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G0VT.

COLLEGE OF NURSING

SPMC, AGH BIKANER

Nursing care plan on: Intranatal patient

Submitted To:-
Mrs.chhotu kumawat
Lecturer Govt.college of nursing
Bikaner.

Submitted by:-
Mrs. Anju didel
M.sc(N)Previous
INTRODUCTION
As a part of my clinical experience in janana hospital PBM bikaner, . When I was
posted to labour ward, I got one patient name as Netravati having full term normal vaginal
delivery. I have selected this case for my care plan on 10/4/2014 in order to use this
knowledge in my day to day clinical practice.

1.BIOGRAPHICAL INFORMATION

Name : pooja

Age : 25 years

Sex : Female

Address : Nagaraj house no.14 cot gate bikaner

MRD No. :299095

Education :10th standard

Occupation :house wife

Religion :hindu

Mother tongue :hindi

Ward :labour room

Date of admission : 10/4/2016

Type of labour : Full term normal vaginal delivery

2.HISTORY COLLECTION:

Chief complaints:-
Patient is pregnant and comes to hospital for delivery.

Present history of illness:-


Medical- Pain in lower abdomen was in constricting type on & off.
Due to this reason he came to hospital

Surgical- not significant


Past history of illness:-
Medical- there is no any history of any medical illness, except
occasional cough and cold.
Surgical- there is no history of any surgery done.

Personal Habits:-

Diet- he takes a mixed diet, and eats two meals per day.

Sleeping habits- regular, 5-6 hours per day, but the last 2-3 days she is
not able to sleep due to abdominal pain.

Bowel and Bladder habits- urinate 5-6 times per day and the bowel
pattern is regular, except the last 3-4
days she is having constipation.
Socialization- she is a socialise person and a loving person.

1) Obstetrics history:- Obstetrics history:- patient is having no child before this.


This is her first pregnancy.
Obstetrical score:- G1P0A0L0
2) Menstrual history :- LMP= 3/7/2015
EDD=10/4/2016

Family history:-

50y 48
rs yrs

27 25yr
22 s
yrs yrs

There is no any history of any hereditary disease like HTN, DM, asthma, epilepsy or seizures
in the client’s family.

Socio- economic status:-


Condition of the house- the client lived in her own house with her
family, which is kaccha with two small rooms including the kitchen. They used gas for
cooking. The house is supplied with electricity.
Water supply- water supply is from the corporation.
Drainage system- closed drainage system.
Surrounding environment- their surrounding environment is unhealthy.
Economic status- the client is the only source of income in their family,
his monthly income is Rs.10000 per month.

3. PHYSICAL EXAMINATION:

Vital signs:-
Temperature : 990 F
Pulse : 78 beat per minute
Respiration : 20 per minute
Blood Pressure: 120/70 mmHg

Height and weight:-


Height: 151cm.
Weight: 60 kg

General appearance:-
Constitution : normal
State of nutrition : good
Personal appearance: Normal
Posture : lordosis
Skin and hair : dark complexion
Emotional state : Anxious
Co-cooperativeness: cooperative

HEAD TO FOOT EXAMINATION:-

Head:
Skull - has no abnormalities noted.
Hair - black hair, hair distribution normal
Movement of head- has full range of movement
Fore head - no scar or lesion noted
Face - anxious looking

Eyes:
Eye brows - equal and even distribution
Eye lids - no lesion or scar noted.
Lacrimation - clear fluid expression
Conjunctiva - appears pale and clear
Sclera - appears white
Cornea - appears moist
Irish pupil - appears round and central in the sclera.
Ears:
Appearance- no mass or lesion noted
Discharge - None
Hearing - normal
Lesion - none

Nose:
Appearance - no septum deviation.
Discharge - none
Patency -both nostrils are patent
Sense of smell - good.
Mouth and throat:
Lips - dry
Tongue - coated tongue
Teeth - yellowish in colour
Gums - brownish
Buccal mucosa- no lesion and ulceration
Tonsil - not palpable
Taste - abnormal

Neck:
General appearance- normal
Lymph nodes - not palpable
Thyroid glands - not palpable
Cysts and tumour - absent

Abdomen:
Inspection - enlargement.
Percussion - tenderness present
Auscultation - FHS present.
Spine and back:
Spine and curvature- lordosis noted.
Movement - all movement are normal
Tenderness - no tenderness noted

Genitalia:
Normal.

Upper and lower extremities:


Upper- normal movement, no lymph node enlargement noted
Lower-oedema on ankles present.

Skin:
Colour of skin- dark complexion
Edema- pedal edema present
Moisture- dry
Turgor- moderate

SYSTEMIC ASSESSMENT:-
Nervous system:
Conscious- client is conscious
Orientation- oriented to time, place and person.
Obeys commands- yes, client obeys commands.

Respiratory system:
Inspiration & expiration- present
Respiration rate- 20 per minute
Ronchi/ wheezing-not present
Gastro-intestinal system:
Peristalsis movement- present
Bowel pattern- normal.

Urinary system:
Frequency- 5 to 6 times per day normally
Burning micturition- present.

INTRANATAL HISTORY

Time of delivery : 10/4/2014 at 10:30 am


Membranes ruptured : Spontaneously
Character of amniotic fluid : Clear
Placenta and membranes : Normal

NURSING DIAGNOSIS:-

(1)Anxiety related to delivery.

(2)Pain related to uterine contractions.

(3)Fluid volume deficient related to escape of liquor.

(4)Risk of infection related to episiotomy.

(5)Risk of perineal trauma related to delivery of baby.


S.no Assessment Diagnosis Goal Intervention Rational Implementation Evaluation
1. Subjective data:- Anxiety To -Provide reassurance -Reassurance helps in -Reassurance is given to the Patient anxiety
patient is saying related to decrease to the patient. reduce anxiety of patient. patient. level is
that i have fear of delivery. patients reduced.
delivery. anxiety. -Explain delivery -delivery procedure is -Delivery procedure is
Objective data:- procedure to the explained to reduce fear explained to the patient.
looks anxious, patient. of patient.
sunken eyes.
-Encourage the patient -Encouragement is given -Patient is encouraged.
for delivery. to keep up morale.

-Clear patients doubt -clearance doubts may -Patient doubt is cleared.


in clear and simple decrease patient’s
words. anxiety.

2. Subjective data:- Pain To -Administer analgesic -Analgesic(pethidine)/IM -Analgesic is given to the -Pain is
Patient is saying related to reduce to the patient. is given when pains are patient. reduced.
that i have acute uterine pain well established in active
pain in abdomen. contractio level. phase of labour to reduce
Objective data:- n. pain.
Facial expression,
seems to be -Allow patient to -Patient chooses a -Patient chosen her comfort
uncomfortable. choose her position. comfortable position to position.
get relief of pain.

-Provide emotional -Emotional support may -Emotional support is


support to the patient. reduce pain. provided.
-Allow patient for -Ambulation can reduce -Patient is allowed for walk.
ambulation during the duration of labour.
first stage labour.
3. Subjective data:- Fluid -To -Give fluids in the -Fluids maintain liquid -Fluids is given to the -Fluids volume
Patient is saying volume maintain form of plain water, equilibrium of body. patient. is maintained.
that i m thirsty deficient fluid ice chips or fruit
and hungry, related to status of juices.
Objective data:- escape of the
Dry lips, Escape liquor. patient. -Intravenous fluid -IV fluids maintain -IV fluids are administered.
of liquor. with ringer lactate patient’s body fluid level.
solution is started.

-Check liquor time to -Liquor is check to -Liquor is checked.


time. identify the progress of
labour.

4. Objective data:- -Infection -To -Administer -Antibiotics help in -Antibiotics are -The chance of
Un gloved hands related to prevent antibiotics to the decrease infection. administered. infection
of nurse and unsterilize from patient. becomes
unclean bed d infection. minimized.
sheets and using instrumen -Maintain scrupulous -Surgical instrument -Surgical cleanliness is
unsterilized ts using surgical cleanliness. cleanliness helps in maintained.
instruments. during decrease chance of
labour. infection.

-Maintain asepsis on -It will decrease chance -Asepsis is maintained on


the part of the patient. of infection. the part of patient.
-Attention is paid on -Perineal
5. Objective data:- -Risk of -To -Paid attention on -Attention is paid on perineum. injury is
Big size of head perineal decrease perineum. perineum for controlled prevented.
of baby. injury the risk delivery of head.
related to of -Head is delivered in
delivery perineal -Deliver the head in -It will help in easy between contraction.
of head. injury. between contraction. delivery.

-Delivery is avoided by
-Avoid delivery by -It will decrease the risk early extention.
early extension. of perineal injury.
HEALTH EDUCATION:-
Name of client - Mrs. pooja
Topic -intranatal care
General Objectives -At the end of health education Patients knowledge will be improved
related to patient’s condition.
Specific objectives:-
1. To increase awareness that disease are significant health problem.
2. To increase awareness of symptoms and signs of disease.
3. To improve the knowledge and attitudes of patients about detection, treatment and
control of disease and infection.
4. To promote the family educational material essential for positive lifestyle habits.
5. To create awareness about the ill-effects drugs, and other substance abused.

s.no. Specific objectives Content Evaluation


1 To increase awareness that Patient is advised Patient’s knowledge
disease are significant health about blood is improved.
problem. transfusion.

2 To promote the family Family members are Patient’s family


educational material essential advised about members
for positive lifestyle habits. provide green leafy understand and say
veg and jaggery with yes about to care of
diet to the patient patient.
for atleast 1 month
consistancely.

3 To improve the knowledge Patients is advised to


and attitudes of patients wear loose and Patient says that she
about detection, treatment cotton cloths and will do all activities
and control of disease and maintain her after discharged
infection. personal hygiene from hospital.
NURSES NOTES:-
 New born baby’s temp.is 38 degree centigrade.
 Heart rate is120/min.
 Blood pressure of new born is 60/40 mmof hg.
 Sponge bath is given to the baby.
 First breast feeding is given by the mother.
 Dressing is done on the mother’s episiotomy sutures.
 Mothers temp. is 37 degree centigrade.
 Mothers pulse rate is78/min.
 General health of mother is normal.