Assessment Diagnosis Rationale Planning Intervention Rationale Evaluation

Subjective: Potential risk for the Because of the fetal Long term: Assess foe the vital signs Identifies changes in After 1 week of nursing
“I’m having terrible patient (Maternal) due malpresentation the After 1 week of nursing baseline data intervention the patient
labor, maybe to fetal malposition patient could be at risk interventions the able to display normal
somethings wrong /abnormality. and can cause serious patient will able to Review the history of Helpful in identifying possible vital signs, no signs of
with my baby.” complications during display normal vital labor, onset, and duration. causes, needed diagnostic bleeding and state the
Revise as Maternal injury labor signs no signs of studies, and appropriate proper nursing
Objective: related to fetal bleeding and state the interventions. interventions
Cervix is 4 cm malposition as evidence proper nursing
Note the condition of A rigid or unripe cervix will
dilated and 75% by ________. ( sign and intervention
cervix. Monitor for signs not dilate, impending fetal
effaced symptom) descent/labor progress
of amnionitis. Note
Uterine contraction
elevated temperature or
duration 30 WBC; odor and color of
seconds vaginal discharge. After 8 hours of nursing
Frequency – every Short term: intervention patient able
5 minutes; 1 After 8 hours of Evaluate the current level Excess maternal exhaustion to participate in
station nursing intervention of fatigue, as well as contributes to secondary interventions to improve
Vital signs: patient will instructed activity and rest prior to dysfunction, or may be the labor pattern and reduce
- BP: 130/80 to participate in onset of labor. result of prolonged identified risk factors.
- PR: 25 interventions to labor/false labor.
- RR: 85 improve labor pattern
Review bowel habits and Bowel fullness may hinder
FHR: 109 bpm and/or reduce
regularity of evacuation uterine activity and interfere
identified risk factors. with the fetal descent

Mark Angelo Fernandez

Subjective: Maternal injury related Because of the fetal Long term: Assess for the vital signs Identifies changes in After 8 hours of nursing
“I’m having terrible to fetal malposition malpresentation the After 8 hours of baseline data intervention the patient
labor, maybe patient could be at risk nursing interventions able to display normal
somethings wrong and can cause serious the patient will able to Review the history of Helpful in identifying possible vital signs, no signs of
with my baby.” complications during display normal vital labor, onset, and duration. causes, needed diagnostic bleeding and state the
labor signs no signs of studies, and appropriate proper nursing
Objective: bleeding and state the interventions. interventions
Cervix is 4 cm proper nursing
Note the condition of A rigid or unripe cervix will
dilated and 75% intervention
cervix. Monitor for signs not dilate, impending fetal
effaced descent/labor progress
of amnionitis. Note
Uterine contraction
elevated temperature or
duration 30 WBC; odor and color of
seconds vaginal discharge. After 3 hours of nursing
Frequency – every Short term: intervention patient is
5 minutes; 1 After 3 hours of Evaluate the current level Excess maternal exhaustion able to participate in
station nursing intervention of fatigue, as well as contributes to secondary interventions to improve
Vital signs: patient will instructed activity and rest prior to dysfunction, or may be the labor pattern and reduce
- BP: 130/80 to participate in onset of labor. result of prolonged identified risk factors.
- PR: 25 interventions to labor/false labor.
- RR: 85 improve labor pattern
Review bowel habits and Bowel fullness may hinder
FHR: 109 bpm and/or reduce
regularity of evacuation uterine activity and interfere
identified risk factors. with the fetal descent

Mark Angelo Fernandez