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DATE TIME
MIDWIFERY DIAGNOSIS 16/3/11 Anxiety related to lower 10:30a abdominal m pains.
MIDWIFERY OBJECTIVE Mrs. Adjei will be relieved of anxiety within one hour as evidence by client verbalizing that she is no more anxious
MIDWIFERY ORDERS
MIDWIFERY INTERVENTION 1. Reassure 1. Mrs.Adjei Mrs. Adjei. was 2. Educ Educat ate e her her reassured on the 2. She was physiology of educated lower on the abdominal physiology pains and of lower waist pains in abdominal late pains and pregnancy waist pains 3. Crea Create te a in late quite pregnancy environment 3. Quiet for rest and environme sleep. nt for rest 4. Allo Allow w her her to and sleep ask questions was and answer created. tactfully. 4. Mrs. Adjei 5. Enco Encour urag age e was her to allowed to express her ask concerns questions and answers were provided tactfully. 5. She was encourage d to
DATE TIME
EVALU EVALUATI ATION ON
16/3/11 Goal fully met as Mrs 2:00pm Adjei said is no more anxious
SIGN SIGN
16/3/11 Alteration in nutritional 10:00a pattern (less m than body requirement) related to losss of apptite.
Mrs. Adjei will be able to eat half plate of food served within 24 hours as evidenced by Mrs Adjei verbalizing that she can eat more than half a plate of food served everyday.
1. Reassured
2.
3.
4.
5.
Mrs. Adjei that she will be able to eat food served everyday Serve Mrs .Adjei food in bits and in frequent interval. Serve her with attractive food Advice Mrs. Adjei to take fruits after every meal. Serve her with food of her choice
1. Mrs. Adjei
2.
3.
4.
5.
18\3\11
was 3;30pm reassured that she will be able to eat food served everyday. Food was served in bits and at frequent intervals. Foods were served attractivel y She took fruits after every meal. She was served with food of her choice
Goal partially met as Mrs. Adjei said she can now eat nore than half of the food that was served her.
16/3/11 10:00a m
Fatigue related to energy expenditure require during walking to the clinic
Mrs. Adjei will be relieved of fatigue as evidence by Mrs. Adjei verbalizing that she is no more tired.
1. Reassure Mrs 2.
3.
4.
5.
Adjei. Advise her to rest when she gets tired as she is walking . Support her emotionally and physically throughout her stay at the clinic. Advise her to ask questions and answer tactfully. Encourage family m embers to assist her in household chores
1. Mrs. Adjei
16/3/11
was 3:00pm reassured 2. She was advised to rest when she gets tired as she is walking. 3. She was supported emotionall y and physically through her stay at the clinic. 4. She was advise to ask questions and was answer tactfully. 5.Family members were asked to help her in household
Goals fully met as Mrs. Adjei said she was no more tired.
chores
16/3/11 Alteration in body comfort 9:30am (heart burns) related to pregnancy.
Mrs. Adjei will be relieved of heart burns within 48 hours as evidenced by Mrs. Adjei verbalizing that her heart burns has reduced.
1. Reassure Mrs 2.
3.
4.
5.
Adjei Educate her on the condition Encorage her to avoid taking too much spicy foods Encourage her to avoid going to bed immediately after eating. Assess her normal breathing pattern
1. Mrs Adjei
2.
3.
4.
5.
LABOUR CARE PLAN
18/3/11
was 3:30pm reassured She was educated on her condition She was educated to avoid taking too much spicy food She was encourage d to avoid going to bed immediat ely after eating Her normal breathing pattern was assessed
Goals fully met as Mrs. Adjei did not experience the heart burns after eating
DATE TIME
MIDWIFERY DIAGNOSIS
MIDWIFERY OBJECTIVES
4/4/11
Anxiety related to the unknown outcome of labour
Miss Doris will be relieved from anxiety within 6 hours as evidenced by Miss Doris verbalizing that she is no more anxious about the unknown outcome of labour.
6:00pm
MIDWIFERY ORDERS
1. Reassure Miss Doris 2. Explain every procedure to her 3. Educate Miss Doris on some of the possible outcome of labour. 4. Communicate all findings to her 5. Encourage her to ask questions and answer them
MIDWIFERY INTERVENTIONS
DATE TIME
1. Miss Doris 5/4/10 was 12:10p reassured m 2. Every procedure was explained to her 3. Miss Doris was educated on some of the possible outcomes of labour 4. All findings were communic ated to her 5. Encourage her to ask questions and answer them.
EVALUATION
Goals fully met as Miss Doris was relieved from anxiety
SIGN
4/4/11 6:00pm
Fatigue related to energy required during labour.
Miss Doris will be relieved of fatique within 6 hours as evidenced by Miss Doris verbalizing that she is no more tired.
1. Reassure Miss Doris 2. Explain the physiology of the stages of labour to her 3. Support her emotionally and physically throughout labour and pueperium. 4. Advise her to have some rest when contractions wear off. 5. Inform Miss Doris about the progress of labour after each procedure done on her.
1. Miss Doris
5/4/11
was 12:15p reassured m 2. The physiolog y of the stages of labour explained to her 3. Miss Doris was supported emotionall y and physically throughou t labour and pueperiu m. 4. Miss Doris was advised to have some rest when contractio ns wear off. 5. She was informed about the procedure
Goals fully met as Miss Doris was no more tired.
4/4/11 6:00pm
Potential for infection related to malhandling of perineal pad
Miss Doris will remain free from infection within 24hours as evidenced by the student midwife verbalizing that Miss Doris did not get any sign of infection
1. Reassure Miss Doris 2. Ensure that she charges perineal pad when soiled 3. Vaginal examinations should be done 4 hours intervals 4. Perform all procedures aseptically 5. Educate Miss Doris to avoid putting her hands at the Vulva
1. Miss Doris 5/4/11 was 12:00a reassured m 2. Miss Doris perineal pad was charged when soiled 3. Vaginal examinatio n was done on 4 hours intervals 4. Procedure was done aseptically 5. Miss Doris was told not to put her hands as the Vulva. 6. She was advised to wash her hands before and after touching perineal pads
Goals fully met as Miss Doris did not experience any sign of infection
4/4/11 6:00pm
Alteration in comfort (Labour pains) related uterine contractions
Miss Doris will have reduced painful uterine contractions within 6hours as evidenced by Miss Doris verbalizing that pain has reduced.
1. Reassure Miss Doris that pains will reduce after delivery. 2. Explain the physiology of painful uterine contractions to her. 3. Allow Miss Doris to walk around. 4. Give sacral massage to relieve pain 5. Educate her on breathing exercise.
1. Miss Doris 5/4/11 was 12:10p reassured m that the pain will reduce after delivery. 2. The physiolog y of painful uterine, uterine contractio n was explained to her. 3. She was encourage d to walk around. 4. She was given sacral massage to relieve pain 5. Miss Doris was educated on breathing exercise
Goals fully met as Miss Doris verbalizing that the pain has reduced
PUEPERIUM CARE PLAN DATE TIME
MIDWIFERY DIAGNOSIS
MIDWIFERY OBJECTIVE
MIDWIFERY ORDERS
MIDWIFERY INTERVENTIONS
DATE TIME
EVALUATION
SIGN
7/4/11 4:20pm
Alteration in comfort (frequency of micturition) related to physiology of pueperium.
Miss Doris will appreciate the need for emptying her bladder when she gets the urge to do so within 2 hours as evidenced by Miss Doris verbalizing that she has resumed her normal bladder habbit.
1. Reassure Miss Doris 2. Educate Miss Doris to empty her bladder whenever she gets the urge to do so. 3. Evaluate her bladder habit it normal 4. Explain the physiology of frequency of micturition
1. Miss Doris 7/4/11 was 7:00pm reassured 2. The physiology of frequency of micturition was explained to her 3. She was educated to empty her bladder whenever she gets the urge to do so 4. Her normal bladder habit was evaluated.
Goals fully met as Miss Doris has resumed her normal bladder habit.
7/4/11 4:20pm
Alteration in comfort (after pains) related to involution
Miss Doris will have a reduced after pains after within 48 hours as evidenced by Miss Doris verbalizing that the pain has reduced
1. Reassure her that the pains will reduce. 2. Explain the physiology of after pains to her. 3. Educate her on post natal exercises 4. Serve her with analgesics. 5. A comfortable bed was provided and a quiet environment was ensured
1. Miss Doris 9/4/11 was 6:30pm reassured 2. The physiolog y of after pains was explained to her. 3. She was educated on post natal exercises 4. She was served with analgesics 5. A comfortab le bed was provided and a quiet environme nt was ensured.
Goals fully met as Miss Doris had a reduced after pain
8/4/11 6:30am
Sleeping pattern disturbances related to demand feeding of baby at night
Miss Doris will sleep (89hours) daily within 24hrs as evidenced by
1. Reassure Miss Doris 2. Assess Mrs. Doris normal sleeping
1. Miss Doris was reassured 2. Miss Doris normal
9/4/11 6:30am
Goals fully met as Miss Doris said she had adequate
9/4/11
Alteration in bowel 6:30pm movement (constipation) related to inadequate intake of fluids.
Miss Doris will be able to make her bowel (normal range) within 24hours as evidenced by Miss Doris verbalizing that she was able to empty her bowel (once daily)
9/4/11
Miss Doris will have a reduced after pains within 48 hours as evidenced
4:20pm
Alteration in comfort (after pains) related to involution.
1. Reassure Miss Doris. 2. Advice her to take more fluids 3. Encourage her to have some exercise like walking. 4. Encourage her to empty her bowel when she gets the urge to do so
1. Reassure her that the pains will reduce. 2. Explain the
1. Miss Doris was reassured 2. She was advised to take more fluids. 3. Encouraged to have some exercises like walking 4. Miss Doris was encouraged to empty her bowel when she gets the urge to do so
1. Miss Doris reassured 2. The physiolog y of after
10/4/11 6:30pm
9/4/11 6:30pm
Goals fully met as Miss Doris empted her bowel once daily.
Goals fully met as Miss Doris had a reduced after pain.
8/4/11 6:30am
Sleeping pattern disturbances related to demand feeding of baby at night.
Miss Doris will sleep (89hours) daily with 24hrs as evidenced by Miss Doris verbalizing that she can now have adequate sleep.
1. Reassure
2.
3.
4.
5.
Miss Doris Assess Miss Doris normal sleeping pattern Advice her to take warm bath in the evening Encourage her to sleep when the baby is sleeping Encourage Miss Doris relatives to help her in the care of the baby for her to sleep during the day.
1. Miss Doris 9/4/11 was 6:30am reassured 2. Miss Doris normal sleeping pattern was assessed. 3. She was advised to take warm bath in the evening. 4. She was encourage d to sleep when the baby is sleeping 5. Miss Doris relatives were encourage d to help her in the care of the baby for her to sleep during the day.
Goals fully met as Miss Doris said she had adequate sleep
