NURSING CARE PLAN

Patient’s Identification Data

 Name: Mrs. Pawan Devi

 Age: 33 Yrs
 Sex: Female
 Marital status: married
 Hospital registration no.:
 Ward/Bed no.: gynic ward
 Address: Ranoli, sikar
 Tel. No.:
 Religion: Hindu
 Education: 12th
 Date of admission:
 Date of discharge:
 Diagnosis: Abortion
 Operation:
 Date of operation:
 Name of doctor: Dr. Sarda mahala
 Occupation: Housewife
 Monthly family income (₹): 90000
 Sensitivity/allergy/precautions:
 Height: 5feet
 Weight: 44kg

Chief Complaints with duration:

Patient having complaint of Pain in abdomen, Discomfort, per vaginal bleeding.

History of Present illness:

Patient admitted in hospital with complaints of per vaginal bleeding and pain in abdomen.

History of excessive bleeding per vagina, passage of poc’s.

After investigation she founded as anemic. Hb level was 5.3gm/dl.

History of Past Medical Illness: Illness/medications/restrictions

There is no relevant past medical Illness & medications & restrictions

History of Past Surgical Illness: Illness/Medications/any restrictions

There is no relevant past surgical Illness & medications & restrictions

Obstetrical History:

No. of Year Type of Gender of Puerperium Remark

pregnancy delivery baby
1 2014 Vaginal Female Normal Nil
delivery

Family History:

S.No. Name of family Age and Relationship Occupation Health Health

members gender with patient status habit
1 Mr. preetam 72 yr./M Father in Shopkeeper Normal
chand law
2 Mrs.veena devi 65 yr./F Mother in housewife Normal
law
3 Mr.Akhlesh 39yr./M husband Private Normal
kumar teacher
4 Ms. Pawan devi 33yr./F Self Housewife client
5 Ms.pooja 10 yr./F daughter Nil Normal

Family Tree:

Genogram key:

Female= Mr. preetam chand 72 yr./M Mrs.veena devi 65 yr./F

Male=

Mr.Akhlesh kumar 39yr./M Ms. Pawan devi 33yr./F

Diseased= or

Patient = points to patient Ms.pooja 10 yr./F

Adoption(vertical): ...........(vertical line)

Consanguinity=

Socioeconomic History:

 Occupation and social relationship: Good

 Monthly family income :90000/month
 Health facility near home: Hospital
Transportation facility: yes

Housing:

 Type: kuccha/Pukka: Pukka

 No. of room:3
 Toilet: Indian
 Electricity: yes
 Drinking water source: tap

Dietary History:

Health habits: Function Health Pattern

 Health perception/health management: good

 Nutrition/Metabolic: good
 Elimination: normal (once a day)
 Activity/exercise: normal
 Sleep/rest: altered
 Self perception/ self concept: normal
 Role relationship : good
 Sensuality/reproductive: normal
 Coping/stress tolerance: normal
 Value/belief: normal
 Other comments/data: no

Physical Examination:

General appearance

 Level of consciousness: conscious

 Orientation: altered
 Mood:
 Height: 160cm.
 Weight: 59kg

Vital sign:

Temperature (°F/°C) Pulse(beat/min) Blood pressure Respiration(breath/min)

(mmHg)
98.°F 100 beat/min. 110/70mmHg 18 breath/min.
Normal Normal Normal Normal
Head:

Scalp Face Sinus Nodes Any other

significant
changes
No Presence of Dull appearance No tenderness normal No any other
dandruff and pain during significant
Hair clean palpation changes
Black in Color

Eyes:

Ocular Pupils Sclera Cornea Any other

movement significant
change
Normal Reactive to light White in colour normal No any other
significant
changes

Ear:

Tympanic membrane Hearing Any other significant changes

No perforation Weber’s test Rinne test No any other significant changes

Normal appearance

Normal Normal

Nose:

Septum Mucus member Patency Olfactory sense Any other

energy significant change

No deviated normal Normal normal No any other

septum significant
changes
Mouth:

Buccal mucosa Gums/tongue Palates and Tonsillar area Voice breath Any other
uvula significant
change
Normal No infection Normal Normal Not present No any other
significant
changes

Neck:

Muscle Trachea Thyroid Nodes Vein Any other

distension significant
change

Normal neck Normal No swelling No swelling No vein No any other

inspection tracheal distended significant
position changes

Female Breast:

Size and Color Areola Nipples Any other

symmetry significant
change
Normal normal pigmented area normal No any other
of skin significant
changes
Thorax:

Chest pain Respiratory Type of Thoracic Palpitation Percussion Breath

Rate respiration expansion sound
No chest 18breath/ Normal Normal Normal Normal Normal
pain min

Cardiovascular system:

Inspection Palpitation Auscultation Apical rate and Any other

rhythm significant change
Normal Normal Normal 100 beat/min. No any other
Regular rhythm significant
changes

Central and Peripheral Vessels:

Brachial Radial Femoral Popliteal Dorsal Post tibial Capillary

pedal refill
Normal Normal Normal Normal Normal Normal Normal
2.5 sec

Abdominal:

Inspection Palpitation Auscultation Percussion

Normal Normal Normal Normal

Musculoskeletal system:

Upper Lower Muscle Joints Range of Gait Spine

extremities extremities strength motion

Dull Dull Normal Normal Slow Normal Normal

Nervous system:

Pain Orientation Memory GCS Cranial Deep Gross fine Temperature

attention nerve tendon motor
span reflex function
No pain Oriented normal 15 normal Present Altered 98°F

Skin, Hair and Nose:

Skin colour Any lesion Texture Moisture Temperature Edema Shape of

on skin nails
Normal No Normal Dry 98°F Present Normal

Genitalia and Rectal Examination

Inspection Palpation(liver, Ascites Appendicitis Pain Any other

spleen, kidney) significant
changes
Normal Normal Normal Normal No pain No any other
significant
changes
Investigations:

Date Investigation Normal value Patient value Inference

done
Hb 11.5-16.5 mg/dl 5.3 mg/dl

TLC 4000-11000 15,100 /mm3

/mm3

neutrophil 1.5-4.5 2.79 lack/mm3

lack/mm3

Platelet count. 13-45 mg/dl 10mg/dl

Urea serum. 0.6-1.3 mg/dl 0.55 mg/dl

Serum 70-140 mg/dl 70 mg/dl

Creatinine.

Serum 35–71 μmol/L 70μmol/L

Creatinine.

Alkaline 44 to 147IU/L 66IU/L

phosphate
 Treatment:

S. Drug trade Pharmacologica Dose and Rout Action Side effects and Nurse
No. name l name frequency e drug interaction responsibility

1. Inj. 0.5 -1gm IV Used as CNS: headache 1-Assess the

Maczone 6hrly broad GI: constipation general
spectrum GU: discolouration condition of
antibiotics of urine. the patient
2-Check the
vital signs
3-Checked
the allergic
reaction.
4-Administer
the five
rights.
5-Always
follow six
rights and
test dose
should be
done.

2. Inj. hypersensitivity
Pantoprazole 0-40mg slow It is a newer 1-Assess the
I/V H+ k+ ATP general
inhibitor condition of
similar in patient.
potency and 2-Always
clinical follow six
efficacy to rights.
omeprazole 3-Check the
allergic
reaction
3. Inj Rantac 2 to 4 IV Blood-
mg/kg Competitively Neutropenia, Absorption
/BD inhibit the thrombocytopenia. not affected
action of CNS-Headache, by food.
histamine malaise, dizziness. Can be taken
(H2)at GI- Nausea, without
receptor sites vomiting. Hepatic- regard to
of the Increased liver meal.
decreasing enzyme. Use
gastric acid Nausea, Pain, continually
secretion. Blood loss in hepatic
Diarrhoea dysfunction
and renal
impairment
 patients.

Assess client
for any sign
of side
effects.
Check of
blood loss
etc.

Nursing diagnosis:

1. 1. Pain in lower abdomen related to mass expel from the uterus.

2. Altered body temperature related to infection as evidence by purulent and smelly discharge.

3. Risk of infection related to vaginal discharge.

4. Activity intolerance related to pain in lower abdomen.

5. Altered sleeping pattern related to pain.

6. Knowledge deficit related to diet, personal hygiene and treatment and its complications.
Nursing care plan:

Nursing assessment Nursing diagnosis Goal Planning Implementation and Evaluation

rationales
Subjective data:-Patient Pain in lower abdomen To relieve the pain of  To assess the  General condition Pain is reduced up to
complaints that she related to product of the patient. general condition of of patient is some extent as
having pain in the conception expel patient. assessed. evidenced by patient
lower abdomen. through the uterus.  To assess the level,  Level, intensity and having good sleep.
Objective data: - By intensity and duration of pain is
observing patient facial duration of pain. assessed. Patient is
expressions and by  To provide the having moderator
doing per vaginal comfortable pain.
examination we know position to the  Comfortable
that patient is having patient. position is given,
pain.  To provide with the help of
diversional extra pillow.
Therapy to the patient.  Divertional therapy
Administer analgesics as is provided to
prescribed by physician. patient. Diverting
her mind by
verbalizing with
patient.
 Analgesic is
administered as
prescribed by
physician.
Nursing assessment Nursing diagnosis Goal Planning Implementation and Evaluation
rationales

Subjective data:-patient Risk of infection related To reduce the risk of  Assess the level of  Level of risk of Risk of infection is
complaints of itching to vaginal discharge. infection. risk of infection. infection is assessed
reduced to some extent
and redness over the by examining the
perineal area. perineal area. as evidenced by
 Educate the patient  Patient is educated
examining the perineal
Objective data: patient about the about the
looks discomfort able maintenance of maintenance of area.
and irritated. hygiene. hygiene.

 Advice the patient

to take plenty of  Patient is advised to
fluids. take plenty of fluids.

Advice to take Patient is advised to

antibiotics as ordered take antibiotics as
by physician. prescribed by physician.
Nursing assessment Nursing diagnosis Goal Planning Implementation and Evaluation
rationales

Subjective data: Activity intolerance To improve  Asses the level  Level of activity Activity tolerance is
patient complaints of the activity tolerance of activity intolerance intolerance is
related to pain in lower improved to some
not able to do daily the patient. of the patient. assessed by
activities. abdomen. observing the extent as evidenced by
 Assist the patient in patient’s activity.
patient’s self care.
Objective data: patient daily activities.  Patient is assisted
looks depressed and in daily activities by
lazy.  Provide active and her family
passive exercises to  Active and passive
the patient. exercises are
 Educate the patient provided to the
to take adequate patient.
rest and healthy  Patient is educated
diet. to take adequate
Assess the tolerance rest and healthy
level of activities. diet.

Level of tolerance of
activities is assessed.
Nursing assessment Nursing diagnosis Goal Planning Implementation and Evaluation
rationales

Subjective data: Altered sleeping To improve the  Assess the  Sleeping pattern of Sleeping pattern is
patient complaints of pattern related to pain sleeping pattern of the client is
sleeping pattern of improved to some
sleeplessness. client. assessed.
client.  Provide calm and  Calm and noise extent as evidenced by
Objective data: noise free free environment
patient’s facial
Patient looks lazy and environment to is provided to the
depressed. the patient. patient. expression.
 Provide well
ventilated  Well ventilated
environment and environment and
position to the position is
patient. provided to the
Provide comfortable patient with the
bedding to the client. help of extra
pillows.
 Comfortable
bedding is
provided to client.
Nursing assessment Nursing diagnosis Goal Planning Implementation and Evaluation
rationales

Subjective data: Knowledge deficit To improve the level of  Assess the level of  Level of knowledge Knowledge is
patient complaints of related to treatment knowledge of patient knowledge of of patient is improved to some
having queries. and its complications. patient. assessed by asking
 Explain to the questions. extent as evidenced by
patient about the  Explanation about patient answer.
Objective data: patient treatment plans the whole
looks confused and and importance of treatment plan and
anxious follow up. follow is provided
 Clear the doubts of to the patient.
the patient.
Provide psychological  All the doubts of
support to the patient. the patient are
cleared.

Psychological support
is provided to the
patient.
Health education:

S. No. Health education

1. Diet and supplements:

 Educate the mother to take adequate diet. Add vegetables, milk, egg, fruits and juices
in her diet.
 The supplementary diet is also important such as iron calcium and folic acid.
 Instructed to patient for taking high caloric diet which is rich in protein & vitamin diet
for the early recovery.
 I told to patient for avoid spicy food & fatty diet.

2. Rest and sleep:

 Encourage client to take adequate rest and sleep.
 Provide calm and quiet environment to client.

3. Personal hygiene:
 The maintenance of personal hygiene is very important to prevent the infection. Daily
bathing is very necessary.

4. Environmental hygiene:
 Educate the mother to keep her surroundings clean.

5. Follow up care:
 Educate the mother regarding follow up care. I gave the health education to patient
& his relatives.
 I explain the all aspect of disease to patient & his family members.
 I instructed to patient & his family members if they have seen any complication then
immediate contact with doctor.

Discharge planning:

 stablishing the discharge date ……and time……

 Checking that the patient understands their medication

 Arranging appointments

 Ensuring the patient has their personal belongings, medicines, medical documents, and
private scans and x-rays
ARAWALI COLLEGE OF NURSING,
BAJOR, SIKAR
NURSING CARE PLAN
On
Abortion
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