NURSING CARE PLAN
Agency/ Area:
Name of Patient: Kadija, 30____________________________
Diagnosis: _______________________________________________________
ASSESSMENT
SUBJECTIVE
 OB SCORE: G9P7
 Full time homemaker, works and runs a
daycare center in her home
 She and her family immigrated to US 5 years
ago. Now lives in a one-bedroom apartment
 LMP: May 28th of this year
 EDD: March 5th of next year
 AOG: 11 weeks’ gestation
 One child “died in childbirth”
 Last delivery was normal vaginal delivery and
labored for 5 hours
 Unaware of baby’s weight, and her family
history
 Had undergone female circumcision as a
child
 She is having nausea and occasional vomiting
 Breast tenderness
 Experienced pink spotting 1 week ago
 Family is deceased except for 1 sibling
 Present Pregnancy is unexpected
 Concerned about transportation to her
appointments because husband works at
days and she does not know how to drive.
_______________________
Rating: ________________
OBJECTIVE
 Well nourished, carefully groomed
 English is her second language but she can
understand some
 Skin is dark tan, smooth, and has a small
scarring on left arm and both legs, she has no
lesions and tattoos
 She has poor dentition, her oral mucosa is
pink, hypertrophy in her gums, her thyroid
glands are small and smooth
 Chest expansion is equal, no effort in
respiration, no presence of lung sounds, and
no CVA tenderness
 HR: 84 bpm, regular rhythm, heart sounds
are normal, with soft blowing systolic
murmur, grade 2/6 at 2nd left interspace
 Breasts are tender, no mass present, she has
large everted nipples. No drainage present.
 No abdominal masses and bowel sound
present in four quadrants, no hepatomegaly
or splenomegaly, uterus is non palpable, no
inguinal lymphadenopathy, no healed
incisions
 No varicosities present in lower extremities,
no edema or redness. She is negative for
Homan’s sign. +1 for Deep tendon reflex.
 BP: 124/76 mmHg
 Female circumcision is present without
scarring
 Bartholin’s, urethra, and skene’s glands are
negative for discharge
 Vagina is pinkish in color, with white, creamy
and non-odorous discharge. The cervix is also
pink, non-friable, closed and approx. 3 cm
long and soft. Vaginal wall muscles are
relaxed. No presence of cystocele or
rectocele
 Uterus size is appropriate for 11 weeks
gestation and it is non-tender. Dextrorotated.
Fetal heart tones are not yet heard by
doppler. Pregnancy is confirmed through
ultrasound.
 Pubic arch is wide; side walls are straight,
spines are blunt , the interspinous diameter is
greater than 12 cm, bituberous diameter is
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 greater than 8 cm, pelvis is spacious,
gynecoid type pelvis = 8 pounds
 Has positive fetal activity
 She is aware of potential language and
cultural issues and already has an interpreter
with her.
 She understands advised prenatal testing,
clinic routine, and warning signs and
symptoms
NURSING DIAGNOSIS
DISCOMFORTS OF PREGNANCY (NORMAL)
 Risk for fluid deficit related to effects or discomforts of pregnancy as evidenced by patient reporting
that she has nausea and occasional vomiting.
 Pain or sensitivity in the breast related to effects or discomforts of pregnancy
ABNORMAL S/SX
 Presence of vaginal discharge as evidenced by patient report of pink spotting one week before the
appointment
OTHER:
 Risk for ineffective childbearing process related to insufficient parental role or support system as
evidenced patient reporting that multiple members of the family are already deceased
 Risk for ineffective childbearing process related to concerns regarding her attendance in her doctor’s
appointments
 Anxiety related to transportation plans regarding her doctor’s appointments

SCIENTIFIC EXPLANATION
NAUSEA AND VOMITING
 Nausea and vomiting is present during the early stages of pregnancy because of the presence of
human chorionic gonadotropin (HCG). HCG is a fetal hormone that is seen as a foreign substance
that is why nausea and vomiting or morning sickness happens.
 After the fertilized egg attaches to the uterine lining that marks the start of production of HCG.
 Normally, morning sickness occurs at around the first months of pregnancy and fades between 14
-20 weeks.
BREAST TENDERNESS
 The pathophysiology for breast tenderness explains that the hormones are preparing the breast for
lactation. The milk ducts are being prepared to grow and produce milk and this causes the breast to
be sensitive.
PINK VAGINAL DISCHARGE
 The pathophysiology of pink vaginal discharge during pregnancy is that the cervix is highly vascular,
so pregnant women bleed easily. Although it may be normal as long as its infrequent. (It may be
implantation bleeding.)
LACK OF SUPPORT
 Pregnant women with poor social support are at higher risk for depression during current and
subsequent pregnancies.
ANXIETY
 Pregnancy can be a very emotional experience.
RISK FOR INEFFECTIVE CHILDBEARING PROCESS
 Kadija may be at risk for not attending appointments because of troubles with her transportation
and it may result to having inconsistent prenatal health visits.
PLANNING
GOAL DESIRED OUTCOME
 My goal is that the patient will verbalize and
acknowledge the normal signs and symptoms
or discomforts of pregnancy by the end of
the appointment.
 Patient will cope and make actions to
manage the said discomforts.

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 NURSING IMPLEMENTATION
INTERVENTIONS RATIONALE
To address nausea and vomiting
1. Educate the patient about the normal events It is important to be knowledgeable about the
or discomforts in pregnancy. discomforts of pregnancy and knowing what to
expect so that the health care team may monitor the
health of the mom and the child.

2. Discuss about the dietary plans of the mom, Some foods trigger their feeling of nausea.
if there are some changes that needed to be
addressed to lessen the symptoms of nausea
and vomiting.

3. Advise the patient to eat small meals It is less likely to have nausea and vomiting if patient
throughout the day and not large meals. does not have a full stomach.

4. Encourage the patient to eat bland foods like
crackers and toast with less salt.
5. Encourage the patient to drink at interval
times a day.
Avoid foods that make you nauseated.
Drinking lots of water will prevent dehydration from
vomiting.

EXPECTED OUTCOME/ EVALUATION

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 The patient will understand and be knowledgeable about the normal signs and symptoms of
pregnancy.
 The patient will have made actions and changes in her dietary/nutritional plans to manage through
the reported discomforts on her last appointment.

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