NURSING CARE PLAN
ON
NORMAL VAGINAL DELIVERY
SUBMITTED TO
Mrs Rajbr kaur
Lecturer OBG
SUBMITTED BY
Rajdawinder kaur
MSC. (N) 1ST YEAR
OBSTETRIC AND GYNAE. (N)
Identification of the patient
1
Name of patient: PARAMJIT KAUR
Husband’s name: gurmeet singh
Age: 24 years
Sex: Female
C.R. No. 267329
Ward: Maternity
D.O.A: 21-04-16
Educational status: Middle
Religion: Majbi Sikh
Language: Punjabi
Occupation: House-wife
Husband’s occupation Labourer
L.M.P: 23-7-15
E.D.O.D: 30-4-16
Address: Musli,Tangra Amritsar.
Diagnose: NVD
D.O.D 28-01-16
2
Chief complaints at the time of admission:
LPV and labour pains X Since 9 hours
History of present illness: patient came to hospital at 6.30 am on 19-11-12 with H/O labour pains and LPV
Chief findings at the time of admission:
B.P. 120/70 mmHg.
Pulse 84/min
Pallor +
P/A 34 weeks
Cephalic
FHS + regular
Uterine contractions +
P/V cervical dilatation 3cm
Cervical effacement 80%
Membranes absent
Station 0
Slight caput present
History of past illness: H/O enteric fever
3
No H/O T.B
No H/O D.M
No H/O STDs
No H/O H.T
Obstetrical history:
G1 P0
Duration of marriage: 1 year.
No. of living children: primigravida
Menstrual history:
Menstrual cycle 28-30 days
Menarche: 17 years.
Duration: 4-5 days
Amount of blood flow: normal
Contraceptive history: No any contraceptive devices used
Immunization his
Patient has undergone TT immunization at 4th month and 5th month of pregnancy.
Trimester history
Ist Trimester
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H/O nausea
No H/o Hyper emesis Gravidarum
No H/o leg cramps with back ache
No H/o x-ray exposure
H/o Constipation
IInd Trimester
No H/o constipation
No H/o Oedema on ankles
H/O good fetal movements
IIIrd Trimester
No H/o oedema
No H/o burning micturation
No H/o polyhydraminios
H/O frequency of micturation
Personal history: Vegetarian, Non Smoker, Non-Alcoholic
Family history: No any family H/O PIH, bronchial asthma, Tuberculosis, diabetes..
5
Family tree: joint family
Father-in-law mother-in-law
(60 years) (58 years)
Brother-in-law husband patient brother-in-law
(30 years) (26 years) (22years) (24 years)
Vital signs:
On 23-04-16 at 8.30 am
Temperature 98oF
Pulse 80/ min
Respiration 22/min
Blood pressure 120/70 mm of hg
6
Lab investigations:
Test Patient Value Normal Valve
Hb 9.4 gm% 12-14gm%
VDRL NR
HIV NR
HBSag NR
HCV NR
Blood group B+ve
BT 3'-5" 1'-6"
CT 5'-2" 3'-10"
RBS 70mg 80-140mg
Treatment received:
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Drug Chemical Dose Route Time Action
constitution
Cap Ampicillin + 500mg orally TDS Antibiotic
Amoxycillin Cloxacillin
Tab Methylergometrine 50 mg orally TDS Ergot
Methargin derivative
Inj Voveron Diclofenac sodium 50 mg IM SOS Analgesic
Short term goal:-
To reduce the anxiety level.
To reduce the pain.
To correct the anaemia.
To maintain the vital signs.
To provide the comfort.
To initiate early breast feeding.
Long term goal:-
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To reduce the puerperal complication.
To maintain the health of the mother.
To educate the mother regarding baby care & feeding.
To educate the mother regarding correction of anaemia.
To educate the mother about postnatal exercise.
To rehabilitate the client as soon as possible.
Nursing diagnosis.
After pain related to child birth trauma & episiotomy..
Altered nutritional status related to poor intake & loss of energy during labour .
Risk for infection related to traumatized tissue
Risk for ineffective parent/infant attachment related to interruption in bonding process
Anxiety related to self care deficit & baby care.
Ineffective breast feeding related to poor knowledge regarding early initiation
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NURSING
CARE PLAN
10
Sr. Nursing Nursing Expected Nursing
Nursing Planning Implementation Rationale
No. Assessment Diagnosis Outcome Evaluation
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1. Subjective After pain To relieve To assess the Assessed the For pain Pain is reduced
data: Client related to child pain. intensity of level of pain. relieving. at some extent.
says ,”I am birth trauma & pain.
suffering with uterine
To explain the
pain” . contraction. Explained the
cause of pain.
client it’s a
Objective
normal process
data: Client is
to involute the
placing the
uterus.
hand on lower
To provide
abdomen Provided tab.
analgesic.
repeatedly. Diclofenac
Provide
Provided
measures to
comfortable
relieve pain
position & calm
like
environment.
comfortable
position &
calm
environment.
Measured
Measured
involution of
involution of
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uterus. uterus.
Subjective
2. data:client To For Client looks
Altered
maintain Monitor vitals Monitored vitals maintain energetic &
says,”I am
nutritional nutritional of the client. of the client. the motivated about
feeling
status related status. nutritional health advises.
nauseated & Provide a glass Provided a glass status
to less intake
ghabrahat”. of milk & 2 of hot milk & 2
during labour.
pieces of pieces of bread.
Objective data:
breads.
Client looks
lethargic & Advise plenty
Advised plenty
restless. of liquids &
of liquids &
roughage to
roughage diet
prevent
constipation &
maintain
hydration.
Advise the
sources of high Advised the
protein , sources of high
calcium & iron protein, calcium
diet to
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maintain the & iron diet.
health status &
lactatation of
the mother.
Advise
elemental
Advised
iron(Govt
elemental iron
supply)
for 3 months.
100mg for 3
months.
To Advise one Improved
motivate litre of milk lactation at some
3. Subjective
the mother Advised one litre extent.
Data:- per day to For
Ineffective for breast of milk & its
Client says , “ I feeding. improve improving
breast feeding benefits.
am not able to lactation so the
feed the baby”. lactation &
that exclusive
Objective breast feeding breast
Data:- feeding.
can be ensure.
Client is not Provided a menu plan
able to put the Provide a
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baby on breast. menu plan of the client.
the postnatal
diet to the
mother.
Encourage the Encouraged the client to
woman to Verbalized the feeling.
discuss her
feelings
regarding
breast feeding.
Demonstrate
the woman the Demonstated the
different different method of
position of breast feeding.
breast feeding.
Advised her to
do so
frequently for
early initiation.
Teach the
woman for Taught the client
exclusive
15
breast feeding for exclusive
for 6 months. breast feeding
for 6 months
16
-
17
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HEALTH EDUCATION.
1. Encourage patient to take well balanced diet.
2. Encourage patient to take roughage diet to prevent constipation.
3. Ask mother to take milk and fruit juice in large amount for more production of
breast milk.
4. Advise mother to put the baby on breast as early as possible.
5. Advise mother about family planning methods for adequate spacing between
two children.
6. Advise patient to report if any sign of infection arises.
7. Educate patient about follow up care.
8. Educate mother about proper rest.
9. Educate mother about neonatal care.
CARE OF NEW BORN
Educate mother about breast feeding.
Educate mother to keep the baby warm.
Educate her to wash her hand before touching the baby.
Educate her about immunization
Educate regarding KMC
FOLLOW UP CARE
Advise women about follow up after a week or earlier if any problem arises
Educate her to get the full immunization of the baby as scheduled.
References
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Dutta D.C,”Textbook of obstetrics including perinatology and contraception”,
6th edition, published by new central book agency. Pp 588-589
Fraser M Diane and Margret A cooper’s, “textbook of midwifery”,14 th edition,
published by Churchill livingstone, Pp 581-590.
Lippincott’s,”Nursing Management-Clinical practice”, published by Williams
and wilikins, Pp 1298-1300.
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