Care Plan Complete List OB 1

Topics: Health care provider, Nursing care plan, Patient Pages: 51 (11800 words) Published: December 30, 2014
Original Care plans are in black text.
Changes made appear in blue directly below the lines or parts that were changed. Minor changes/additions appear in blue within black text. Multiple interventions within the same nursing diagnosis have been indicated “Same reference as above” to save space.

Nursing Diagnosis Form 1 (no changes made)
NURSING DIAGNOSIS: Anxiety related to lack of knowledge about diagnostic procedures and uncertain condition of fetus as evidenced by (S) patient states she has fears about what will happen to the baby, and (O) patient speaks with a trembling voice and exhibits restlessness. LONG TERM GOAL/OUTCOME: Patient will demonstrate ability to reassure self and have increased external focus AEB relaxed tone of voice and affect by time of discharge. SHORT TERM GOAL/OUTCOME: Patient will verbalize knowledge of test procedure before test initiated; couple will verbalize concerns and seek knowledge about fetus by end of shift. PLANNED INTERVENTIONS

RATIONALE (sources cited)
Use therapeutic touch and healing touch techniques.

Anxiety was significantly reduced in a therapeutic touch placebo condition. Healing touch may be one of the most useful nursing interventions available to reduce anxiety. Ackley, B., Ladwig, G. (2008) Nursing diagnosis handbook an evidenced based guide to planning care. (pp. 140-142, 354-357) 8th ed. St. Louis, Mosby Elsevier.

Ascertain client preferences about the desire to be distracted before and during noxious medical procedures. Clients have individual preferences for the use of distraction during anxiety-provoking procedures. Same reference as above.

Explain all activities, procedures, and issues that involve the client/fetus: use nonmedical terms and calm, slow speech. Do this in advance of procedures when possible, and validate the client’s understanding. Triad communication or talking to another staff or family member in front of the client is a way to provide additional information to assist in understanding. Same reference as above.

Intervene, when possible, to remove sources of anxiety. For example provide Doppler sound of fetus heart beat to reassure client of “baby’s” vitality. Anxiety has a negative effect on quality of life that persists over time. Same reference as above.

Encourage the client to use positive self-talk such as, “anxiety won’t kill me, my baby is healthy,” “I just need to breathe and stretch, I can do this.” Cognitive therapies focus on changing behaviors and feelings by changing thoughts. Replacing negative self-statements with positive statements helps to decrease anxiety Same reference as above.



Nursing Diagnosis Form 1
NURSING DIAGNOSIS: Readiness for enhanced family coping R/T needs sufficiently gratified to enable goals of self-actualization AEB (S) Pt. expressed desire to participate in treatment plan for high-risk antepartum, and (O) Pt. is emotionally stable with positive affect. Readiness for enhanced family coping related to high-risk pregnancy as evidenced by patient asking appropriate questions and seeking educational opportunities with the Nurse. LONG TERM GOAL/OUTCOME: Patient will be able to verbalize 3 environmental, social or lifestyle risks to health condition and verbalize 3 measure to combat these risks by time of discharge. SHORT TERM GOAL/OUTCOME: Patient will be able to identify 4 ways to cope effectively with current condition (high-risk) by end of shift. PLANNED INTERVENTIONS

RATIONALE (sources cited)
Provide parenting information based on individual and couple changes in meaning and identity, roles, and relationships and interaction during the transition to parenthood. Address mother and father roles, infant communication abilities, and patterns of first 3...
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