NURSING CARE PLAN

ANTENATAL WARD
PATIENTS PROFILE

 IDENTIFICATION DATA:

Client name : Ashu Mishra

Age/sex : 23 year/F

Spouse name : Akhilesh Mishra

Hospital registration number (OPD) : 188620

Ward :- Antenatal Ward

Bed No. (IPD) :- 20056

Address :- Semariya Rewa

Education :- Graduate

Occupation :- House Wife

Marital status :- Married

Religion :- Hindu

Date of admission :- 20/04/2023

Date of discharge : 27/04/2023

Diagnosis :- Primi with 36 wk+6 days pregnancy with

Breech Presentation

Meaning: -Breech presentation refers to the fetus in the longitudinal lie with the buttocks or
lower extremity entering the pelvis first. The three types of breech presentation include frank
breech, complete breech, and incomplete breech.

Definition:- In breech presentation, "The lie is longitudinal and podalic pole presents at the
pelvic brim". or it is the commonest malpresentation.

Surgery (if any) :- No any surgery done.

Date of Surgery :- NAD

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Doctor In-charge :- Dr Sheetal

Chief complaints :- Lower Abdominal Pain

History of present Illness :- Lower abdominal pain

History of present pregnancy :- Primi with 36 week + 6 days pregnacy with

breech presentation.

III trimester :- 3rd trimester

No. Of antenatal visits :- 06

Immunization status :- Mother immunized

Obstetric history :- NAD

Obstetrical score :- G1P0L0A0D0

Health status of baby :- FHS 140 b/m

Immunization :- NA

 Marital history:
 Age of marriage :- 21 year
 Duration of marriage :- 2 year
 Menstrual history:
 Menarche :- 13 year
 Duration :- 4-5 days
 Interval :- 28 days
 Flow :- Moderate
 LMP :- 07/08/2022
 EDD :- 14/05/2022
 Past medical history :- NAD
 Past surgical history :- No any history of any surgery in the past.
 Family history

S.No. Name of family Age/sex Occupation Relation to Health Education

members family status
member
1. Ramnarayan 45 year Bussiness father-in-law Healthy Graduate
Patel
2. Lalita Patel 42 year Housewife Mother-in- Healthy 12 th pass
law

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 3. Ramchandra 25 year Business Husband Healthy Graduate
Family Tree:-

 Personal History:

Dietary habits :- Vegetarian/ non vegetarian.

Addiction :- NAD.

Drug allergy :- No

Socio-economic status :- Good

 Physical Examination
 General Appearance:-

Body build :- Mesomorph body type

Height :- 5'2"
Weight :- 63 kg
Colour of skin :-
 Head:
Shape and size of skull :- Normo cephaly
Scalp :- Clean
Face :- symmetrical features
 Eyes:
Vision :- 6/6
Eye brow and eyelid :- Symmetrical
Eye ball:-
Conjunctiva :- Pinkish

Sclera :- White

Cornea and iris :- Translucent, smooth

Pupil :- Equal in size

Lens :- Transparent

 Ears:

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 External ear :- Normal

Tympanic membrane :- Intact

Hearing problem :- Ecquty

 Nose:

External nares :- Normal

Nostrils :- Clean not inflammation

 Mouth and pharynx:-

Mouth :- Oval shaped cavity

Teeth :- Clean

Tongue :- Dry, light Pinkish

Throat and pharynx :- Not enlarge

 Neck:

Thyroid gland :- Not enlarge

Lymph node :- Not enlarge

Range of motion :- Rotation

 Chest:

Breath sounds :- No abnormalities like wheezing

Lungs :- Relaxed posture normal musculature rate 18b/m

Heart :- S1S2 present

breast :- Symmetrical, enlarged

-On Inspection :- Symmetrical

-On palpation :- Slight tenderness

 ABDOMINAL:

Inspection:

tone of muscles :- Relaxed

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 Linea Nigra :- Present

Striae Gravidarum :- Present

Auscultation:

Bowel Sound :- Present

F.H.R :- 140 b/m

Palpation:

Abdomin Girth :- 98 cm

Fundal height :- 36cm

Fetal-lie :- longitudinal.

presentation :- breech.

position :- RSA.

engagement :- not done.

Other :- No any uterine mass tendemess

Percussion:

 Extremities :-

Upper Extremity :- Symmetrical

Lower Extremity :- Symmetrical

 Back-
 Pelvic approximation :- Appropriate
 Genital and rectum :-

- Per vaginum: any discharge or bleeding membrane status/ colour of

amniotic fluid/odour of discharge station cervical dilatation lochia/
episiotomy scar.

 Vital Signs :-

S.No Date And Time Temperature Pulse Respiration B.P,

1. 20/04/2023 99.2 0F 88 /m 20 /m 126/80 mmof
hg

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  Investigations :-

S.No. Name of Investigation Normal Values Patient Values Remarks

1. Hemoglobin 12.5 - 14.5 gm/dl 10.2 gm/dl
2. Total WBC count 4.5-5.5million/cumm 4.49million/cumm
3. Bilirubin more than 1.2mg/dl 0.7mg/dl
4. Lymphocytes 25-40% 18%
5. Creatinine 0.7mg/dl 0.39mg/dl

 Medications :-

S.No. Drug Class/ Mechanism of Dose & Rou Side Nurses

Name Catego action Frequenc te effects Responsibility
ry y
1. Ibuprofen NSAID Ibuprofen is a type of 500 mg Oral Upset Monitor patients
S medicine called a stomach, vital signs and
non-steroidal anti- nausea, condition.
inflammatory drug vomiting,
(NSAID). It works by headache
reducing hormones ,
that cause pain and diarrhoea
swelling in the body ,
constipati
on,
dizziness
, or
drowsine
ss
2. Pantop proton The mechanism of 40 mg Oral Headach Advise patient
pump action of e nausea, to avoid alcohol and
inhibito pantoprazole is to vomiting foods that may cause
rs inhibit the final step an increase in GI
(PPIs). in gastric acid irritation. Instruct
production. In the patient to report
gastric parietal cell of bothersome or
the stomach, prolonged side
pantoprazole effects, including
covalently binds to headache or GI
the H+/K+ ATP effects

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 pump to inhibit
gastric acid and basal
acid secretion.
3. Mvbc Water As the building oral Constipat Multivitamins are
soluble blocks of a healthy ion, dark used to treat
vitamin body, B vitamins stool, orprevent vitamin
s have a direct impact nausea, deficiency due to
on your energy vomiting. poor diet or certain
levels, brain function, illnesses
and cell metabolism.
Vitamin B
complex helps
prevent
infections and helps
support or promote:
cell health. growth of
red blood cells.
4. Metronida antimic Metronidazole is an 400 mg oral Dizziness, Administer with
zole robials. antibiotic. It works by headache, food or milk prevent
stopping the growth stomach GI irritation
of the bacteria (or upset,
parasites) causing the nausea,
infection. For most vomiting,
infections, you loss
should feel better ofappetit
within a few days. e,
diarrhoea,
constipati
on

Priority needs

1.Need to provide a comfortable position

2.Need to reduce pain

3.Need to improve dressing

4. Needto improve bonding

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5.Need to maintain skin integrity

6. Need to improve nutritional status

7.Need to reduce anxiety

8.Need to provide emotional support

9. Need to improve knowledge regarding infant care

Nursing Diagnosis

1. Acute pain related to uterine contraction.

2. Imbalance nutritional status less than body requirement related to inadequate intake.

3. Anxiety related to unfamiliar environments and lack of birth preparation.

4. Deficient knowledge regarding self-care during pregnancy.

5. Risk for maternal injury related to the delivery of the fetus via breech presentation.

6. Constipation related to decrease peristalsis movement.

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 NURSING CARE PLAN

Theory Assessment Nursing Goals Interventions Rationale Implementation Evaluation

implementati Diagnosis
on
Roy’s SUBJECTIV Acute pain To reduce 1.Provideassessment the For base line Assessment is done After nursing
adaptation E DATA- related to the pain patient & take vital sign & data viral sign T- intervention
theory Patient uterine assess by pain scale. 98.6F,P – 80b/m,R the patient
concept complains of contracrion. – 18b/ m & pain has able to
having pain in 2. Provide comfortable Prevent nerve mild in nature verbalize
The four lower position Such as thigh damage. relief or
modes of abdomen. apposed & provide cool Provided control of
adaptation & calm environment. comfortable pain.
defined in Roy OBJECTIVE position.
Adaptation DATA- 3. Windows and doors are Can prevent Windows and doors
Model are open& air ventilation by viruses and are opened.
physiologic, I observe by fanare provide . other
self-concept, facial pathogen
role function expression. 4.Provide aroma as well as from Windows and doors
and oil massage therapy to spreading are opened.
interdependen extremities. Relief
ce modes. fromanxiety
5.provide medication & depression Provided aroma and
prescribed by Dr such as That help in massage therapy.
Tab.Ibrufen relieve from Provided medicine
pain.

Theory Assessment Nursing Goals Interventions Rationale Implementation Evaluation

9
implementati Diagnosis
on
Henderson's SUBJECTIV lmbalance To 1. Assess the condition of 1. To know 1. Assest the She tell us
theory E DATA - nutritional maintain the would be mother. the mother condition of the Modify food
concept Client told me status less food condition . would be mother by intake. habits
beliefs about that i m not than body intake ensuring eating
nursing taking food requirement habit. 2. To explain the eating habits.
include a properly. related to pattern of food. 2. Divert the 2. To explain take
nurse's OBJECTIVE inadequate mother mind. small and frequient
responsibility DATA - intake. 3. Improve serving 3. To meal.
to provide the I observe by tachniques . increase 3. To serve food in
best care for a food intake of salivation. attractive manner.
patient; clients. 4. Serve balance and High 4. Serve balance
maintaining a fibour rich diet. and High fibour
patient's rich diet.
balance in
health; and
developing
knowledge
and skills in
nursing to
communicate
with
individuals,
families and
societies

Theory Assessment Nursing Goals Interventions Rationale Implementation Evaluation

implementation Diagnosis

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Roy’s SUBJECTIVE Anxiety related To reduce 1. Maintain a 1. Calm 1. Express sakshi
adaptation DATA - to Unfamiliar the anxiety calm and provides confidence in her relaxes a bit
theory Sakshi complaint environments of the confident manner reassurance that ability to give after taking
concept that having and lack of patients when caring for laboris normal birth. with the
anxiety and fear birth sakshi. and that shehas nurse and
The four modes of environments. preparation. the resources slows her
of adaptation within her to breathing
defined in Roy OBJECTIVE 2. Use manage it. sakshi says
Adaptation DATA- I observe therapeutic 2. Clarity 2. Adapt "I feel better
Model are by facial communication identities communication to now. I hope
physiologic, self- expression. when taking with dominant the situation, I can have
concept, role sakshi. conces so that simptying my baby
function and they can be explanations and before you
interdependence properly directions as labor go home."
modes. addressed. intensifies.
3. Determine the 3. Determining
couple's plans for their plan 3. Determine the
birth, and work enhances their couple's plans for
within them as sense of control birth, and work
much as and helps them within them as
possible. have a much as possible.
4. Stay with satisfying birth
sakshi as much experience. 4. Stay with sakshi
as possible 4. A nurse can as much as
during labor. provide possible during
5. Orient sakshi reassurance labor.
to the labour through human 5. Orient sakshi to
room, and contact and can the labour room,
explain produres reduce fear of and explain
and equipment abandonment. produres and
she will 5. Information equipment she will
encounter. reduces fear of encounter.
the unknown.

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Theory Assessment Nursing Goals Interventions Rationale Implementation Evaluation
implementation Diagnosis
Dorothea SUBJECTIVE Deficient To increase 1. Assess the This is done to Assessment is Patient will
Orem’s DATA- knowledge knowledge patient determine if the done. able to
CONCEPT Mother told me regarding about psychological patient needs perform
Self-Care that she is no selfcare during selfcare. health. any counseling activities of
Theory, the goal idea about self pregnancy. and support. daily living
of nursing was to care during 2. Explain the and will be
render the patient pregnancy importance Taking care of able to
capable of OBJECTIVE of the daily the New born Explained the properly care
meeting self-care DATA –I activities can cause importance of the of newborn.
needs, a process observe that including fatigue, daily activities.
that often facial expression. exercise and inadequate rest
includes patient sleep routine periods and self
teaching. Yet, as well as the care.
many factors nutrition Al
influence patient status.
education, 3. Advise the
including age, patient that it
cognitive level, is to take To avoid Adviced the
developmental some time exhaustion. patient regarding
stage, physical for herself care of herself.
limitations, the every day
primary disease like taking
process and warm bath
comorbidities, doing
and sociocultural moderate
factors. exerciseetc. Regular follow
Determine the to bringing the Determined the
patient regular patient to good patient regular
follow up holistic health. follow up.

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Theory Assessment Nursing Goals Interventions Rationale Implementation Evaluation
implementation Diagnosis
Henderson's SUBJECTIVE Constipation To reduce  Assess the To obtain data Assessment is Now all over
theory DATA- related to constipation. general for care. done. care my
concept Mother told me decrease condition of  To taught the patient is
beliefs about that she is peristalsis patient patient about feeling well
nursing include a havinghard stool. movement.  To teach the  Help to early and her
nurse's OBJECTIVE patient increase bowl ambulation constipation
responsibility to DATA –I about early movement. after 10 to 12 is reduced.
provide the best observe that ambulation hrs of
care for a patient; facial expression after 10 to delivery.
maintaining a because is 12 hrs of
patient's balance having caused.  Encouraged
delivery.  Help in stool
in health; and  Encourage softener. the patient
developing the patient about to take
knowledge and about to plenty of
skills in nursing take plenty  To help stool fluids.
to communicate of fluids. softener.Stool  To teach the
with individuals,  To teach the soft patient about
families and patient to take fibre
societies about to rich diet.
take fibre To provided stool
rich diet. softener as
 To provide prescribe by
stool Doctor
softener as
prescribe by
Doctor.

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HEALTHEDUCATION

Diet

• Need extra 300kcal/day from 2nd trimester onwards

• Protein

• Salt

• Iron

• Calcium: 1.5 g daily

• Vit. C, folic acid, Vit. B12

Weight gain: total of 11 kg. 500 g/wk during 2 nd trimester

Rest: to proper rest pregnant lady and do not doing heavy work at last trimester.

Activity & Exercise: normal activity doing in home.

Clothes: to wear loose & comfortable cloths

Coitus Smoking & alcohol: abortion, growth restriction, fetal alcohol syndrome restricted.

Drugs: to take medicine proper time & routine.

Care of breasts: to check the breast engorgement and proper breast care.

Travel: do not travel last trimester.

Warning signals -

• Bleeding p/v at any time in pregnancy

• Headache, blurring vision, epigastric pain & oliguria

• Pedal oedema, severe, not subsiding with rest, or on face & hands

• Decrease/ loss of fetal movements

• Abdominal pain, Urinary tract infection, Clear fluid p/v PROM

Conclusion:-
Antenatal care is an essential aspect of health care delivery for improving pregnancy outcome.
By this service we can detect high risk pregnancies and we can direct them for proper
management

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 BIBLIOGRAPHY-:

 Dutta, DC.(2011).Text Book Of Obstetrics Including Perinatology and Contraception.(7 th

ed), Delhi; New Central Book Agency (P) Ltd. 144.
 Jacob, A.(2012). A Comprehensive Text Book Of Midwifery And Gynecological Nursing. (5
th ed), Bengaluru; Jaypee Brother’s Medical Publishers. 254,486.
 Sira, S. & Magon, S. (2015). Textbook Of Midwifery and Obstetrics, (3 rd ed). Punjab; Lotus
Publishers. 175-179.
 https://www.ncbi.nim.gov>books.

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