NURSING CARE PLAN

ON

NORMAL VAGINAL DELIVERY

SUBMITTED TO

Mrs Rajbr kaur

Lecturer OBG

SUBMITTED BY

Rajdawinder kaur
MSC. (N) 1ST YEAR
OBSTETRIC AND GYNAE. (N)

Identification of the patient

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Name of patient: PARAMJIT KAUR

Husband’s name: gurmeet singh

Age: 24 years

Sex: Female

C.R. No. 267329

Ward: Maternity

D.O.A: 21-04-16

Educational status: Middle

Religion: Majbi Sikh

Language: Punjabi

Occupation: House-wife

Husband’s occupation Labourer

L.M.P: 23-7-15

E.D.O.D: 30-4-16

Address: Musli,Tangra Amritsar.

Diagnose: NVD

D.O.D 28-01-16

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Chief complaints at the time of admission:

LPV and labour pains X Since 9 hours

History of present illness: patient came to hospital at 6.30 am on 19-11-12 with H/O labour pains and LPV

Chief findings at the time of admission:

B.P. 120/70 mmHg.

Pulse 84/min

Pallor +

P/A 34 weeks

Cephalic

FHS + regular

Uterine contractions +

P/V cervical dilatation 3cm

Cervical effacement 80%

Membranes absent

Station 0

Slight caput present

History of past illness: H/O enteric fever

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 No H/O T.B

No H/O D.M

No H/O STDs

No H/O H.T

Obstetrical history:

 G1 P0
 Duration of marriage: 1 year.
 No. of living children: primigravida

Menstrual history:

 Menstrual cycle 28-30 days

 Menarche: 17 years.
 Duration: 4-5 days
 Amount of blood flow: normal
 Contraceptive history: No any contraceptive devices used

Immunization his

Patient has undergone TT immunization at 4th month and 5th month of pregnancy.

Trimester history

Ist Trimester

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  H/O nausea
 No H/o Hyper emesis Gravidarum
 No H/o leg cramps with back ache
 No H/o x-ray exposure
 H/o Constipation

IInd Trimester

 No H/o constipation
 No H/o Oedema on ankles
 H/O good fetal movements

IIIrd Trimester

 No H/o oedema
 No H/o burning micturation
 No H/o polyhydraminios
 H/O frequency of micturation

Personal history: Vegetarian, Non Smoker, Non-Alcoholic

Family history: No any family H/O PIH, bronchial asthma, Tuberculosis, diabetes..

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Family tree: joint family

Father-in-law mother-in-law

(60 years) (58 years)

Brother-in-law husband patient brother-in-law

(30 years) (26 years) (22years) (24 years)

Vital signs:

On 23-04-16 at 8.30 am

Temperature 98oF

Pulse 80/ min

Respiration 22/min

Blood pressure 120/70 mm of hg

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Lab investigations:

Test Patient Value Normal Valve

Hb 9.4 gm% 12-14gm%
VDRL NR
HIV NR
HBSag NR
HCV NR
Blood group B+ve
BT 3'-5" 1'-6"
CT 5'-2" 3'-10"
RBS 70mg 80-140mg

Treatment received:
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Drug Chemical Dose Route Time Action
constitution
Cap Ampicillin + 500mg orally TDS Antibiotic
Amoxycillin Cloxacillin

Tab Methylergometrine 50 mg orally TDS Ergot

Methargin derivative

Inj Voveron Diclofenac sodium 50 mg IM SOS Analgesic

Short term goal:-

 To reduce the anxiety level.

 To reduce the pain.

 To correct the anaemia.

 To maintain the vital signs.

 To provide the comfort.

 To initiate early breast feeding.

Long term goal:-

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  To reduce the puerperal complication.

 To maintain the health of the mother.

 To educate the mother regarding baby care & feeding.

 To educate the mother regarding correction of anaemia.

 To educate the mother about postnatal exercise.

 To rehabilitate the client as soon as possible.

Nursing diagnosis.

 After pain related to child birth trauma & episiotomy..

 Altered nutritional status related to poor intake & loss of energy during labour .
 Risk for infection related to traumatized tissue
 Risk for ineffective parent/infant attachment related to interruption in bonding process
 Anxiety related to self care deficit & baby care.
 Ineffective breast feeding related to poor knowledge regarding early initiation

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 NURSING
CARE PLAN

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Sr. Nursing Nursing Expected Nursing
Nursing Planning Implementation Rationale
No. Assessment Diagnosis Outcome Evaluation

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1. Subjective After pain To relieve  To assess the  Assessed the For pain Pain is reduced
data: Client related to child pain. intensity of level of pain. relieving. at some extent.

says ,”I am birth trauma & pain.

suffering with uterine
 To explain the
pain” . contraction.  Explained the
cause of pain.
client it’s a
Objective
normal process
data: Client is
to involute the
placing the
uterus.
hand on lower
 To provide
abdomen  Provided tab.
analgesic.
repeatedly. Diclofenac
 Provide
 Provided
measures to
comfortable
relieve pain
position & calm
like
environment.
comfortable
position &
calm
environment.
 Measured
 Measured
involution of
involution of

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 uterus. uterus.

Subjective
2. data:client To For Client looks
Altered
maintain  Monitor vitals  Monitored vitals maintain energetic &
says,”I am
nutritional nutritional of the client. of the client. the motivated about
feeling
status related status. nutritional health advises.
nauseated &  Provide a glass  Provided a glass status
to less intake
ghabrahat”. of milk & 2 of hot milk & 2
during labour.
pieces of pieces of bread.
Objective data:
breads.
Client looks
lethargic &  Advise plenty
 Advised plenty
restless. of liquids &
of liquids &
roughage to
roughage diet
prevent
constipation &
maintain
hydration.

 Advise the
sources of high  Advised the
protein , sources of high
calcium & iron protein, calcium
diet to
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 maintain the & iron diet.
health status &
lactatation of
the mother.

 Advise
elemental
 Advised
iron(Govt
elemental iron
supply)
for 3 months.
100mg for 3
months.

To  Advise one Improved

motivate litre of milk lactation at some
3. Subjective
the mother  Advised one litre extent.
Data:- per day to For
Ineffective for breast of milk & its
Client says , “ I feeding. improve improving
breast feeding benefits.
am not able to lactation so the
feed the baby”. lactation &
that exclusive
Objective breast feeding breast
Data:- feeding.
can be ensure.
Client is not Provided a menu plan
able to put the  Provide a

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 baby on breast. menu plan of the client.
the postnatal
diet to the
mother.

 Encourage the Encouraged the client to

woman to Verbalized the feeling.
discuss her
feelings
regarding
breast feeding.
 Demonstrate
the woman the Demonstated the
different different method of

position of breast feeding.

breast feeding.
Advised her to
do so
frequently for
early initiation.
 Teach the
woman for  Taught the client
exclusive
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 breast feeding for exclusive
for 6 months. breast feeding
for 6 months

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 -

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18
HEALTH EDUCATION.

1. Encourage patient to take well balanced diet.

2. Encourage patient to take roughage diet to prevent constipation.
3. Ask mother to take milk and fruit juice in large amount for more production of
breast milk.
4. Advise mother to put the baby on breast as early as possible.
5. Advise mother about family planning methods for adequate spacing between
two children.
6. Advise patient to report if any sign of infection arises.
7. Educate patient about follow up care.
8. Educate mother about proper rest.
9. Educate mother about neonatal care.
CARE OF NEW BORN

 Educate mother about breast feeding.

 Educate mother to keep the baby warm.
 Educate her to wash her hand before touching the baby.
 Educate her about immunization
 Educate regarding KMC
FOLLOW UP CARE

 Advise women about follow up after a week or earlier if any problem arises
 Educate her to get the full immunization of the baby as scheduled.

References
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  Dutta D.C,”Textbook of obstetrics including perinatology and contraception”,
6th edition, published by new central book agency. Pp 588-589
 Fraser M Diane and Margret A cooper’s, “textbook of midwifery”,14 th edition,
published by Churchill livingstone, Pp 581-590.
 Lippincott’s,”Nursing Management-Clinical practice”, published by Williams
and wilikins, Pp 1298-1300.

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