GOVERNMENT COLLEGE OF NURSING,

JODHPUR(RAJ.)

Nursing Care Plan

On
ANTENATAL MOTHER
Subject-Obstetrics & Gynecology Specialty-I

SUBMITTED TO - SUBMITTED BY-

Mrs. ANNMA SUMON HEMLATA BHANWARIA
NURSING LECTURER M.sc (N) Pre. year
GCON, Jodhpur GCON, Jodhpur
PATIENT PROFILE:
Name of patient :SOHNI DAVI
Husband’s name :RAJKUMAR JI
Age : 35 years
Religion : Hindu
Occupation : House wife
Education : 10th pass
Address : Masuriyaphatak, masuriya, Jodhpur
Duration of marriage : 11years
Ward : ANW
Date of admission : 29/07/19 at 05.00 a.m.
Registration No. : 30195
Obstetrical score : G3
L.M.P. : 01/09/18
E.D.D. : 07/07/19

ADMISSION HISTORY:

On admission complain:
Bright red bleeding

Personal History:
She is vegetarian, non-alcoholic, no smoker, have 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 hereditary and genetically disorder.
Obstetrical History:
Primi gravida
Patient has received three antenatal visits and received both doses of T.T. vaccine.
Score - G3P0A1L1

Previous labour History:

Not any

Menstrual History:
Regular normal flow 3-5 days cycles 26-28 days.
Menstrual cycle is regular of 4-5 days. No intermenstrual bleeding and no coital bleeding.

CONDITION ON ADMISSION;
General examination:
Temp. - 37.6ºC B.P. 120/90 mm of Hg
Pulse - 86/min Hydration - Adequate
Resp. - 22/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.
PHYSICAL EXAMINATION:
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
Anaemia :no
Pallor :no
Heart :NAD
Lungs :NAD

EXAMINATION:

Abdominal and pelvic examination:

On inspection fundal height: below the xyphi-sternum

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
Presentation 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

NEED ASSESSMENT
NEED PROBLEM
Physical need:
Pain r/t physiological changes and episiotomy
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 episiotomy
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
S.No. Nursing Nursing Goal Nursing intervention Nursing implementation Nursing evaluation
diagnosis
1. Pain r/t To reduce the -rest and comfortable positioning. -provide comfortable position –left lateral Pain is reduced to
physiological pain position. some extent.
changes and
episiotomy -hot water fomentation on wound site - Rest is given 8-10 hours in a day.

-encourage sitz bath - Encouraged for sitz bath after second

day.

-encourage administer analgesic as required. - Hot water fomentation is given at wound

site and applied the ointment.

2. Anxiety r/t To reduce the -encourage variety of position -position like- side lying, semi-fowler, Anxiety is reduced.
care of baby anxiety vary position for each feeding is
and breast explained.
feeding
- baby is put on his breast for close - encourage the family member to help in
bonding. baby care.

- family member participation. - explained about reflexes of neonate. e.g.

rooting, suckling reflex.

-explain how neonates’ feeding is differ -adequate rest is provided to mother.

from older infants.

-discuss about the positioning of breast

feeding.

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

-to examine the reflexes of the baby.

-empty the breast with breast pump
-examine the temp., colour and consistency
of breast for breast abscess. -checked the rooting and suckling reflex.

-assess the frequency of breast feeding,

-teach the nipple care –avoid use of soap,
use breast cream.

-instruct to mother minimum 8-10-time

breast feed give in a day.

4. Less nutrition To provide -teach about extra caloric (450cal.) -give the small and frequent diet in form Nutritional
less then body sufficient requirement. of milk, dal, cheese, leafy vegetable and requirement is
requirement nutrition. fruits. fulfilled.

-explain the importance of nutrition in -liquid diet milk and juices intake quantity
infant growth. are increased.

-to increase fluid intake to 2500-3000ml. -calcium and iron are given as supplement
diet.
-advice to take one more cup milk or eat
equivalent amount dairy product.

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

-advice to change diapers before and after

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

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

HEALTH EDUCATION:
For healthy mother and healthy child mother should be able to: -
1. Educate the mother about importance of colostrum’s 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 new born- 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.