Assessment Diagnosis Planning Intervention Rationale Evaluation

Subjective: Anxiety related At the end of the  Explain the  Information and At the end of the
“ Ma okay lang to shift the patient procedures, nursing knowledge of the shift the patient:
akong baby Situatio must: interventions, and reasons of these  verbalized
ma’am? “ nal  will verbalize treatment regimen. activities can understan
crisis as understandin Keep communication decrease fear of
evidenc g of individual open; discuss with the the unknown. ding of
ed by situation and client the possible individual
Objective: Apprehe possible side effects and situation
 Restlesness nsion outcomes. outcomes while
and
  will report maintaining an
 Vital Signs: anxiety is optimistic attitude.  Provision of clear possible
T- 37 reduced  Answer questions information can outcomes.
P- 70 bpm and/or honestly, especially help the client or  reported
R- 20 cpm manageable. information regarding couple understand
BP- 130/90 mmhg  will appear contraction pattern what is happening anxiety is
relaxed; with and fetal status. and may reduce reduced
maternal vital anxiety. and/or
signs within manageabl
normal limits.  Encourage use of  Enables the client
relaxation techniques. to obtain maximum e.
benefit from rest  appeared
periods; prevents relaxed;
muscle fatigue and
with
improves uterine
blood flow. maternal
 Monitor maternal and  Vital signs of client vital signs
fetal vital signs. and fetus may be within
altered by anxiety.
Stabilization may normal
reflect reduction limits.
anxiety level.
 Assess support
systems available to  The assistance
the client or couple, and caring of
whether the client significant others,
remains hospitalized including
or is to return home to caregivers, are
await delivery. extremely
important during
this time of
uncertainty and
stress. If the client
is to return home,
additional support
will be required to
meet self-care
needs and
homemaker
activities as well as
child care, as
appropriate.