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ANTENATAL CAREPLAN

Introduction:

My self Susmita Sen M .Sc Nursing 1st Year student Tripura Institute of Paramedical Science. I
was posted in IGM Hospital, antenatal wand. Here I got a patient who is suffering from weak
ness ,anorexia, palpitation, pallor, tiredness. I have taken this case for my care plan.

HISTORY COLLECTION

DATA COLLECTION—

Name of the mother :-Sneha Das

Age of the mother :- 24 yrs

Obstetrical score :- G1P0A0L0

Antenatal diagnosis :-Anemia in pregnancy

Last menstrual period :- 20\2\23

Expected date of delivery :- 27\11\23

Date of admission :- 20\11\23

Gestational age (as on date of admission) :- 36 weaks

Name of the husband :- RakeshDas

Age of the husband :-30 Yrs

Language spoken :- Bengali

Religion :- Hindu
Address :- Amtali
SOCIO ECONOMIC HISTORY—

Head of the family: Her husband

Income: Rs. 30,000/month.

House type: Pucca

Water supply: Tap water

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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 - Nuclear family.
No of family member- 4
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 Mr 46 Father in law 12 Passed Business Healthy
Prabir yrs(M)
Das
2 Mrs. 39 Mother in law IX passed House wife Healthy
Roma yrs(F)
Das
3 Mr. 28 Husband B.A passed Govt service Healthy
Rakesh yrs(M)
Das
4 Mrs. 24 Patient himself XII passed House Wife UN
Sneha yrs(F) Healthy
Das
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FAMILY TREE-

Lt Mohesh ch Das Lt Mina Das(Grand Mother)

(Grand Father)

IN

PRABIR DAS FATHERR IN LAW RUMA DAS MOTHER IN LAW

Rakesh Das(Husband) Sneha Das

(Patient)
Family key

=Male

=FEMALE

= Male death person

=Female death person

=Sick person

FPERSONAL HISTORY—
Nutrition-She is non vegetarian ,she take 3 times meals .she also take fruits juice.
Education- Her educational qualification is XII passed
Rest and sleep-6-7 hours per day
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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-5 to 6 days
Flow-Normal
Lmp-20\1\23
Marital history-
Married-1 Year ago
Relationship with husband-Good
Consanguineous marriage-Absent
Contraception history- she not use any contraceptive device
Drug history- she not take 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 ,head
ache ,weakness ,dehydration , sleeplessness

PRESENT SURGICAL HISTORY=Nill

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PAST OBSTETRICAL HISTORY

SI MOTHER CHILD
NO
YEAR GRAVIDA PRE FULL ABOR MODE SEX ALIVE STILL
REMAR WEIGHT
NATAL TERM TION OF OF BORN
KS BABY
PERIOD
DELIVERY
MOTHER IS PRIMI GRAVIDA

PRESENT OBSTETRICAL HISTORY:

LMP:20\2\23
EDD:27\11\23
Current gestational age (with date):39 weaks 2 Days (20\11\23)
1st trimester-
In 1st trimester she feels very weakness ,restlessness .She has confirm her pregnancy at 6 week
by urine test and she takes 2 does of T.T injection.
2nd trimester-
In 2nd trimester she feels quickening at the 18 th 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
ANTHROPOMETRIC MEASUREMENTS—
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Weight -62 kg
Height -5 feet 4 inch
GENERAL HEAD TO FOOT EXAMINATION—
General appearance-
Body Built - Thin
Activity – Dul
Posture-Normal
Pallor- Present
Consciousness - Patient is Conscious
Skin:
Colour-Patient skin colour is pallor.
Moisture-Skin moisture is dry
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.
EARS
External Ear - Extermal car is normal absent of any discharge.
Gross hearing- Gross hearing normal
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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.
Palpation:
Abdominal girth-80 com
Fundal height-32 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.
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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-130 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
Genito urinary system:
Discharge- Absent
Bleeding -Absent
Vulva- Normal
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MEDICAL MANAGEMENT

PHARMACO TRADE DOS ROUTE FREQU MODE OF SIDE EFF NURSES

LOGY NAME E ENCY ACTION ECT RESPONS
CAL NAME IBILITY
Folic Acid Folate Inj Im/iv OD Active Constipation .Check the
5 mg reduced form Swelling doctors order
of folic acid Hyper .Follow the 16
required for sitivity rights
nucleons .If any
protein complication
synthesis and Occur than
maintenance immediately
of normal Consult doctor
erythropoiesi
s
Iron dextran Iron 25 IV OD Elevated the Nausea Check the
dextron Mg serum iron Vomiting doctors order
concentration Constipation .Follow the 16
and is then rights
converted to .If any co
hemoglobin mpication
or trapped in Occur than
the reticulo immediately
endothelial Consult doctor
cells for
storage and
evertual
convertion to
usable form
of iron
Ferrous sulfate Ferrous 10-15 orally OD Elevates the Headache .Check the
sulfate mg serum iron Dizziness doctors order
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concentration Chestpain .Follow the 16

and then rights
converted to .If any
hemoglobin compication
and eventual Occur than
cinversion to immediately
a usable from Consult
of iron doctor
Inj Inj 50mg IV BD Proton pump Head ache Check the
pantoprazole pantop inhibitor Dizziness doctors order
which Chestpain .Follow the 16
suppress rights
gastric .If any co
secretion mpication
Occur than
immediately
Consultdoctor
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INVESTIGATION-
Date Investigation Mothers value Normal Value Remarks
BLOOD
19/11/23 HB 8.2 gm/dl Decreased
19/11/23 BLOOD GROUP A(+) 12-13 gm\dl Normal
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
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 evidence by patients verbalization
2.In effective breathing pattern related to decrease 02 supply heart and lungs as evidence by
restlessness.
3.impaired tissue perfusion related to interruption of arterial or venous flow as evidence by
cyanosis.
4.Impaired nutrition level less than body requirement related to in adequate intake of essential
nutrition as evidence by weakness.
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5.Knowledge deficit related to the cause sign and symptoms and treatment process as evidence
by asking frequent question.

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 evidence 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
evidence by therapy if -It will help necessary.
restlessness. necessary. to maintain -Administered
- 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

MENT DIAGNOSI TATION A
S TION
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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 evidence 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.

HEALTH EDUCATION:-

Nutrition and dietary pattern:-

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 Provide notorious diet to the patient.

 Advice the family members give proper position to the patient before giving food.
 Provide liquid diet to the patient.

Personal hygiene:

 Advised the patient and family members to wash hands before and after touching the
dialysis site.
 Advised the patient to brush the teeth twice a day.
 Advised the patient to wash clothes regularly

Exercise:

 Encouraged the patient to do some active and passive exercise.

 Advice the patient to do deep breathing exercise.

Medication:

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

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

Follow up care:

 Advised the patient to come for regular check-up.

 Advised the family members to provide psychological support to the patient.

CONCLUSION
As per my clinical posting I had posted in the Antenatal ward and during my posting I got
aa mother in anemia in pregnancy. He was suffering lower abdomen pain , weak
ness ,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.