Nursing Care Plan of the Mother

Nursing care plan Of The Mother

Nursing Care Plan of the mother Prenatal Assessment 

Cues/Evidence

SUBJECTIVE DATA:

Nursing Diagnosis

Disturbed sleep

Patient verbalized that pattern r/t shortness she easily wakes up of breath and urinary whenever she hears frequency noise. Furthermore, 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

Objective

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

Intervention

Rationale

Evaluation

1. Assess vital signs especially her blood pressure level

Elevated blood pressure is usually observed in sleep disturbed client

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

2. Encourage the mother to void before sleeping

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

Absence of  dark circles under eyelids and frequent yawning, improved face 3. Provide a quiet expression environment conducive for sleeping Verbalized understanding on the cause of sleep 4. Promote use of  disturbance bedtime rituals such as drinking a glass of milk Report before sleeping, taking increased a bath, reading a book

A quiet environment promotes continuation of  sleep without disturbances Promotes relaxation and readiness for

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.

sense of well – being and 5. Teach client to feeling of  elevate head by using rested more pillows during sleep or have her on Report an side – lying position increased number of  hours of sleep

OBJECTIVE DATA:

Sleepy eyed noted

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

Dark circles under eyelid observed Frequent Frequent yaw ning noted Vital signs:  T=37˚C RR=14 cpm BP= 138/74 mmHg PR= 72 bpm 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.

associated with pregnancy

body image as manifested by:

Physiologic changes: Contour of the abdomen changes Presence of linea nigra on the abdomen

Improves nurseclient relationship.

image as evidenced by:

Expressed positive feeling towards Creates a sense of  self and others. 3. Discuss with mother trust at the same physiologic changes time educate Verbalized during pregnancy mother about acceptance of  changes during body image: Verbalize pregnancy “Ok na man ako acceptance of  pagkita sa ako body image 4. Allow pt to express  To create a kaugalingon” feelings towards her positive outlet of  Perceived pregnancy emotions Perceived pregnancy in pregnancy in a a positive positive light and light 5. Teach pt coping claimed she is strategies: Help overcome excited to see her maladaptive baby. Preparing for upcoming delivery behaviors Provide literary OBJECTIVES FULLY articles about MET pregnancy

Express positive feeling towards self  and others

OBJECTIVE DATA:

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

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1st  stage of labor 

Cues/ Ev Evidence

Nursing Di Diagnosis

Objectives

Interventions

Rationale

Evaluation

SUBJECTIVE DATA:

Altered comfort: pain related to Client verbalized increased uterine excruciating pain on contractions and the abdomen and pressure on further stated that pelvic structures

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

Within our care, client shall experience increased comfort as evidenced by: V/S within normal range:   T: 36.5-37.5 PR: 60-100bpm RR: 12-20cpm BP: 110-140/6090mmHg

Independent 1. Monitor vital  To obtain baseline signs every 15 data. minutes for 2 hours and 30 minutes until stable.

Within our care, the client was able to:

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

 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.

 T: 37.4C PR: 66bpm RR: 16cpm BP: 110/70mmhg

Verbalize discomfort as 3. Provide comfort controlled with non- measures: pharmacologic Encourage methods comfortable positioning. Rates pain as < 8 Position the in a scale of 1-10, client in a 10 as the highest left side lying and 1 is the lowest. position.

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

Verbalization Verbalization pain within tolerable limits throughout the duration of  labor

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Restlessness noted especially during exacerbation of  contractions.

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Maintained v/s within normal range:

Verbalize Verbalize pain within tolerable limits. Verbalize Verbalize discomf ort 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

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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.

promote fetal descent.

Proper breathing technique can 4. Teach proper breathing technique prevent exhaustion, therefore preventing prolonged delivery of the fetus and prolonged pain. 5. Inspect the A full bladder client’s suprapubic area and palpate for contributes to discomfort and bladder distention. impedes fetal Encourage the descent. client to void. 6. Provide information and update client on labor progress Dependent 7. Administer

Helps alleviate any anxiety and fears that may exacerbate pain.

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

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: 36.5-37.5 PR: 60-100bpm RR: 12-20cpm BP: 110-140/6090mmHg Acknowledge and discuss fears, recognizing healthy vs. unhealthy fears

analgesia as ordered Collaborative

Mechanism of  action is to reduce pain.

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

 To provide immediate medical intervention.

Independent 1. Monitor Vital Signs

At the end of our   To To obtain baseline baseline care, the client was data. able to:

2. Assess level of  anxiety through verbal and nonverbal cues.

Identify areas of  Maintained v/s concern that might within normal interfere with the range: normal progress of  labor.  T: 37.4C PR: 66bpm Enhances nurseRR: 16cpm client relationship. BP: 110/70mmhg

3. Employ a calm, caring, confident, and non-judgmental approach. Provides a healthy outlet of emotions 4. Allow client to and relieves express fears and anxiety. feelings of anxiety appropriately. Adequate

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

Appears preoccupied; decreased perceptual field.

Absence of facial tension and improved attention span.

5. Acknowledge normalcy of fear and provide opportunity for Verbalizes Verbalizes control of  questions and the situation answer honestly within client’s level Verbalizes desire to of understanding. participate in labor process as tolerated 6. Offer support by staying with the Expresses patient, pating her confidence in arms, and brushing herself, her support a whisp of hair off  person, and the her forehead, and healthcare provide a cool cloth personnel. on her forehead as needed. Acquires knowledge about childbirth and Dependent  is better prepared to cope with future 1. Administer antibirths anxiety medication as ordered by the physician. Collaborative

1. 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. OBJECTIVES PARTIALLY PARTIALLY MET

SUBJECTIVE DATA:

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

Vital signs:  T=37˚C RR=14 cpm BP= 138/74 mmHg PR= 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: V/S within normal range:   T: 36.5-37.5 PR: 60-100bpm RR: 12-20cpm BP: 110-140/6090mmHg Adequate urinary output with normal specific gravity

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). • •

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

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

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

2. Provide frequent oral and skin care.

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

Verbalize

3. Discuss

 To  To prevent preve nt

OBJECTIVES PARTIALLY PARTIALLY MET

understanding of  withholding food and fluids during labor

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

aspiration which can lead to respiratory distress.

Demonstrate behaviors to monitor and prevent dehydration as indicated.

 To  To prevent preve nt 4. Identify means to dehydration and prevent dehydration preserve kidney such as providing function. ice chips or saturate OS with water to be sipped by the pt. Dependent: 5. Assist in IV  To  To prevent preve nt infusion as ordered. dehydration and preserve kidney function

2nd  stage of labor 

Cues/ Ev Evidence

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.

Nursing Di Diagnosis

Objectives

Anxiety related to lack of knowledge about labor experience

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

Interventions

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

Verbalize Verbalize awareness 2. Employ a calm, of feelings of  caring, confident, anxiety and non-judgmental approach. Verbalize willingness to 3. Allo Allow w clie client nt to cooperate and expr expres esss fears fears and and follow instructions feelin feelings gs of anxiety anxiety carefully during the appropriately. entire course of  labor 4. Acknowledge normalcy of fear Manifest positive and provide attitude towards opportunity for healthcare questions and personnel and answer honestly support persons. within client’s level of understanding Verbalizes Verbalizes control of  the situation 5. Assist pt. in

Rationale

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

Evaluation

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

Enhances nurseclient relationship. OBJECTIVES PARTIALLY PARTIALLY MET 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

proper positioning – reducing stress and Verbalize desire to Lithotomy position anxiety from participate actively prolonged labor during the course of  labor 6. Promote effective Acquires knowledge second-stage about childbirth and pushing by is better prepared instructing client to to cope with future push with each births contractions and rest between them 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:

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

Verbalize Verbalize pain within tolerable limits.

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

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

3. Accept patient’s description of pain

Pain is a subjective experience and cannot be felt by

Verbalize desire to continue with the labor process.

Provide baseline data for future interventions

Within our care, the client was able to: 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.

others.

4. Support pt. paincoping activities: Offe Offerr supp suppor ortt by stay stayin ing g with with the the patien patient, t, pating pating her arms, and brushing a whisp of hair off  Demonstrate use of  her forehe forehead, ad, and relaxation and provide a cool cloth diversional on her forehead as activities as needed. indicated (Guidedimagery, Deep5. Instruct patient breathing). to do proper breathing technique Demonstrate proper (panting). breathing techniques Collaborative: 6. Participate in the delivery process with other health care team members (Doctor/Midwife, Handle, Assist, IC, and Circulating)

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 OBJECTIVES PARTIALLY PARTIALLY MET

SUBJECTIVE DATA:

Client reported difficulty in breathing and cried for help.

Ineffective breathing pattern related to inadequate lung expansion secondary to immobility

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

Independent: 1. Assess for concomitant pain/ discomfort

RR will be within the 2. Encourage deep normal range (16breathing exercise 20cpm).

OBJECTIVE DATA:

Hyperventilation noted

Establish a normal/ 3. Maintain calm effective respiratory attitude while pattern dealing with client

RR= 31cpm Appears restless Profuse sweating noted

Be free from cyanosis and other signs of hypoxia Participate actively in the labor process Demonstrate appropriate coping behavior to promote proper breathing

4. Encourage pt. to assume various position during active labor (ex. Squatting position) Encourage rest period between bearing down

Pain can limit respiratory effort

Within our care, the client was able to: Was free from cyanosis and other signs of hypoxia

Facilitates alveolar lung expansion thus improving gas Participated actively exchange in the labor process through effective  To limit level of  pushing anxiety Demonstrated appropriate coping behavior to promote Various positions proper breathing facilitates lung such as using deep expansion and easy breathing expulsion of the technique. fetus.  To limit fatigue

OBJECTIVES PARTIALLY PARTIALLY MET

3rd  stage of labor 

Cues/ Ev Evidence

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 bpm RR= 14 cpm BP = 138/74 mmHg

Nursing Di Diagnosis

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

Objectives

Interventions

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

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).

V/S within normal range:   T: 36.5-37.5 PR: 60-100bpm RR: 12-20cpm BP: 110-140/6090mmHg Adequate urinary output with normal specific gravity Exhibit moist mucous membrane, good skin trugor, and prompt capillary refill.

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Rationale

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

Within our care, the client was able to: Maintained v/s within normal range:  T: 37.4C PR: 66bpm RR: 16cpm BP: 110/70mmhg

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

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OBJECTIVES PARTIALLY PARTIALLY MET

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2. Provide frequent

Evaluation

 To preserve skin integrity, prevent dehydration and preserve kidney

oral and skin care.

Dependent: 3. Assist in IV infusion as ordered.

function. Prevent dehydration and preserve kidney function.

Promotes uterine contraction which prevents uterine 4. Administration of  atony or bleeding methergin as ordered 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:

1. Assess the level of pain experience by the client and Report pain her ability to reduction, from a perform scale of 7 to 5 normal normal task task such such as eating, Demonstrate use of  breastfeeding and relaxation skills and dressing diversional activities 2. Check vital signs Exhibit absence of  facial grimacing Manifest normal RR

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 a numeric value of 3 Able to perform breathing exercise

Serves as comparison from previous measurements thus determine any improvement or

Able to exhibit minimal pain gramacing RR= 18 cpm

( 12-20 cpm) Moaning and crying can be heard from the patient but didn’t screamed or gave any verbalizations

Verbalize Verbalize method that that pro provi vide de relie elieff

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

further deterioration of the client’s condition 3. Revie eview w clie client nt’s ’s previous experiences with pain and methods found helpful for pain control in the past

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

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

4. Provide comfort measures ( backrub, therapeutic touch)

 To provide nonpharmacologic pain management

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

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

Interventions

Rationale

4th stage of labor 

Cues/ Ev Evidence

Nursing Di Diagnosis

Objectives

Evaluation

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

A slight elevation in temperature suggests fever.  To assess if  2. Note signs/ infection is symptoms of fever, occurring pallor and chills  To prevent infection 3. Perform surgical to the area and handwashing before inhibit cross and after doing contamination perineal care on the site of episiotomy Give the client the 4. Explain why and idea on the how infection is causative factors on likely to happen infections formation 5. o perineal care and teach the mother on the importance of  proper perineal cleaning

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

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

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

Detect signs and symptoms of  possible infection

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

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

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

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

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

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. OBJECTIVES FULLY MET