Nursing care plan Of The Mother

Nursing mother Prenatal Assessment Cues/Evidence Evaluation Nursing Diagnosis Objective

Care

Plan

of

the

Intervention

Rationale

SUBJECTIVE DATA: Patient verbalized that easily wakes she up whenever she hears Furthermore, noise. she reported frequent awakenings during the to go bathroom night 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 area near the her buttocks due to the pressure she feels on her chest which affects her breathing. said that She also she with a pillow sleeps

Disturbed sleep pattern shortness of breath urinary frequency

r/t and

Within our care, the will client improve sleep as pattern evidenced by: Absence of dark circles under eyelids and frequent yawning , improved face expression Verbalized understandin g the cause on of sleep disturbance Report increase d

1. Assess vital signs especially her blood level pressure 2. Encourage the mother to void before sleepin g

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

3. Provide a quiet environment conducive for sleeping

Within our care, the client had improved sleeping pattern as evidenced by: Absence of dark under circles 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

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

and a blanket. (We to inquire about failed her having nightmares or sleepwalking). She a nap when takes she like taking a feels nap only for a short but time. OBJECTIVE DATA: Sleepy eyed noted Dark circles under eyeli dbserved o Frequent yawning noted Vital signs: T=37C RR=14 cpm BP= 138/74 mmHg PR= 72 bpm

sense of well being and feeling of rested Report an increase d number of hours of sleep

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

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

SUBJECTIVE DATA: Client verbalized that feels sad she 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 inpositive a light

2. Employ a calm, caring, confident, and non-judgmental approach . 3. Discuss with mother physiologic changes during pregnancy

Improves nurse-relationship. client Creates a sense of at the same trust time educate mother about changes during pregnanc y To create a positive outlet of emotions

4. Allow pt to express feelings towards her pregnanc y 5. Teach pt coping strategies: Preparing for upcoming delivery literary Provide articles about pregnanc y

image as evidenced by: Expressed positivetowards feeling self and others. Verbalized acceptance of body image:na man Ok ako pagkita sa ako kaugalingon Perceived pregnancy in a positive light and claimed she is excited to see her baby . OBJECTIVES FULLY MET

Help overcome maladaptiv e behaviors

1st stage of labor Cues/ Evidence Evaluation Nursing Diagnosis Objectives Interventions Rationale

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 experienc e increased comfort as evidenced by: within normal V/S range: T: 36.5-37.5 PR: 60-100bpm RR: 12-20cpm BP: 110-140/6090mmHg Verbalization pain tolerable within limits throughout the duration of labor Verbalize discomfort as controlled with nonpharmacologic methods Rates pain as < 8 a scale of 1-10, in 10 as the highest and 1 is the lowest.

Independen t Monitor vital 1. signs every 15 minutes for 2 hours and 30 minutes until stable. 2. Assess contraction patterns, bloody show and the degree of pain and its characteristics, location, severity, and duration, frequency .

To baseline data.

obtain

Within our care, the was able to: client Maintained v/s within normal range:

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 venousand return enhances placental circulation. Position changes promote comfort , reduce muscle tension, relieve pressure and

T: 37.4C PR: 66bpm RR: 16cpm BP: 110/70mmhg Verbalize pain tolerable within limits. Verbalize discomfort as controlled with non-pharmacologic methods Rated pain as 8 in a scale of 1 10 Groaning, facial grimacing not noted. and

3. Provide comfort measures: Encourage comfortable positioning. Position the client in a left side lying position.

Was observed to be

Absence of expressiv e behaviors such as restlessness , moaning, sighing, irritability, and facial grimacing. Verbalize desire to participate in labor as tolerated Responds to questions and instructions appropriatel y Identifies need for additional pain measures as relief tolerated.

Encourage client to assume different positions and change them regularly.

promote fetal descent .

restless when contractions occur. Responded to questions and instructions appropriately . OBJECTIVE S PARTIALLY MET

4. Teach proper breathing technique

5. Inspect the clients suprapubic area and palpate for bladder distention. the Encourage client to void. 6. Provide information and update client on labor progress Dependen t 7. Administer

Proper breathing technique can prevent exhaustion, therefore preventin g prolonged delivery and of the fetus prolonged pain. A full bladder contributes to discomfort and impedes fetal descent . Helps alleviate any anxiety and fears that may exacerbate pain.

analgesia as ordered Collaborative 8. Refer to physician any abnormalities that may be observed. 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 hospitalizatio n and upcoming delivery process Within our care, client will manage anxiety with positive coping mechanisms as evidenced by: V/S within normal range: T: 36.5-37.5 PR: 60-100bpm RR: 12-20cpm BP: 110-140/6090mmHg Acknowledge and discuss fears, recognizing healthy unhealthy vs. fears Independen t Monitor Vital 1. Signs 2. Assess level of anxiety through verbal and nonverbal cues.

Mechanism of action is to reduce pain. To provide immediate medical intervention.

To baseline data.

obtain

At the end of our care, the client was to: able Maintained v/s within normal range: T: 37.4C PR: 66bpm RR: 16cpm BP: 110/70mmhg Claimed that shes about the worried condition of her baby . Verbalized that she is capable of

Identify areas of concern that might interfere with the normal progress of labor. Enhances nurse-relationship. client Provides a healthy emotions outlet of and relieves anxiety . Adequat e

3. Employ a calm, caring, confident, and nonjudgmental approach . 4. Allow client to express fears and feelings of anxiety appropriately .

Appear s preoccupied ; decrease d 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 healthcar e personnel. Acquires knowledge about childbirth and is better prepared to cope with future births

5. Acknowledge of normalcy fear and provide opportunity for questions and answer honestly within clients level of understanding. 6. Offer support by staying with the patient, pating her arms, and brushingof hair off a whisp her forehead, and provide a cool cloth on her forehead as needed . Dependent 1. Administer antianxiety medication by as ordered the physician . Collaborative 1. Refer to support groups as needed.

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

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

delivering the baby. Claimed excited to see her baby. She claimed that trusts the she nurses in the hospital. OBJECTIVE S PARTIALLY MET

Mechanism of action is to relieve anxiety .

Provides ongoing and timely support.

SUBJECTIVE DATA: Client requested for a glass of water since she feels thirsty as reported. OBJECTIVE DATA: Vital signs: T=37C RR=14 cpm BP= 138/74 mmHg PR= 72 bpm Received D5LR at right metacarpal at 33 vein flowing gtts/min

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

Within our care, our client will maintain adequate fluid volume and electrolyte balance as evidenced by: V/S within normal range: T: 36.5-37.5 PR: 60-100bpm RR: 12-20cpm BP: 110-140/6090mmHg Adequate urinarywith normal output specific gravity Exhibit moist mucous membrane, good skin trugor, and prompt capillary refill. Verbalize

Independent : 1. Assess patients status: hydration Monitor V/S Do PA (skin turgor, mucous membranes , and capillary refill). Observ e urinary output, color, measure amount, and specific gravity . Review lab data (Hb/hct, serum electrolytes). 2. Provide frequent oral and skin care.

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

Within our care, the was able to client Maintained v/s within normal range: T: 37.4C PR: 66bpm RR: 16cpm BP: 110/70mmhg Exhibited moist mucous membrane; has good skin and prompt turgor, capillary refill.

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

OBJECTIVE S PARTIALLY MET

3. Discuss

understanding of withholding food and fluids during labor Demonstrate behaviors to monitor and prevent dehydration as indicated.

importance of withholding food and water during labor the entire course. 4. Identify means to prevent dehydration as such providingor saturate ice chips OS with water to be sipped by the pt. Dependent : . Assist in 5 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

Cues/ Evidence Evaluation SUBJECTIVE DATA: Client verbalized she is worried about the delivery of the baby because this be her first time will to do so. OBJECTIVE DATA: Exhibit poor eye contact Facial tension and grimacing observed Impaired attention noted Appear s preoccupied ; decrease d perceptual field.

Nursing

Diagnosis

Objectives

Interventions

Rationale

Anxiety related to of knowledge lack about labor experience

Within our care, our client will manage anxiety with positive coping mechanisms as evidenced by: Verbalize awareness of of feelings anxiet y Verbalize willingness to cooperate and follow instructions carefully during the course of entire labor Manifest positive attitude towards healthcar e personnel and support persons. Verbalizes control of the situation

Independent : Assess level 1. of anxiety through verbal and nonverbal cues. 2. Employ a calm, caring, confident, and nonjudgmental approach . 3. Allow client to express fears and feelings of anxiety appropriately . 4. Acknowledge of normalcy fear and provide opportunity for questions and answer honestly within clients level of understanding 5. Assist pt. in

Identify areas of concern that might interfere with the normal progress of labor. Enhances nurse-relationship. client Provides a healthy emotions outlet of and relieves anxiety . Adequat e explanation helps reduce anxiety, fears, soothe and provides assurance.

Within our care, the was able to: client Verbalized desire to participate actively effective through pushing OBJECTIVE S PARTIALLY MET

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

Verbalize desire to participate actively course of during the labor Acquires knowledge about childbirth and is better prepared to cope with future births

proper positioning Lithotomy position

reducing stress and anxiety from prolonged labor

6. Promote effective secondstage pushing by instructing client to push with each contractions and rest between them Independent : 1. Assess the degree of pain and its characteristics, location, severity, and duration, frequency . 2. Employ a calm, caring, confident, and nonjudgmental approach . 3. Accept patients of pain description Within our care, the was able to: client Claimed that she can deliver the baby . Perceived labor experience in a positive light and comply with the instructions of the physicia n effectively .

SUBJECTIVE DATA: Client was frequently shouting and moaning. slight Reported difficulty in bearing down. OBJECTIVE DATA: Sighing and moaning observed Facial tension and grimacing noted

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

Within our care, our client shall actively in labor participate and cope with the discomfort effectively as evidenced by: Verbalize pain tolerable within limits. Verbalize desire to continue with the labor process.

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

Restlessness observed Profuse sweating noted

Perceive labor experience in a positive light and comply with the instructions of the physicia n effectively . Demonstrate use of relaxation and diversional activities as indicated (Guidedimagery, Deepbreathing) . Demonstrate proper breathin g techniques

others. 4. Support pt. pain- activities: coping 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) . Provides feeling or sense of security and trust between the nurse and the patient.

Demonstrated proper breathing techniques OBJECTIVE S PARTIALLY MET

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

Proper breathing technique can prevent exhaustion, therefore preventin g prolonged delivery and of the fetus prolonged pain. To minimize workload, therefore saving time and making the delivery faster. of the fetus

SUBJECTIVE DATA: Client reported difficulty in breathing and cried for help. OBJECTIVE DATA: Hyperventilatio n noted RR= 31cpm Appears restless Profuse sweating noted

Ineffective breathing pattern to related inadequate lung expansion secondary to immobilit y

Within our care, the will improve client breathing pattern as manifested by: RR will be within the normal range (1620cpm). Establish a normal/ effective respiratory pattern Be free from cyanosis and other signs of hypoxia Participate actively in the labor process Demonstrate appropriate coping to behavior promote proper breathin g

Independent : Assess for 1. concomitant pain/ discomfort 2. Encourage deep breathing exercise 3. Maintain calm while attitude 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 exchang e To limit level of anxiet y

Within our care, the was able to: client Was free from cyanosis and other signs of hypoxia Participated actively in the labor process effective through pushing Demonstrated appropriate coping to promote behavior proper breathing using such as deep breathin g technique. OBJECTIVE S PARTIALLY MET

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

3rd stage of labor Cues/ Evidence Evaluation SUBJECTIVE DATA: Claimed that shes not allowed to drink or eat since she entered the delivery room. OBJECTIVE DATA: Placenta delivered pm at: 12:12 Gush of blood is present during the delivery of the newborn and placenta Vital signs: T = 37C PR = 72 bpm RR= 14 cpm BP = 138/74 mmHg Nursing Diagnosis Objectives Interventions Rationale

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

Within our care, our client will maintain adequate fluid volume and electrolyte balance as evidenced by: V/S within normal range: T: 36.5-37.5 PR: 60-100bpm RR: 12-20cpm BP: 110-140/6090mmHg Adequate urinarywith normal output specific gravity Exhibit moist mucous membrane, good skin trugor, and prompt capillary refill.

Independent : 1. Assess patients status: hydration Monitor V/S (Check BP right after expulsion of placenta) Do PA (skin turgor, mucous membranes , and capillary refill). Observ e urinary output, color, measure amount, and specific gravity . Review lab data (Hb/hct, serum electrolytes). 2. Provide frequent

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

Within our care, the was able to: client Maintained v/s within normal range: T: 37.4C PR: 66bpm RR: 16cpm BP: 110/70mmhg Exhibited moist mucous membrane, good skin trugor, and prompt capillary refill. OBJECTIVE S PARTIALLY MET

To preserve skin integrity, prevent dehydration and preserve kidney

oral and care.

skin

function. Prevent dehydration and preserve kidney function. Promotes uterine contraction which prevents uterine atony or bleeding

Dependent : Assist in 3. IV infusion as ordered. 4. Administration of methergin as ordered SUBJECTIVE DATA: Claimed to feel slight pain during episiorrhaph y OBJECTIVE DATA: Weak and exhausted Facial grimacing is evident Eyes are closed as observed Altered Comfort: to Pain related tissue trauma to secondary medial episiorrhaph y Within our care, the will: client 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 experienceclient by the and ability her to perform normal task such as eating, breastfeeding and dressin g 2. Check vital signs

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

Within our care, the client: Reported pain perception as having numeric 3 value of

Serves as comparison from previous measurements thus determine any improvement or

Able to perform breathing exercise Able to exhibit minimal pain gramacin g RR= 18 cpm

( 12-20 cpm) Moaning and crying be heard can from the patient but didnt screamed or gave any verbalizations Narrowed focus is evident (reduced with interaction people) Rated pain as 4 in a scale of 1-10, 1 as the lowest and 10 as the highest Verbalize method that provide clients relief 3. Review 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 imager y

further deterioration of the clients condition Identify possible how ways on to handle the pain experiences by the client

Verbalized Mo ko og tambal inom kung sakitan na jud ko kaayo pareha anang mag sakit akong pus-on kung reglahon ko. OBJECTIVE S PARTIALLY MET

To provide nonpharmacologic pain management May help decrease pain perception by interrupting the conduction of nerve pain impulse

4th stage of labor Cues/ Evidence Evaluation Nursing Diagnosis Objectives Interventions Rationale

SUBJECTIVE DATA: Client verbalized: naa pay mga nanggawas nga sa akong dugo kinatawo sakit lihok sa ang paa dapit pa e akong

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

Within our care, the will: client Not exhibit any signs and symptoms of infection such as fever and chilling Identif y 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, and chills pallor 3. Perform surgical handwashing before and after doing perineal care on the of episiotomy site 4. Explain why and infection is how likely to happen 5. o perineal care teach and the mother on the importance of proper perineal cleanin g

A slight elevation in temperature suggests fever. To assess if infection is occurring To prevent infection area to the and cross inhibit 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 of infection signs (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 risk factors the OBJECTIVE S PARTIALLY MET

OBJECTIVE DATA: Method of delivery: NSVD with thick meconium staining Episiotomy area is Swollen and reddish in color.

SUBJECTIVE DATA: Client verbalized, naa pay mga nanggawas nga sa akong dugo kinatawo sakit lihok sa ang paa dapit pa e akong

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 integrit y 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 the pt. In assist the of sitz bath use

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 increasin g circulation to the perineum and prevent edema. Provide knowledgeto apply on how 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 infection without Regained skin integrit y Identified s/s that suggest infection have occurred. OBJECTIVES FULLY MET

OBJECTIVE DATA: Method of delivery: NSVD with meconium staining Episiotomy area is Swollen and reddish in color.

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