Nursing Care Plan of the Mother

Nursing care planOf The Mother

Nursing Care Plan of the mother

Prenatal Assessment

Cues/Evidence Nursing Diagnosis Objective Intervention Rationale Evaluation

SUBJECTIVE DATA:Patient verbalized that she easily wakes up whenever she hears noise. Furthermore, she reported frequent awakenings during the night to go bathroom due increased urge to urinate which happened around 5times.She also added that she finds it difficult to sleep sometimes because she felt slight pain on the area near her buttocks due to the pressure she feels on her chest which affects her breathing. She also said that she sleeps with a pillow

Disturbed sleep pattern r/t shortness of breath and urinary frequency

Within our care, the client will improve sleep pattern as evidenced by:

Absence of dark circles under eyelids and frequent yawning, improved face expression

Verbalized understanding on the cause of sleep disturbance

Report increased

1. Assess vital signs especially her blood pressure level

2. Encourage the mother to void before sleeping

3. Provide a quiet environment conducive for sleeping

4. Promote use of bedtime rituals such as drinking a glass of milk before sleeping, taking a bath, reading a book

Elevated blood pressure is usually observed in sleep disturbed client

Voiding before bedtime may limit the sleep disturbance brought about by urinary frequency

A quiet environment promotes continuation of sleep without disturbances

Promotes relaxation and readiness for

Within our care, the client had improved sleeping pattern as evidenced by:

Absence of dark circles under eyelids and frequent yawning as observed

Decrease urinary frequency from 5 times each night to 3 times

Report of rested and more relaxed

OBJECTIVES FULLY MET

and a blanket. (We failed to inquire about her having nightmares or sleepwalking). She takes a nap when she feels like taking a nap but only for a short time.

OBJECTIVE DATA:Sleepy eyed noted

Dark circles under eyelid observed

Frequent yawning noted

Vital signs:T=37˚CRR=14 cpmBP= 138/74 mmHgPR= 72 bpm

sense of well – being and feeling of rested

Report an increased number of hours of sleep

5. Teach client to elevate head by using more pillows during sleep or have her on side – lying position

sleep

Elevating the head promotes lung expansion, being in a side – lying position decrease the pressure on the chest wall and vena cava by the gravid uterus

SUBJECTIVE DATA:Client verbalized that she feels sad about

Disturbed Body mage related to change of appearance

Within our care, client shall accept

1. Assess readiness to accept changes in body image

Give patient sense of control over situation

Within our care, client had accepted her body

her physique and body image.

OBJECTIVE DATA:Physiologic changes:

Contour of the abdomen changes

Presence of linea nigra on the abdomen

associated with pregnancy

body image as manifested by:

Express positive feeling towards self and others

Verbalize acceptance of body image

Perceived pregnancy in a positive light

2. Employ a calm, caring, confident, and non-judgmental approach.

3. Discuss with mother physiologic changes during pregnancy

4. Allow pt to express feelings towards her pregnancy

5. Teach pt coping strategies:

• Preparing for upcoming delivery

• Provide literary articles about pregnancy

Improves nurse-client relationship.

Creates a sense of trust at the same time educate mother about changes during pregnancy

To create a positive outlet of emotions

Help overcome maladaptive behaviors

image as evidenced by:

Expressed positive feeling towards self and others.

Verbalized acceptance of body image:“Ok na man ako pagkita sa ako kaugalingon”

Perceived pregnancy in a positive light and claimed she is excited to see her baby.


1st stage of labor

Cues/ Evidence Nursing Diagnosis Objectives Interventions Rationale Evaluation

SUBJECTIVE DATA:Client verbalized excruciating pain on the abdomen and further stated that the intensity of pain is increasing.

OBJECTIVE DATA:Rated pain as 9 in a scale of 1 to 10; 10 being most painful while 1 being least painful.

Facial grimacing noted

Abdominal guarding noted

Restlessness noted especially during exacerbation of contractions.

Altered comfort: pain related to increased uterine contractions and pressure on pelvic structures

Within our care, client shall experience increased comfort as evidenced by:V/S within normal range: T: 36.5-37.5PR: 60-100bpmRR: 12-20cpm BP: 110-140/60-90mmHg

Verbalization pain within tolerable limits throughout the duration of labor

Verbalize discomfort as controlled with non-pharmacologic methods

Rates pain as < 8 in a scale of 1-10, 10 as the highest and 1 is the lowest.

Independent1. Monitor vital signs every 15 minutes for 2 hours and 30 minutes until stable.

2. Assess contraction patterns, bloody showand the degree of pain and its characteristics, location, severity, duration, and frequency.

3. Provide comfort measures:

• Encourage comfortable positioning.

• Position the client in a left side lying position.

To obtain baseline data.

This is to monitor the progress of labor and the condition of both the mother and the baby. Helps to identify areas of chief concern, providing baseline for future interventions.

Left lateral position increases venous return and enhances placental circulation.Position changes promote comfort , reduce muscle tension, relieve pressure and

Within our care, the client was able to:

Maintained v/s within normal range:

T: 37.4CPR: 66bpmRR: 16cpmBP: 110/70mmhg

Verbalize pain within tolerable limits.

Verbalize discomfort as controlled with non-pharmacologic methods

Rated pain as 8 in a scale of 1 – 10

Groaning, and facial grimacing not noted.

Was observed to be

Absence of expressive behaviors such as restlessness, moaning, sighing, irritability, and facial grimacing.

Verbalize desire to participate in labor as tolerated

Responds to questions and instructions appropriately

Identifies need for additional pain relief measures as tolerated.

• Encourage client to assume different positions and change them regularly.

4. Teach proper breathing technique

5. Inspect the client’s suprapubic area and palpate for bladder distention. Encourage the client to void.

6. Provide information and update client on labor progress

Dependent

7. Administer

promote fetal descent.

Proper breathing technique can prevent exhaustion, therefore preventing prolonged delivery of the fetus and prolonged pain.

A full bladder contributes to discomfort and impedes fetal descent.

Helps alleviate any anxiety and fears that may exacerbate pain.

restless when contractions occur.

Responded to questions and instructions appropriately.

OBJECTIVES PARTIALLY MET

analgesia as orderedCollaborative

8. Refer to physician any abnormalities that may be observed.

Mechanism of action is to reduce pain.

To provide immediate medical intervention.

SUBJECTIVE DATA:Client verbalized concern about upcoming delivery and expresses worries about her child inside her womb.

OBJECTIVE DATA:Exhibit poor eye contact

Facial tension observed

Impaired attention noted

Anxiety related to hospitalization and upcoming delivery process

Within our care, client will manage anxiety with positive coping mechanisms as evidenced by:

V/S within normal range:T: 36.5-37.5PR: 60-100bpmRR: 12-20cpm BP: 110-140/60-90mmHg

Acknowledge and discuss fears, recognizing healthy vs. unhealthy fears

Independent1. Monitor Vital Signs

2. Assess level of anxiety through verbal and non-verbal cues.


4. Allow client to express fears and feelings of anxiety appropriately.

To obtain baseline data.

Identify areas of concern that might interfere with the normal progress of labor.

Enhances nurse-client relationship.

Provides a healthy outlet of emotions and relieves anxiety.

Adequate

At the end of our care, the client was able to:



Claimed that she’s worried about the condition of her baby.

Verbalized that she is capable of

Appears preoccupied; decreased perceptual field.

Absence of facial tension and improved attention span.

Verbalizes control of the situation

Verbalizes desire to participate in labor process as tolerated

Expresses confidence in herself, her support person, and the healthcare personnel.

Acquires knowledge about childbirth and is better prepared to cope with future births

5. Acknowledge normalcy of fear and provide opportunity for questions and answer honestly within client’s level of understanding.

6. Offer support by staying with the patient, pating her arms, and brushing a whisp of hair off her forehead, and provide a cool cloth on her forehead as needed.

Dependent1. Administer anti-anxiety medication as ordered by the physician.

Collaborative1. Refer to support groups as needed.

explanation helps reduce anxiety, soothe fears, and provides assurance.

Provides feeling or sense of security and trust between the nurse and the patient.

Mechanism of action is to relieve anxiety.

Provides ongoing and timely support.

delivering the baby.

Claimed excited to see her baby.

She claimed that she trusts the nurses in the hospital.


SUBJECTIVE DATA:Client requested for a glass of water since she feels thirsty as reported.

OBJECTIVE DATA:Vital signs:T=37˚CRR=14 cpmBP= 138/74 mmHgPR= 72 bpm

Received D5LR at right metacarpal vein flowing at 33 gtts/min

Risk for fluid volume deficit related to prolonged lack of oral intake and diaphoresis

Within our care, our client will maintain adequate fluid volume and electrolyte balance as evidenced by:


Adequate urinary output with normal specific gravity

Exhibit moist mucous membrane, good skin trugor, and prompt capillary refill.

Verbalize

Independent:1. Assess patient’s hydration status:

• Monitor V/S• Do PA (skin

turgor, mucous membranes, and capillary refill).

• Observe urinary output, color, measure amount, and specific gravity.

• Review lab data (Hb/hct, serum electrolytes).

2. Provide frequent oral and skin care.

3. Discuss

To obtain baseline data. Determine alterations in fluid volume and electrolyte imbalance.

To maintain skin integrity, prevent dehydration and preserve kidney function.

To prevent

Within our care, the client was able to



Exhibited moist mucous membrane; has good skin turgor, and prompt capillary refill.


understanding of withholding food and fluids during labor

Demonstrate behaviors to monitor and prevent dehydration as indicated.

importance of withholding food and water during the entire labor course.

4. Identify means to prevent dehydration such as providing ice chips or saturate OS with water to be sipped by the pt.

Dependent:5. Assist in IV infusion as ordered.

aspiration which can lead to respiratory distress.

To prevent dehydration and preserve kidney function.

To prevent dehydration and preserve kidney function

2nd stage of labor


SUBJECTIVE DATA:Client verbalized she is worried about the delivery of the baby because this will be her first time to do so.

OBJECTIVE DATA:Exhibit poor eye contact

Facial tension and grimacing observed

Impaired attention noted

Appears preoccupied; decreased perceptual field.

Anxiety related to lack of knowledge about labor experience

Within our care, our client will manage anxiety with positive coping mechanisms as evidenced by:

Verbalize awareness of feelings of anxiety

Verbalize willingness to cooperate and follow instructions carefully during the entire course of labor

Manifest positive attitude towards healthcare personnel and support persons.

Verbalizes control of the situation

Independent:1. Assess level of anxiety through verbal and non-verbal cues.


3. Allow client to express fears and feelings of anxiety appropriately.

4. Acknowledge normalcy of fear and provide opportunity for questions and answer honestly within client’s level of understanding

5. Assist pt. in

Identify areas of concern that might interfere with the normal progress of labor. Enhances nurse-client relationship.

Provides a healthy outlet of emotions and relieves anxiety.

Adequate explanation helps reduce anxiety, soothe fears, and provides assurance.

This position aids in the easy expulsion of the fetus, thus


Verbalized desire to participate actively through effective pushing


Verbalize desire to participate actively during the course of labor

Acquires knowledge about childbirth and is better prepared to cope with future births

proper positioning – Lithotomy position

6. Promote effective second-stage pushing by instructing client to push with each contractions and rest between them

reducing stress and anxiety from prolonged labor

SUBJECTIVE DATA:Client was frequently shouting and moaning. Reported slight difficulty in bearing down.

OBJECTIVE DATA:Sighing and moaning observed

Facial tension and grimacing noted

Altered comfort: Pain related to bearing down efforts and distention of the perineum

Within our care, our client shall actively participate in labor and cope with the discomfort effectively as evidenced by:

Verbalize pain within tolerable limits.

Verbalize desire to continue with the labor process.

Independent:1. Assess the degree of pain and its characteristics, location, severity, duration, and frequency.


3. Accept patient’s description of pain

Provide baseline data for future interventions

Gives pt a sense of trust and Improves nurse-client relationship.

Pain is a subjective experience and cannot be felt by


Claimed that she can deliver the baby.

Perceived labor experience in a positive light and comply with the instructions of the physician effectively.

Restlessness observed

Profuse sweating noted

Perceive labor experience in a positive light and comply with the instructions of the physician effectively.

Demonstrate use of relaxation and diversional activities as indicated (Guided-imagery, Deep-breathing).

Demonstrate proper breathing techniques

4. Support pt. pain-coping activities:Offer support by staying with the patient, pating her arms, and brushing a whisp of hair off her forehead, and provide a cool cloth on her forehead as needed.

5. Instruct patient to do proper breathing technique (panting).

Collaborative:6. Participate in the delivery process with other health care team members (Doctor/Midwife, Handle, Assist, IC, and Circulating)

others.

Provides feeling or sense of security and trust between the nurse and the patient.

Proper breathing technique can prevent exhaustion, therefore preventing prolonged delivery of the fetus and prolonged pain.

To minimize workload, therefore saving time and making the delivery of the fetus faster.

Demonstrated proper breathing techniques


SUBJECTIVE DATA:Client reported difficulty in breathing and cried for help.

OBJECTIVE DATA:Hyperventilation noted

RR= 31cpm

Appears restless

Profuse sweating noted

Ineffective breathing pattern related to inadequate lung expansion secondary to immobility

Within our care, the client will improve breathing pattern as manifested by:

RR will be within the normal range (16-20cpm).

Establish a normal/ effective respiratory pattern

Be free from cyanosis and other signs of hypoxia

Participate actively in the labor process

Demonstrate appropriate coping behavior to promote proper breathing

Independent:1. Assess for concomitant pain/ discomfort

2. Encourage deep breathing exercise

3. Maintain calm attitude while dealing with client

4. Encourage pt. to assume various position during active labor (ex. Squatting position)

Encourage rest period between bearing down

Pain can limit respiratory effort

Facilitates alveolar lung expansion thus improving gas exchange

To limit level of anxiety

Various positions facilitates lung expansion and easy expulsion of the fetus.

To limit fatigue


Was free from cyanosis and other signs of hypoxia

Participated actively in the labor process through effective pushing

Demonstrated appropriate coping behavior to promote proper breathing such as using deep breathing technique.


3rd stage of labor


SUBJECTIVE DATA:Claimed that she’s not allowed to drink or eat since she entered the delivery room.

OBJECTIVE DATA:Placenta delivered at: 12:12 pm

Gush of blood is present during the delivery of the newborn and placenta

Vital signs:T = 37˚C PR = 72 bpmRR= 14 cpmBP = 138/74 mmHg

Risk for Fluid Volume Deficit related to hypovolemia secondary to excessive blood loss

Within our care, our client will maintain adequate fluid volume and electrolyte balance as evidenced by:


Adequate urinary output with normal specific gravity

Exhibit moist mucous membrane, good skin trugor, and prompt capillary refill.

Independent:1. Assess patient’s hydration status:

• Monitor V/S (Check BP right after expulsion of placenta)

• Do PA (skin turgor, mucous membranes, and capillary refill).

• Observe urinary output, color, measure amount, and specific gravity.

• Review lab data (Hb/hct, serum electrolytes).

2. Provide frequent

To obtain baseline data. Determine alterations in fluid volume and electrolyte imbalance.

To preserve skin integrity, prevent dehydration and preserve kidney




Exhibited moist mucous membrane, good skin trugor, and prompt capillary refill.


oral and skin care.

Dependent:3. Assist in IV infusion as ordered.

4. Administration of methergin as ordered

function.

Prevent dehydration and preserve kidney function.

Promotes uterine contraction which prevents uterine atony or bleeding

SUBJECTIVE DATA:Claimed to feel slight pain during episiorrhaphy

OBJECTIVE DATA:Weak and exhausted

Facial grimacing is evident

Eyes are closed as observed

Altered Comfort: Pain related to tissue trauma secondary to medial episiorrhaphy

Within our care, the client will:

Report pain reduction, from a scale of 7 to 5

Demonstrate use of relaxation skills and diversional activities

Exhibit absence of facial grimacing

Manifest normal RR

1. Assess the level of pain experience by the client and her ability to perform normal task such as eating, breastfeeding and dressing

2. Check vital signs

Assessing the pain level experienced by the client determines her capability to comply with other interventions

Serves as comparison from previous measurements thus determine any improvement or

Within our care, the client:

Reported pain perception as having a numeric value of 3

Able to perform breathing exercise

Able to exhibit minimal pain gramacing

RR= 18 cpm

Moaning and crying can be heard from the patient but didn’t screamed or gave any verbalizations

Narrowed focus is evident (reduced interaction with people)

Rated pain as 4 in a scale of 1-10, 1 as the lowest and 10 as the highest

( 12-20 cpm)

Verbalize method that provide relief 3. Review client’s

previous experiences with pain and methods found helpful for pain control in the past

4. Provide comfort measures ( backrub, therapeutic touch)

5. Encourage the use of relaxation technique such as deep breathing and imagery

further deterioration of the client’s condition

Identify possible ways on how to handle the pain experiences by the client

To provide nonpharmacologic pain management

May help decrease pain perception by interrupting the conduction of nerve pain impulse

Verbalized “ Mo inom ko og tambal kung sakitan na jud ko kaayo pareha anang mag sakit akong pus-on kung reglahon ko.”


4th stage of labor


SUBJECTIVE DATA:Client verbalized:“naa pay mga nanggawas nga dugo sa akong kinatawo”

“ sakit pa e lihok ang sa akong paa dapit”

OBJECTIVE DATA:Method of delivery: NSVD with thick meconium staining

Episiotomy area is Swollen and reddish in color.

Risk for infection r/t impaired skin integrity secondary to medial episiotomy

Within our care, the client will:

Not exhibit any signs and symptoms of infection such as fever and chilling

Identify interventions to prevent/ reduce risk of infection

Verbalized understanding of individual risk factors

1. Monitor vital signs especially temperature

2. Note signs/ symptoms of fever, pallor and chills

3. Perform surgical handwashing before and after doing perineal care on the site of episiotomy

4. Explain why and how infection is likely to happen

5. o perineal care and teach the mother on the importance of proper perineal cleaning

A slight elevation in temperature suggests fever.To assess if infection is occurring

To prevent infection to the area and inhibit cross contamination

Give the client the idea on the causative factors on infections formation

Perineal area should be cleansed well to prevent the growth of microorganisms

Within our care, the client:

Did not manifest the signs of infection (fever and chilling) T = 37.4C

Listened upon explanation on the a factor ( impaired skin integrity ) of developing infection

Was not able to verbalize an understanding of the risk factors


SUBJECTIVE DATA:Client verbalized,“naa pay mga nanggawas nga dugo sa akong kinatawo”

“ sakit pa e lihok ang sa akong paa dapit”

OBJECTIVE DATA:Method of delivery: NSVD with meconium staining

Episiotomy area is Swollen and reddish in color.

Impaired skin integrity r/t episiotomy secondary to vaginal delivery

Within our care, client will have improved skin integrity as evidenced by:

Episiotomy will heal in due time without infection

Identify signs and symptoms of infection that can further impair skin integrity

Verbalized understanding of individual risk factors

Verbalize understanding on the need to maintain proper personal hygeine

1. Inspect status of the perineum

2. Check clients medical record and lab findings especially platelet count, bleeding time, clotting time

3. Instruct and assist the pt. In the use of sitz bath

4. Teach pt. How to apply and remove maternity perineal pad

5. Instruct pt. To watch for s/s of infection such as: fever, foul odor on

Detect signs and symptoms of possible infection

Any deviation may suggest blood clotting/coagulation is impaired and healing will be affected.

Sitz bath aids in healing process by increasing circulation to the perineum and prevent edema.

Provide knowledge on how to apply and remove pads that can help maintain skin integrity.

Suggests infection has occurred and immediate intervention is required.

Within of our care, client had improved skin integrity as evidenced by:

Episiotomy healed without infection

Regained skin integrity

Identified s/s that suggest infection have occurred.


Documents

Nursing Care Plan of the Mother