College of Allied Health Sciences

School of Nursing

ASSESSMENT NURSING DIAGNOSIS PLANNING NURSING INTERVENTIONS RATIONALE EVALUATION

Impaired Spontaneous
Subjective Data: Pushing related to Short Term Goals: After 30 minutes of
ineffective uterine Nurses’ shift, the patient
contractions as evidenced ● After 30 minutes has:
● The patient has by prolonged labor and of Nursing Dependent Intervention
verbalized failure to deliver the Intervention, the ● Administer Oxytocin. ● Oxytocin enhances ● Patient has
difficulty and shoulders. patient/ client will: uterine demonstrate
prolonged labor contractions, effective pushing.
during pushing ● The client will aiding in cervical
phase. demonstrate dilation and The goal has been meet
● The patient has effective pushing descent of the
verbalized anxiety during fetal head.
and concern about contractions,
the progress of leading to the Independent Intervention
labor. successful delivery ● Help the patient ● Patient has shown
of the infant. adjust their position. ● Changing positions
can help reposition compliance to
change position in
Objective Data: the fetus,
Long Term Goals: order to reposition
● Cervical dilatation potentially
the fetus.
progressed from 3 ● After 1 hour of resolving shoulder
cm to 10 cm over 8 Nursing dystocia and The goal has been meet
hours. Intervention, the facilitating a
● Spontaneous patient/ client will: smoother delivery.
rupture of
membranes. ● Collaboration
● Syntocinon ● The infant will be Collaborative Intervention ensures a ● Patient
infusion initiated. delivered safely ● Collaborate with the coordinated effort understood and
● Epidural without Obstetric Team. among healthcare demonstrated
administered. compromising professionals to compliance the
● The Fetal head maternal or fetal address the Obstetric team.
crowned but well-being. complex situation
shoulders are not The goal has been meet
and provide the
descending
necessary support.
normally.
Independent Intervention ● Emotional support
● Provide Emotional helps alleviate
Support. anxiety and stress, ● Patient becomes
calm and positive
promoting a more
during the labor.
positive birthing
experience. The goal has been meet
● The McRoberts
● Apply McRoberts Maneuver is a
Maneuver. first-line ● The patient
intervention for
laboratory results
shoulder dystocia.
are all in the
It helps to increase
normal or
the pelvic outlet by
flattening the acceptable
sacrum, making findings.
more space for the
The goal has been meet
baby to pass
through.
 ● Accurate
documentation is
● Document the
Interventions and crucial for
Responses continuity of care,
communication ● The Client
among the presented a
healthcare team, stabilized
and potential condition and
delivered a healthy
future references.
baby.
It provides a
comprehensive The goal has been meet
record of the labor
progression and
interventions
implemented.

Name: ________________________________________________________________ Section: ______________________ Date: ________________________