstetrician review ensures appropriate escalation of care. 8. Preparedness ensures rapid neonatal resuscitation if needed.
Nursing Implementation	FHR monitored every 15 minutes and documented on partograph. Patient positioned in left lateral. Oxygen administered at 4 L/min. Oxytocin dose reviewed with obstetrician. Resuscitation trolley checked and positioned at delivery room. Obstetrician notified of CTG finding.
Evaluation (include date & time)	FHR returned to 140 bpm with no further decelerations after repositioning and oxygen. Baby delivered with Apgar 8/9. Goal met. (Date/Time: _____)
Name & Sign	(Nurse's name and signature)

SUMMARY TABLE (Quick Reference for the Form)

#	Nursing Diagnosis	Goal	Key Interventions	Rationale	Evaluation
1	Acute Pain r/t uterine contractions	Pain ≤4/10 within 30 min	Pain assessment, breathing techniques, positioning, analgesia	Reduces pain perception; promotes coping	Pain manageable; goal met
2	Anxiety r/t unfamiliar labour process	Verbalizes reduced anxiety within 1 hr	Therapeutic presence, information giving, involve support person	Reduces fear of unknown; improves cooperation	Anxiety reduced; goal met
3	Risk for Deficient Fluid Volume r/t restricted intake	Urine output ≥30 mL/hr; stable vitals	IV fluids, I&O monitoring, assess mucous membranes	Prevents hypovolemia and maternal/fetal compromise	Hydration adequate; goal met
4	Fatigue r/t prolonged labour	Adequate energy for pushing	Rest between contractions, coaching, oxygen, IV glucose	Conserves energy; optimizes pushing effectiveness	Patient pushing effectively; goal met
5	Risk for Impaired Fetal Gas Exchange r/t contractions/cord compression	FHR 110-160 bpm; Apgar ≥7	FHR monitoring, left lateral position, oxygen, notify OB	Detects and prevents fetal hypoxia	FHR normal; baby born with Apgar 8; goal met

Notes for completing the form:

Fill in patient name, age, bed number, IP number, date of admission, and ward from the actual patient file.
The diagnosis field should read: Active Labour / Spontaneous Labour / Induced Labour (as applicable).
Each nursing diagnosis should occupy one row in the table.
The partograph must be maintained alongside this care plan.
All interventions must be signed and timed by the attending nurse.

This is a shared conversation. Sign in to Orris to start your own chat.