CARE PLAN

S. SUBJECTIVE OBJECTIVE NURSING GOAL PLAN OF IMPLEMENTATI RATIONALE EVALUA

NO. DATA DATA DIAGNOSIS ACTION ON TION
1. The client The client is Anxiety To  Assess the  To Assessed  For baseline Anxiety
complaints anxious about related to reduce general the general information. reduced to
about 3 days the post term post term the condition of condition of  To improve some
post term pregnancy pregnancy level the patient the patient the extent
and its of  Assess the  Assessed the psychology
termination anxiety level of level of of the
anxiety. anxiety client.
 Provide the  Provided  To prevent
psychological psychological fetal
support. support. jeopardy.
 Advice to 
undergo  Advised to
termination undergo
through termination
Cesarean of pregnancy.
Section.
 Advice  Advised
adequate rest adequate rest
and sleep. and sleep.
2. Client has pain The client has Discomfort To  Assess the  Assessed the  For baseline Pain is
in the Cesarean pain in the related to reduce level of pain. level of pain. information. reduced
Section site lower pain in lower pain  Provide  Provided  To facilitate
abdomen and abdomen and comfortable comfortable better
back back position left position left circulation
following following lateral lateral and thus
Cesarean Cesarean position. position. healing.
Section delivery  Massage the  Massaged the  To relieve
 back. back. pain.
 Provide  Provided  To promote
diversional diversional comfort.
therapy. therapy.  To reduce
 Administer  Administered pain.
analgesic analgesic
.according according
physician physician
order order
3. Fever and Patient has Fever related To  Assess the  Assessed the  For baseline After care
feeling of chills 101.4 to operative bring body body information. & and
temperature conditions the temperature. temperature.  To reduce treatment
and chills body  Provide sips Provided sips body my patient
temper of water. of water. temperature condiation
ature  Provide  Provided . is good
within warm warm  To relieve maintain
normal blankets. blankets. rigor. body
limits  Administer  Administered  To bring the temperatur
antipyretics. antipyretics. body e.
temperature
to the
normal
limits.
4. Lochial Patient has Risk for To  Assess the  Assessed the  For baseline Risk for
discharge discharge and perineal reduce lochia lochia information. perineal
unable to infections the discharge. discharge.  For infections
maintain related to risk of  Provide  Provided anesthetic reduced to
perineal lochia perinea perineal perineal effects. some
hygiene discharge and l wash. wash.  To reduce extent
improper infecti  Change pad 4  Changed pad the risk of
perineal ons hourly. every 4 infections.
hygiene  Clean hours.
properly  Cleaned
 after every properly.
act of
micturition
and
defecation.
 Administer  Administered
antibiotics. Antibiotics
according to
physician order
5. Patient Patient is Knowledge To  Assess the  Assessed the  For baseline Knowledg
verbalizes her having deficit related improv level of level of information. e level is
difficulty in knowledge to breast e the knowledge of knowledge of  To feed the improved
feeding the deficit feeding and level the client. the patient. baby to some
baby and about regarding self care of  Teach the  Taught the properly. extent
self-care breast feeding knowle techniques of techniques of  To keep the
dge breast breast breast
feeding. feeding. hygienically
 Teach the  Taught about and healthy.
methods the methods  To improve
about the of breast the level of
breast care. care. knowledge.
 Explain the  Explained the
importance importance
of self care of self care.
 DIET CARE

S. DIET FOR
NO. THE DAY TIME MENU QUATITY CARBO PROTEIN FATS CALORIE

1. Early 7:30 am Tea 1 cup 20 gms 22 gms 15 gms 52

Morning biscuit/ toast 2-3 Nos. 07 gms 10 gms 10 gms 25
2. Breakfast 09:00 am Paratha/ Bread with 02 Nos. 100gms 12 gms 25 gms 297
Butter 59
Apple 01 whole 100 gms - - 160
Juice 01 glass 200 gms 25 gms 12 gms
3. Lunch 01:00 pm Rice 01 bowl 100 gms 15 gms 10 gms 111
Chapatti 03 Nos. 70 gms 10 gms 05 gms 170
Daal 01 small bowl 27 gms 70 gms 35 gms 100
Sabji/ curry 01 small bowl 130 gms 35 gms 38 gms 134
Salad 01 large bowl 100 gms 18 gms 05 gms 148
4. Evening 05:00 pm Tea 01 cup 20 gms 22 gms 15 gms 52
Biscuit 02 Nos. 07 gms 10 gms 10 gms 25
5. Dinner 08:30 pm Rice 01 bowl 100 gms 15 gms 10 gms 111
Chapatti 03 Nos. 70 gms 10 gms 05 gms 170
Daal 01 small bowl 27 gms 70 gms 35 gms 100
Sabji/ curry 01 small bowl 130 gms 35 gms 38 gms 134
Salad 01 large bowl 100 gms 18 gms 05 gms 148
6. Late Night 10:00 pm Milk 01 glass 25 gms 75 gms 32 gms 117