Student Name: Date of Care: Pt initials
Client Age & Gender: 33 y.o F
Medical Diagnosis: 42 wk
pregnancy laboring
Relevant data from assessment:
Water broke
Dilated at 8
No epidural
P2 G2
ST goal (pt will…by…) patient will report decreased anxiety episodes and discharge
LT goal: pt will identify healthy ways to deal with and express anxiety.
ND #1 (Problem …R/T…AEB…) Anxiety R/T maturational crisis AEB living at pregnancy support
center
Medications related to diagnosis:
Pit, NS
5 Interventions with rationales to achieve goals:
Assist with developing skills such as awareness of negative
thoughts like saying no or stop and replace it with positive
thoughts.
Pt is able to talk feelings out and go to counseling
Pt can use strategies to reduce anxiety such as meditation,
relaxation, spending time for yourself, exercise, find humor
Educate the pt on how to correctly take the PRN anti-anxiety
medication
Provide a psychiatrist refer per md request
Citation (using APA format)
Gulanick, M., & Myers, J. L. (2017). Nursing care plans: diagnoses interventions, & outcomes.9th edition. St.
Louis, Missouri: Mosby, an imprint of Elsevier Inc.
Patient Response to Interventions:
Pt states she does not have the
money for a counsel but would
love to learn cheap free
alternatives. Pt knows she needs
help but doesn’t have much
family support in her life. Per RN
suggested she talk to MD about
setting up a psych consult.
Evaluation of Short-Term Goal: pt was not discharged by the time I left. Pt stated she would work on
looking up mediation and relaxations techniques.
Past Medical/Surgical History
P1
Relevant Psychosocial Data
Pt lives in a pregnancy center to
help her with the baby.
