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ANTENATAL CAREPLAN

Introduction:

Myself Sujit Kr. Nath, M. Sc Nursing 1 st Year student Tripura Institute of Paramedical Science. I
was posted in IGM Hospital, antenatal wand. Here I got a patient who is suffering from
weakness, anorexia, palpitation, pallor, tiredness. I have taken this case for my care plan.

HISTORY COLLECTION

DATA COLLECTION—

Name of the mother:- Purnima Shil

Age of the mother :- 18 yrs

Obstetrical score :- PGR

Antenatal diagnosis :-Anemia in pregnancy

Last menstrual period :- 08\09\23

Expected date of delivery :- 15\06\24

Date of admission :- 08\06\24

Gestational age (as on date of admission) :- 38 weeks

Name of the husband :- Sanjoy Shil

Age of the husband :-28 Yrs

Language spoken :- Bengali

Religion:- Hindu
Address :- Kalamcherra, Sepahijala
SOCIO ECONOMIC HISTORY—
Head of the family: Her husband

Income: Rs. 20,000/month.

House type: Pucca

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Water supply: Tap water

Electricity: Available

Ventilation: Available, cross ventilation is present

Sanitation: Sanitary latrine is present.

Drainage system: Open drainage system is present

FAMILY HISTORY—
Type of Family - Joint family.
No of family member- 5
History of consanguineous marriage-Absent
History of hereditary illness- Absent

Family composition: -
SL NAME AGE RELATIONSHIP EDUCATION OCCUPATION HEALTH
N AND WITH PATIENT STATUS
O SEX
1 Paresh 71 yrs. Father-in-law V Passed Barber Healthy
Shil (M)
2 Basanti 58 yrs. Mother -in-law V passed House Wife Healthy
Chanda (F)
3 Sanjoy 28 yrs. Husband IX passed Barbar Healthy
Shil (M)
4. Purnima 18 yrs. Patient IX Passed House wife Un
Shil (F) healthy
5. Pradip 22 yrs. Brother-in-law College Student Healthy
Shil (M) student
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FAMILY TREE-

Lt Binod Shil Lt Bimala Shil (Grand Mother)

(Grand Father)

IN

Paresh Shil (Father-in-law) Basanti Chanda (Mother-in law)

Sanjoy Shil, 28 Yrs. Purnima Shil,18 Yrs. (Patient)

(Husband)
Family key

=Male (Expired)

=Female (Expired)

= Male

=Female (Patient)

= Female
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FPERSONAL HISTORY—
Nutrition-She is non vegetarian; she takes 3 times meals. she also takes fruits juice.
Education- Her educational qualification is IX passed
Rest and sleep-6-7 hours per day
Activity-She do some home activity
Habits and hobbies-she like watch to TV in free time
Hygiene-She maintain her personal hygiene
Menstrual history-
Age of menarche-12 yrs.
Duration-4 to 5 days
Flow-Normal
Lmp-08\09\23
Marital history-
Married-1 Year ago
Relationship with husband-Good
Consanguineous marriage-Absent
Contraception history- she did not use any contraceptive device
Drug history- she not takes any drug or medicine in before pregnancy
Sexual history- Her sexual life is normal
Elimination history- she passed urine 5-6 times per day
She passed stool 1-2 times per day
PAST MEDICAL HISTORY-
There is no significant of any past medical history except of common cold and cough.

SURGICAL HISTORY—

There is no significant of any past surgical history

PRESENT MEDICAL HISTORY

Patient was admitted in IGM Hospital with complain of pain in lower abdomen, headache,
weakness, dehydration, sleeplessness

PRESENT SURGICAL HISTORY=Nill

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PAST OBSTETRICAL HISTORY

SI MOTHER CHILD
NO
YEAR GRAV PERIN FULL ABOR MODE REMA SEX ALI STIL WEIG REMA
IDA ATAL TERM TION OF RKS OF VE BOR HT RKS
PERIO DELIV BABY N
D ERY

MOT HER IS PRIMI GRA VIDA

PRESENT OBSTETRICAL HISTORY:

LMP:08\09\23
EDD:15\06\24
Current gestational age (with date):38 weeks (08\06\24)
1st trimester-
In 1st trimester she feels very weakness, restlessness. She has confirmed her pregnancy at 6
weeks by urine test and she takes 1st does of T.T injection.
2nd trimester-
Inj. TT 2nd dose taken in 2nd trimester after one month interval of 1 st dose. In 2nd trimester she
feels quickening at the 18th week of gestation and she take iron and folic acid and calcium tablet.
3rd trimester-
In 3rd trimester she suffering pain in lower abdomen, weakness, restlessness sleeplessness.
PHYSICAL EXAMINATION—
VITAL SIGNS-
Temperature – 98.6 f
Pulse - 88 b\m
Respiration - 20 b\m
B.P - 90\60 mm of hg
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ANTHROPOMETRIC MEASUREMENTS—
Weight -58 kg
Height -152 cm
GENERAL HEAD TO FOOT EXAMINATION—
General appearance-
Body Built - Thin
Activity – Dull
Posture-Normal
Pallor- Present
Consciousness - Patient is Conscious
Skin:
Colour-Patient skin colour is pallor.
Texture-Skin texture is dry.
Edema- Edema is absent.
Head:
Hair-Hair colour is black, equally distributed
Scalp-Scalp is clear, dandruff absent.
Face
Anxiousness is present
Eyes
Eye brows-symmetrical
Eye lids- Eye lids is normal,
Eye lashes - Eye lashes is equally distributed
Eye balls- Eye balls is movable
Sclera-Sclera is normal whitish colour
Conjunctiva -conjunctiva is slight white
Pupils - Pupils is react with light
Vision-Normal•
Nose
Nasal Septum- Not deviated
Nostril- Nostril is normal.
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EARS
External Ear - External car is normal absent of any discharge.
Gross hearing- Gross hearing normal
Pinna - Pinna is symmetrical.
Discharge - Discharge absent.
MOUTH
Lips- Lips are dry.
Gums-Gums are normal and gingivitis absent
Teeth-Teeth are whitish and equally distributed
Tongue - Tongue are normal but slight white in colour
Throat - Throat are normal.
Neck:
Range of motion-Ronge of motion normal
Thyroid gland-Thyroid gland are not enlarged
Lymph nodes - Lymph nodes are not enlarged
Chest:
Inspection
Shape-chest shape is normal.
Symmetry of expansion Respiration rate - 20b / m –
Breast - Primary and secondary areola present Montgomery tubercles are also present, nipples
are erected.
Palpation-Absence of any abnormal mass
Auscultation-S1andS2 sound are present
Abdomen:
Inspection:-
Size-Normal
Shape-cylindrical shape
Linea nigra-present
Striae gravidrum - Present
Umbilicus - Protruded.
Scar marks-Absent.
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Palpation:
Abdominal girth-82 com
Fundal height-34 cm
Fundal palpation-Broad irregular mass I felt, suggest as buttock of fetus.
Lateral Palpation:
Left Side-Smooth and continuous resistant is feel suggest as back of fetus.
Right Side-Knob like Structure are present Suggest as limbs.
Pelvic Grip- The fetal head is not engaged
Pawlick grip: In the Pawlick grip smooth hand felt, Suggest of fetal head is present in the lower
part of uterus.
Auscultation:
Fetal Heart Sound-146 b/min
Finding of the abdominal Examination
Lie-Longitudinal
Presentation-Cephalic presentation.
Attitude-flexion
Position - LOA
Denominaton-occiput
Extremities:
Upper:
Capillary refill - Normal.
Numbness- Absent.
Range of motion-Performed, but dull.
Nails: Nails are clean and short.
Lower:
Range of motion-very dull
Edema-Absent.
varicosity-Absent.
Homan's sign-pain absent.
Back:
Curves- Absent, Lordosis on kyphosis are absent
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Genito urinary system:

Discharge- Absent
Bleeding -Absent
Vulva- Normal

MEDICAL MANAGEMENT

PHARMACO TRADE DOSE ROUTE FREQ MODE OF SIDE EFF NURSES

LOGY NAME U ACTION ECT RESPONS
CAL NAME ENCY IBILITY
Folic Acid Tab Folvite 5 mg Orally OD Active Constipation .Check the
reduced form Swelling doctors
of folic acid Hypersensitivit order
required for y .Follow the
nucleons 16 rights
protein .If any
synthesis and complication
maintenance Occur than
of normal immediately
erythropoiesis Consult
doctor
Iron Sucrose Inj. Orofer 200m IV with OD Elevated the Nausea Check the
g 100ml serum iron Vomiting doctor’s
NS concentration Constipation order.
and is then Follow the
converted to 16 rights. If
hemoglobin any
or trapped in complication
the reticulo Occur than
endothelial immediately
cells for Consult
storage and doctor
eventual
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conversion to
usable form
of iron.
Ferrous Tab.Ferrous 60 mg orally OD Elevates the Headache Check the
sulfate sulfate serum iron Dizziness doctors
concentration Chest pain order.
and then Follow the
converted to 16 rights.
hemoglobin If any
and eventual complication
conversion to Occur than
a usable from immediately
of iron. Consult
doctor
Pantoprazole Inj Pantop 40mg IV OD Proton pump Head ache Check the
inhibitor Dizziness doctors
which Chest pain order
suppresses .Follow the
gastric 16 rights
secretion .If any
complication
Occur than
immediately
Consult with
doctor

Blood Whole 1 unit IV 1 unit Increase the Allergic Cross match

transfusion blood daily hemoglobin reaction, before
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level. Fever, chills. infused.

Check
expiry date,
monitor vital
sign, If any
complication
Occur than
immediately
Consult with
doctor.

INVESTIGATION-
Date Investigation Mothers value Normal Value Remarks
BLOOD
19/11/23 HB 8.2 gm/dl 12-13 gm\dl Decreased
19/11/23 BLOOD GROUP B (+VE)
4/3/23 RBS 85 mg\dl 80-110 mg\dl Normal
4/11/23 HIV/HBSAG Negative Normal
URINE
4/11/23 Albumin & Sugar Absent Absent Normal
4/11/23 Blood urea 18mg\dl 10-45 mg \dl Normal
10/5/23 Serum sodium 140mg\dl 135-145mg\dl Normal
10/5/23 Serum potassium 10mg\dl 8-11mg\dl Normal
10/5/23 Creatinine 1mg\dl 0.5-1.4 mg\dl Normal

NURSING MANAGEMENT
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ASSESSMENT
1.Assess the patient pain level
2.Assess the nutrition level of the patient
3.Assess the activity level of the patient
4.Assess the breathing pattern of the patient
5.Assess the knowledge level of the patient

NURSING DIAGNOSIS
1.Actue pain related to progress of labour as evidenced by patient’s verbalization
2.In effective breathing pattern related to decrease 02 supply heart and lungs as evidenced by
restlessness.
3.impaired tissue perfusion related to interruption of arterial or venous flow as evidenced by
cyanosis.
4.Impaired nutrition level less than body requirement related to in adequate intake of essential
nutrition as evidenced by weakness.
5.Knowledge deficit related to the cause sign and symptoms and treatment process as evidenced
by asking frequent question.
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Nursing care plan

ASSESS NURSING GOAL PLANNING RATIONAL IMPLEMEN EVALU

MENT DIAGNOSIS TATION ATION
Subjective Acute pain To -Assess the -To know the -Assessed the Patients
Data related to reduce pain level. baseline data. pain level. pain level
Patient disease the -Provide -To minimize -Provided is reduced
says that condition as pain comfortable the pain level. comfortable in some
“I am evidenced by level. position. -To divert the position. extent.
having patients -Provide main from -provided
pain in verbalization. diversional pain. diversional
lower therapy and -To reduce therapy and
abdomen.” psychological the pain level. psychological
Objective support. support.
Data -Administer -
Patient medication as Administered
looks dull. per as doctors medication as
order. per doctors
order.
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ASSESSMEN NURSING GOAL PLANNIN RATIONA IMPLEME EVALU

T DIAGNOSI G L NTATION A
S TION

Subjective Ineffective To -Assess the -It will help -Assessed Patient

data breathing maintain respiration to collect Respiration breathing
Patient pattern normal pattern of the base pattern of the difficulty
complain that related to breathin the patient. line data patient. is
she can not decrease g -Provide for care -Provided reduced
take breath oxygen pattern comfortabl planning. comfortable slightly.
properly. carrying e position -It will help position to the
Objective capacity of to the to reduce patient.
data blood in to patient. the -Provided
Patient is look the lungs -Provide breathing oxygen
anxious. and heart as oxygen difficulty. therapy if
evidenced therapy if -It will help necessary.
by necessary. to maintain -Administered
restlessness. - normal Bronchodilato
Administer breathing r.
bronch pattern.
odilator. -it will help
maintain
normal
breathing
pattern.
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ASSESS NURSING GOAL PLANNING RATIONAL IMPLEMEN EVALU

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MENT DIAGNOSI TATION A

S TION
Subjective Activity To -Assess the -It will help -Assessed the Patient
data intolerance increase activity to collect activity level of maintained
Patient related to the level of the base line the patient. normal
complain decrease activity patient. data for case activity
that she is oxygen level. -Encourage study. level.
feel weak carrying the patient -It will help -Encouraged the
and not capacity of to do some to promote patient to do
interest to the blood as exercise. activity some exercise.
do any evidenced by -Arrange all level of the
work weakness. the article patient.
Objective near the
Data patient side.
Patient is -Advice the -It will also -Arrange all the
look weak patient to help to article near the
and take food promote patient side.
anxious. properly. activity
level of the
patient.

-It will help -Advised the

to reduce patient to take
weakness of food properly
patient.
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THEORY APPLICATION

Mrs. Purnima Shil was admitted in the IGM hospital. She is PGR mother.
Suffering lower abdominal pain with anemia and weakness. So,
she cannot do care himself due to her condition. She needs support from others
to perform daily living activities. So, I applied Dorothea Orem’s self-care Deficit
Theory for my patient while caring him to improve her health status by
setting the goals with both the nurse and the patient’s mutual understanding.

According to Dorothea Orem the conceptual frame work is

SELF
CARE

R R

SELF
THERAPEUTI
R
CAPABILITIES C SELF CARE

(SELF CARE DEMAND

AGENENCY)

R R

NURSING
CAPABILITIES
(NURSING
AGENCY)
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IIN MY PATIENTS CONDITION THE FRAMEWORK ARE AS FOLLOWS: -

SELF CARE

R R

SELF THERAPEUTIC
CAPABILITIES SELF CARE
(SELF CARE R DEMAND
AGENCY)
ACTIVITY
LIMITED ACTIVITY
INFECTION
RISK OF
CONTROL
INFECTION

R R

NURSING CAPABILITIES
(NURSING AGENCY)

 IMPROVE THE
LEVEL OF
ACTIVITY
 MAINTAIN
NUTRITIONAL
LEVEL
 MAINTAIN
PROPER
PEERSONAL
HYGIENE.
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HEALTH EDUCATION:-

Nutrition and dietary pattern: -

 Mothers are advised to take light nutritious diet which are easily digestible.
 Iron, Protein, Vitamin containing diet like green leafy vegetables, fish, meat egg, milk,
seasonal fruit take mostly.
 Drink plenty of fluid.

Personal hygiene:

 Advised the mother to wash hands before and after touching the private part.
 Advised the patient to brush the teeth twice a day.
 Advised the patient to wash clothes regularly.
 Advised the mother for proper perineal and breast care.

Exercise:

 Encouraged the mother to do some active and passive antenatal exercise.

 Advice the mother to do deep breathing exercise.

Rest and Sleep: -

 To take adequate rest and sleep.

 Mostly sleep in left lateral position.

Medication:

 Advised the mother to take medicine at proper time without forgetting.

 Encouraged the mother to complete the full dose as ordered by the physician/surgeon.

Follow up care:

 Advised the mother to come for regular check-up in OPD.

 Advised the family members to provide psychological support to the mother.
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Psychological Support: -
 Pregnant mother should be educated antenatal care, normal labor and puerperium.
 To teach mother how to look after the newborn baby and herself.
 Prepare mother for hospital delivery.
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CONCLUSION
As per my clinical posting I had posted in the antenatal ward and during my posting I got
a mother in anemia in pregnancy. He was suffering lower abdomen pain, weakness,
anorexia, palpitation, pallor, tiredness. I have given care as per the need of the patient
and it will help me to deal with the same kind of patient in future.
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BIBLIOGRAPHY:-

1. Konar Hiralal .D.C Dutta's “Textbook of gynecology”. 10th ed. New Delhi:
Wolters Kluwer (India)
Pvt Ltd; 2013. P. 697-703.

2. Bhaskar Nima. “Midwifery and Gyna ecological Nursing”: A NURSING

PROCESS APPROACH.
Volume 1. 1st ed. New Delhi: The Trained Nurses' Association of India; 2013. P.
1145-1149.

3. Chintamani. Mani M, Lewis SL, Heitkemper MM, Dirksen SR, O'Brien PG,
Bucher L editors. “Textbook of gynecology”. New Delhi: Elsevier India Pvt Ltd;
2011. P. 613-618

4. 10.Murray Sharon Et Al. “Foundations of Maternal-Newborn and Women’s

Health Nursing”.7th Edition. Elsevier Publication. 2019.Page No.654-661.