NURSING CARE PLAN

PATIENT PROFILE:

Name of patient : Anita

Husband’s name : Mukesh

Age : 23 years

Religion : Hindu

Occupation : House wife

Education : 12th

Address : Gumanpura ,kota

Duration of marriage : 3 years

Ward : post natal ward

Registration No. : 32687

Obstetrical score : G1(primi)

ADMISSION HISTORY:

On admission complain :

Amenorrhoea since 9monhs. Labor pain.

Persona History:

She is vegetarian, non alcoholic, no smoker, no drug allergy.

Medical History:

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

Surgical History:

No H/o any type of surgery.

Family History:

No history of herediterical 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.

II. CONDITION ON ADMISSION;

General examination:

Temp. - 37.6ºC B.P. 120/90 mm of Hg

Pulse - 86/min Hydration - Adequate

Resp. - 21/min Oedema – nil

Anaemia- No Heart – NAD

Lungs - NAD Liver – NAD

Abdominal and pelvic examination:

By palpitation :
Fundal height : 36cm. by fundal grip

Position of fetus : LOA by lateral grip

Presentation of fetus : vertex by pelvic grip

Relation of head with pelvic : head is engaged 2/5

By auscultation

F.H.S. 140/min

Vaginal examination:

Dilatation of Cervix : 6cm.

Effacement of Cx : 75%

Membrane : intact
 Moulding :+

Investigation and special observation:

Hb : 10.5gm%

ABORh : B+ve

Blood sugar : 86gm/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 Mch on
14-11-2021 at 2.00 p.m. placenta and membrane complete and intact delivered.
Episiotomy is repaired in back stitches. Tab. Mesoprost 600µg inserted into
rectum.

Baby notes :

Wt. of 3.0 kg, baby delivered vertex. Cry after suctioning of mouth

skin colour – body is pink and palm is blue,

posture – flexed

grimminces – present

NEED ASSESSMENT

NEED PROBLEM

Physical need

1. Risk of infection r/t postpartal

sepsis.

2. insufficient feeding r/f brest

problems

3. less nutrition than body

reqirement.

4. Knowledge deficit lack of

exposure.

5. pain r/t delivery process.

psychological need 1. anxiety r/t post partum

management.

NURISING CARE PLAN

Main objective :- To bring back the physiological and psychological health of

pre pregnant state.

Contributory objectives: -

1. To reduce the pain in post natal period.

2. To maintain the personal hygiene of woman.

3. To explain about the postnatal exercises.

4. To provide the proper nutritional diet.

5. To reduce the maternal and infant morbidity and mortality

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

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

- Hot water
fomentation is given
at wound site and
applied the ointment.

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

-adequate rest is provided to

mother.

3. Insufficient To provide -to assess the breast feeding . -explain exercise of Breast
breast feeding effective breast retracted nipple. feeding will
-to examine the breast for
r/t breast feeding. be
retracted nipple, breast -prepare a breast pump of
problems effectively.
engorgement and breast abscess. syringe.

-to examine the reflexes of the -empty the breast with

baby. breast pump

-examine the temp., colour and -checked the rooting and

consistency of breast for breast suckling reflex.
abscess.
-teach the nipple care –
 -assess the frequency of breast avoid use of soap, use breast
feeding, cream.

-instruct to mother
minimum 8-10 time breast
feed give in a day.

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

5. Knowledge Her family will -assist parents to meet infant’s -infant is rooming-in. Infant care
deficit r/t lack of accept and basic physical needs: is accepted
-infant holding of head and
exposure. incorporate by family.
-encourage rooming in. back support is
infant into
demonstrated.
family. -holding demonstrate techniques
(football, cradle upright hold) and -avoided the tub bath until
provision of head and back
 support. chord stump is off.

-discuss avoiding of tub bath until -avoided the wet wiper.

umbilical stump is off.
-separately washing infant
-advice to change diapers before cloth and linen in practice.
and after feeding .
-to wear appropriate cloths
-encourage washing infant cloth to infant in winter 3-4
and linen separately. layers and in summer 1-
2layers .
-explain that infants neither shiver
nor perspire, dress appropriately
for external environmental
temperature.

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

7. Hypothermia r/t Protect from -rooming– in. -skin to skin contact Baby is
immature protected
 thermoregulatio hypothermia -keep dry and warm baby. maintained with mother. from
n centre. hypothermia
-do not wet the baby. -wet diaper changed
.
frequently.
-maintain room temperature.
-baby head is covered with
-proper cover with cloths.
cap and 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 Protect from -maintain personal hygiene. -use of neat and clean cloths Risk of
r/t poor infection. for child. infection is
-breast feeding regularly.
developed minimised.
-change wet and soiled
primary -assess changes in vital signs.
diaper frequently.
defences.
-use universal precaution for
-wash hands pre and post
prevention of infection.
feeding,
HEALTH EDUCATION:

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

1. Educate the mother about importance of colstrum 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.