NURSING CAREPLAN FOR POSTNATAL MOTHER (POST OPERATIVE DAY -1) (23/6/2019)

Assessment Nursing diagnosis Expected outcome Intervention Evaluation

Subjective data Pain related to surgical To reduce the level of Patient’s level of Patient will have reduce
Mrs. Rojalin says that, incision as evidenced by pain. pain, severity, pain after 1 days
i am having pain on visualization of facial duration of pain was
incision area expression. assessed.
Objective data Comfortable
Facial expression position provided.
i.e. tiredness Vital sign checked.
Calm and quiet
environment
Provided.
Visitors restricted.
Diversional therapy
was provided.
Analgesic dynaper
AQ 75 mg in 100ml
NS, IV was given as
per Physician advice

Subjective data Fluid volume deficiet To maintain fluid & Hydration status of Fluid volume level
She said I am feeling related to blood loss electrolyte balance. the client was maintained to some
thirsty during caesarean assessed extent
Objective data section Vital signs was
Dry mouth checked
I/O chart maintained
IV fluid was given as
per physician advice.
NURSING CAREPLAN FOR POSTNATAL MOTHER (POST OPERATIVE DAY -2)(24/6/2019)
Assessment Nursing diagnosis Expected Intervention Evaluation
outcome
Subjective data Pain related to To reduce the Patient’s level of pain, Patient will have reduce
Mrs. Rojalin says that, inadequate breast level of pain. severity, duration of pain was pain after 1 days
i am having pain on feeding as evidenced assessed.
breast area by engorgement of Comfortable position provided.
Objective data Breast. Vital sign checked.
Breast engorgement Warm compression was
provided
Health education to mother
regarding breast feeding
provided.
Manual expression of Breast
milk done

Subjective data Constipation related to To relief from Presence of bowel sound was Patient resume normal
Mrs. Rojalin says that i decreased muscle tone , constipation. auscultated elimination pattern
am having difficulty in lack of fluid intake Encouraged to drink at least six
passing stool glasses of water per day.
Encouraged deep breathing
and relaxation techniques.
Encourage for mild ambulation.
NURSING CAREPLAN FOR POSTNATAL MOTHER (POST OPERATIVE DAY -3)(25/6/2019)
Assessment Nursing diagnosis Expected Intervention Evaluation
outcome
Subjective data Activity intolerance Mother Assess mother’s level of Mother activity level
Mrs. Rojalin says that, i related to pain in the maintains mobility. increased up to some
feel very weak to incision site and activity level Encourage adequate rest extent.
perform any task weakness. within normal periods especially before
Objective data limit. ambulation.
Can not able to move by Assistance was given to mother
self for mobility.
Ambulate mother as early as
possible.

Subjective data Knowledge deficiet To improve Assisted client in identifying Patient verbalizes
She said I don’t know regarding self care, the needs, self care understanding of needs
how to give care to baby infant care knowledge of Provide information regarding
at home & self care the client & psychological changes
Objective data also relatives assosciated with post natal
Frequent asking period & also regarding Baby
regarding how to give care
care to baby at home & Discuss resumption of coitus
to self Provide information related to
follow up care
NURSING CAREPLAN FOR BABY (POST OPERATIVE DAY -1)(23/6/2019)
Assessment Nursing diagnosis Expected Intervention Evaluation
outcome
Assessed the vital sign, Ineffective To maintain Baby dressed with caps, socks, Vital sign maintained
weight, exposure to cold thermoregulation temperature dress and covered in warm within normal limits
related to exposure to within normal blankets
environment. range. New born placed in Prewarm
environment or in Ptient’s arms
K.M.C maintained
Exclusive breast feeding
continued
NURSING CAREPLAN FOR BABY (POST OPERATIVE DAY -2)(24/06/2019)

Assessed maternal risk Potential risk of To reduce risk Risk of infection was assessed Baby developed no signs
factor infection related to of infection Cord care given of infection
newly clamped umbilical Dressed with clean dress
cord Strict aseptic precaution
maintained while handling the
baby
NURSING CAREPLAN FOR BABY (POST OPERATIVE DAY -3)(25/6/2019)
Assessment Nursing diagnosis Expected Intervention Evaluation
outcome
Assessed the newborn Risk for imbalanced To correct Baby weight was checked Neonates remain well
activity pattern e.g. nutrition less than body nutritional Hydration level was assessed hydrated & evidenced
Feeding pattern, sleep requirement evidenced status e.g. status of frontanells, urine adequate urine output
pattern, less than by decreased urine output, mucus membranes
average weight gain output. Mother was encouraged to
breastfeed baby properly

Assessed Parents Risk for injury related to To provide Demonstrate the use of Parent adopt behaviour
knowledge about inadequate knowledge safe, growth mummy restraint & nestling for that provide safe,
patient safety measures monitoring baby promoting environment
environment Discussed with mother & for the newborns.
relative about safety measures
 CASE STUDY
ON
“NORMAL VAGINAL DELIVERY WITH EPISIOTOMY”

SUBMITTED TO: SUBMITTED BY:

Mrs. Gomathi B. Mahalingam Ms. Itismita Biswal
Assosciate professor M.sc. nursing 1st year
Obstetrics & Gynaecological department Obstetrics & Gynaecological department
Sum nursing college, BBSR Sum nursing college, BBSR

SUBMITTED ON: