POSTNATAL CARE PLAN

FOR

POST-NATAL MOTHER

PATIENT PROFILE:

Name of patient : Bhawari devi

Husband’s name : Jagdish

Age : 28 years
Religion : Hindu

Occupation : House wife

Education : 12th

Address : Katosar , Ossia, Jodhpur

Duration of marriage : 3 years

Ward : post natal ward

Date of admission : 26/6/19 at 05.00 a.m.

Registration No. : 30195

Obstetrical score : G1(primi)

L.M.P. : 21/9/18

E.D.D. : 28/6/19

Date of delivery : 27/6/19

ADMISSION HISTORY:

1. On admission complain :

Amenorrhoea since 9 monhs. Labor pain since morning.

Personal History:
 She is vegetarian, non alcoholic, no smoker, have no drug allergy.

Medical History:

No H/o HTN,D.M. and lungs diseases.

Surgical History:

No H/o any type of surgery.

Family History:

No history of hereditary and genetically disorder.

Obstetrical History:

Primi gravida

Patient has received three antenatal visits and received both doses of T.T. vaccine.

Previous labor History:

Primi gravida

Menstrual History: Regular normal flow 3-5 days cycles 26-28 days

2. CONDITION ON ADMISSION;

General examination:

Temp. - 37.6ºC B.P. 120/90 mm of Hg

Pulse - 86/min Hydration - Adequate

 Resp. - 22 b/min Oedema – nil

Anaemia- No Heart – NAD

Lungs - NAD Liver – NAD

Personal history:

Patient is vegetarian. No history of drug allergy or drug addiction. Absence of any type of substances abuse like smoking, drug and alcohol
etc.

Functional history:

Sleep pattern, appetite, bladder and bowel functions are normal.

Contraceptive history:

Use of oral contraceptive.

Past obstetrical history:G1P0A0L0

3. ASSESSMENT OF PATIENT ON ADDMISSION:

General:-

Body built: moderate

Weight: 65 kg.

Vital signs (at the time of admission)

Temperature: 37.4degree C
 Pulse: 78/ min.

Respiration: 22/min.

B.P: 120/80 mm of Hg.

Hydration: Adequate

Anemia: no

Pallor: no

Heart: NAD

Lungs: NAD

4. EXAMINATION:

Abdominal and pelvic examination:

On inspection fundal height: below the xyphisternum

By palpitation through GRIP :

Fundal height : 36cm. by fundal grip

Lateral Grip : in left lateral Grip felt like a continuous hard, flat surface and irregular small knobs opposite side.

Pelvic Grip : hard round part felt it means presenting part is head and station is 3/5.

Pawlik’s Grip : head is fixed

Uterine contraction : 4 contraction/ 10 min , duration > 30 second

Position of fetus : LOA by lateral grip

Presentation of fetus : vertex by pelvic grip

Relation of head with pelvic : head is engaged 3/5

On auscultation

: F.H.S 140/ min.

Vaginal examination:

Vulva : normal

Vagina : normal

Dilatation of Cervix : 4cm.

Effacement of Cx : 80%

Membrane : intact

Presentating part : head

Moulding : ++

Pelvis : adequate

Investigation and special observation:

Hb : 10.6gm%

Blood group : B+ve

Blood sugar : 110gm/dl

 Urine sugar :Nil

Albumin :Nil

HBAsg : non reactive

Delivery notes:

Type of delivery: FTND

Under all aseptic condition patient normally vaginal delivered an alive Fch on 27/6/19 at 11a.m. placenta and membrane complete and intact
delivered. Episiotomy is repaired in back stitches.

Baby notes :

Wt. of 2.8 kg, baby delivered vertex. Cry after suctioning of mouth

skin colour – body is pink and palm is blue,

posture – flexed.

NEED ASSESSMENT

NEED PROBLEM

Physical need :

 Pain r/t physiological changes and epsiotomy

  Anxiety r/t care of baby and breast feeding
 Insufficient breast feeding r/t breast problems
 Less nutrition then body requirement
 Knowledge deficit r/t lack of exposure.

psychological need

1. Anxiety r/t post partum management.

2. Family coping.

NURISING CARE PLAN

Main objective :- To bring back the physiological and psychological health of pre pregnant state.

Contributory objectives: -
 i. Pain r/t physiological changes and epsiotomy
ii. Anxiety r/t care of baby and breast feeding
iii. Insufficient breast feeding r/t breast problems
iv. Less nutrition then body requirement
v. Knowledge deficit r/t lack of exposure.
vi. Risk of infection r/t inadequate primary defences and invasive procedure

NURSING CARE PLAN

S.n. Nursing diagnosis Nursing objective Nursing intervention Nursing implimention Nursing
evaluation

1. Pain r/t physiological To reduce the pain -rest and comfortable positioning. - provide comfortable position – Pain is reduced
 changes and left lateral position. some extent.
epsiotomy
-hot water fomentation on wound site - Rest is given 8-10 hours in a
day.
-encourage sitz bath
- Encouraged for sitz bath after
-encourage administer analgesic as reqired.
second day.

- Hot water fomentation is given

at wound site and applied the
ointment.

2. Anxiety r/t care of To reduce the -encourage variety of position -position like- side lying, semi-fowler, Anxiety is
baby and breast anxiety vary position for each feeding is reduced.
feeding - baby is put on his breast for close bonding. explained.
- family member participation . - encourage the family member to help
-explain how neonates feeding is differ from in baby care.
older infants. - explained about reflexes of neonate.
-discuss about the positioning of breast e.g. rooting, suckling reflex.
feeding. -adequate rest is provided to mother.

3. Insufficient breast To provide effective -to assess the breast feeding . -explain exercise of retracted nipple. Breast feeding
feeding r/t breast breast feeding. will be
problems -to examine the breast for retracted nipple, -prepare a breast pump of syringe. effectively.
breast engorgement and breast abscess.
-empty the breast with breast pump
-to examine the reflexes of the baby.
-checked the rooting and suckling
 -examine the temp., colour and consistency of reflex.
breast for breast abscess.
-teach the nipple care –avoid use of
-assess the frequency of breast feeding, soap, use breast cream.

-instruct to mother minimum 8-10

time breast feed give in a day.

4. Less nutrition then To provide sufficient -teach about extra caloric (450cal.) -give the small and frequent diet in Nutritional
body requirement nutrition. requirement. form of milk, dal, cheese, leafy requirement is
vegetable and fruits. fulfilled.
-explain the importance of nutrition in infant
growth. -liquid diet milk and juices intake
quantity is increased.
-to increase fluid intake to 2500-3000ml.
-calcium and iron is given as
-advice to take one more cup milk or eat supplement diet.
equivalent amount dairy product.

5. Knowledge deficit r/t Her family will -assist parents to meet infant’s basic physical -infant is rooming-in. Infant care is
lack of exposure. accept and needs: accepted by
incorporate infant -infant holding of head and back family.
into family. -encourage rooming in. support is demonstrated.

-holding demonstrate techniques (football, -avoided the tub bath until chord
cradle upright hold) and provision of head and stump is off.
 back support. -avoided the wet wiper.

-discuss avoiding of tub bath until umbilical -separately washing infant cloth and
stump is off. linen in practice.

-advice to change diapers before and after -to wear appropriate cloths to infant
feeding . in winter 3-4 layers and in summer 1-
2layers .
-encourage washing infant cloth and linen
separately.

-explain that infants neither shiver nor

perspire, dress appropriately for external
environmental temperature.

6. Risk of infection r/t Protect from -assess the temperature every 4 hourl y first -temperature is taken with in normal Protected from
inadequate primary infection. day then 6 hrly. limit. infection.
defences and invasive
procedure -assess odour of lochia. -lochia colour is light red and no
odour.
- inspect episiotomy every 8 hourly
-maintained perineal hygiene with
-teach about perineal hygiene. antiseptic solution after every void.

Baby care

7. Hypothermia r/t Protect from -rooming– in. -skin to skin contact maintained with Baby is
immature hypothermia mother. protected from
thermoregulation -keep dry and warm baby. hypothermia.
centre. -wet diaper changed frequently.
-do not wet the baby.
-baby head is covered with cap and
-maintain room temperature.
 -proper cover with cloths. hand and feet covered shocks.

-baby whole body covered with 3-4

layers of cloths.

-room temperature maintained b/w 28-

30ºC.

8. Risk of infection r/t Protect from -maintain personal hygiene. -use of neat and clean cloths for child. Risk of
poor developed infection. infection is
primary defences. -breast feeding regularly. -change wet and soiled diaper minimised.
frequently.
-assess changes in vital signs.
-wash hands pre and post feeding,
-use universal precaution for prevention of
infection.
HEALTH EDUCATION:

For healthy mother and healthy child mother should be able to:-

1. Educate the mother about importance of colostrum feeding and exclusive breast feeding up to 4-6 moths.

2. Keep the baby clean, dry and warm to avoiding the hypothermia.

3. Educate the mother about rest and sleep to promote psychological support.

4. Explain about the requirement of the additional food supplement and fluid to ensure adequate breast milk.

5. Explain about the danger signs –excessive bleeding, fever, pain abdomen and headache. Danger signs of newborn- child have
fever, child is not suckling well, and the child has difficulty in breathing. If any symptom occurs then come soon to hospital.

6. Regular antenatal visit for evaluation of health of mother and growth –development of infant.

7. Educate the mother to adopt appropriate family planning methods.

8. Explain about the appropriate position of baby at the time of breast feeding.

9. Educate the mother about importance of personal hygiene.

10. Educate the mother about importance of immunisation of baby.