GOVERNMENT COLLEGE

OF NURSING,
JODHPUR(RAJ.)

Nursing Care Plan

On

Subject-Obstetrics & Gynecology Specialty-I

SUBMITTED TO -
SUBMITTED BY-
Mrs. ANNMA SUMON
PRIYANKA GEHLOT
NURSING LECTURER
M.sc (N) Pre. year
GCON, Jodhpur

PATIENT PROFILE:
Name of patient :SOHNI DAVI
Husband’s name :RAJKUMAR JI
Age : 35 years
Religion : Hindu
Occupation : House wife
Education : 10th pass
Address : Masuriyaphatak, masuriya, Jodhpur
Duration of marriage : 11years
Ward : ANW
Date of admission : 29/07/19 at 05.00 a.m.
Registration No. : 30195
Obstetrical score : G3
L.M.P. : 01/09/19
E.D.D. : 07/07/20

ADMISSION HISTORY:

On admission complain:
Vaginal pain.

Personal History:
She is vegetarian, non-alcoholic, no smoker, have no drug allergy.

Medical History:
No H/o HTN,D.M., CAD, and lungs diseases.

Surgical History:
No H/o any type of surgery.

Family History:
No history of hereditary and genetically disorder.

Obstetrical History:
Primi gravida
Patient has received one antenatal visits and received one doses of T.T.
vaccine.
Score - G3P0A1L1

Previous labour History:

Not any

Menstrual History:
Regular normal flow 3-5 days cycles 26-28 days.
 Menstrual cycle is regular of 4-5 days. No intermenstrual bleeding and no
coital bleeding.

CONDITION ON ADMISSION;
General examination:
Temp. - 99 F B.P. 120/90 mm of Hg
Pulse - 86/min Hydration - Adequate
Resp. - 22/min Oedema – nil
Anaemia- No Heart – NAD
Lungs - NAD Liver – NAD

Personal history:
Patient is vegetarian. No history of drug allergy or drug addiction. Absence of any type of
substances abuse like smoking, drug and alcohol etc.

Functional history:
Sleep pattern, appetite, bladder and bowel functions are normal.

Contraceptive history:
Use of oral contraceptive

PHYSICAL EXAMINATION:
General: -
Body built : moderate
Weight : 65 kg.
Vital signs (at the time of admission)
Temperature : 99 degree F
Pulse :78/ min.
Respiration :22/min.
B.P :120/80 mm of Hg.
Hydration :Adequate
Anaemia :no
Pallor :no
Heart :NAD
Lungs :NAD

EXAMINATION:

Abdominal and pelvic examination:

On inspection fundal height: below the xyphi-sternum

By palpitation through GRIP:

Fundal height : 36cm. by fundal grip
Lateral Grip : in left lateral Grip felt like a continuous hard, flat surface and
irregular small knobs opposite side.
Pelvic Grip : hard round part felt it means presenting part is head and station is 3/5.
Pawlik’s Grip : head is fixed
Uterine contraction : 4 contraction/ 10 min, duration > 30 second
Position of fetus : LOA by lateral grip
Presentation of fetus : vertex by pelvic grip
Relation of head with pelvic : head is engaged 3/5

On auscultation
: F.H.S 140/ min.

Vaginal examination:
Vulva : normal
Vagina : normal
Dilatation of Cervix: 4cm.
Effacement of Cx : 80%
Membrane :intact
Presentation part : head
Moulding : ++
Pelvis : adequate

Investigation and special observation:

Hb : 10.6gm%
Blood group : B+ve
Blood sugar : 110gm/dl
Urine sugar : Nil
Albumin : Nil
HBAsg : non-reactive

NEED ASSESSMENT
NEED PROBLEM
Physical need:
S. Nursing Nursing Goal Intervention Rationale Evaluation
NO assessment diagnosis
Obtain information Multiple sexual
regarding client’s partners or
Patient will past and intercourse
verbalize present sexual with bisexual men
understanding partners and increases risk of
of exposure to any exposure to STDs
individual caus STDs. and HIV/AIDS.
ative/risk Obtain information
factors. about client’s
cultural background
for risk factors.
S. Nursing Nursing Goal Intervention Rationale Evaluation
NO assessment diagnosis
S. Nursing Nursing Goal Intervention Rationale Evaluation
NO assessment diagnosis