Al-Balqa'a applied university

Irbid University collage

Maternal health Nursing/
clinical
Poat-partum Nursing care plan( 10%)

Student name osama MOH tawalbeh Date

Biographical Data:
Name of client: raghad mohammad jamrah
Age: 30 marital status:
Religion:
Ward : Bed number:
Date of admission:
Suggested Diet:
Allergy: food:
Drug:
Others:
Occupation:
Educational level:
Height:
Weight (preconception): kg; during pregnancy: kg

4" stage:

V/S: Temp Resp pulse Bp

Fundal palpation: firm boggy
Contracted: yes NO, fundal height,
After pain
Lochia: rubra serosa Alba
Number of pads changed
Scant light moderate heavy
Bladder emptying
Bowel habit
Breast feeding breastengorgement milk Nipple:
erected inverted flat
Method of delivery: spontaneous vaginal delivery . forceps assisted vaginal delivery.
vacuum assisted vaginal delivery.
C/S
Legs: edema pain redness
hotness Symmetrical Asymmetrical
Newborn assessment:
Reflexes list present or not:

Length wt: chest circumference

Head circumference

V/S: temp pulse Resp Bp

Gestational age

Vit K administration

Skin assessment:
Vernix caseosa strok bite milia Mongolian spot

Head: anterior fontanel shape posterior fontanel shape

Support system:
Husband
family member
friends'
Nurse/Dr
Family history (Family Tree):

Obstetric and Gynecology History:

GTPAL:
Gravida:- Abortion-.:- Term::- preterm:-:-
living children:-

Order Months/years Sex of Weight Weeksgestation Hours Types of Complicationto

Of Baby at Ofdelivery deliver mother or infant
Birth birth
1

5
6

Menstrual history:

o Menarche: frequency: :
o Duration:: average: :
o Last menstrual period (LMP): :
o. Estimated date of delivery (EDD):. :
Activity of daily living:

Activity of daily living Pre-pregnancy During pregnancy

Siceping hours/day
Diet
Elimination pattern (urinary)
Smoking/number of cigarette
Bowel habit
exercise
Medication (over the counter drug)
Medication according to case (if present) name,
dose, route, freg
Using seat belt(as driver, sitting in
'the car)

History since L.MP:

Headache Nausea
Abdominal
pain
Vaginal discharge
Edema
Rubella exposure
Radiation exposure
Use of contraceptives
Type:
Date of last use of contraceptives:
Initial visits (booking):
Reviews of body system:
Breasts:
Masses: nipple discharge: pain BSE
breastfeeding

Gastrointestinal (GI):
Nausea vomitting constipation diarrhea
Dysphagia heart burn hemorrhoid Abdominal pain weight
loss weight gain

Abdomen:
Stria gravidarum lineanigra. fundal height em Fetal
position fetalmovement fetal heart sound

Laboratory test:

Date Test Normal value Results Nursing considerations

Medication:

Name of Drug (5 action Side effect Nsg consideration

right)

Intravenous fluid (IVF):

Type:
Frequency
Amount
Drop/ min
assessment Diagnosis Goal intervention Evaluation(according
to Goal)

Subjective
Data: Pt said”

Objective data: