NURSING CARE PLAN FOR MOTHER :

SNO ASSESSMENT DIAGNOSIS PLANNING IMPLEMENTATION EVALUATION

1. SUBJ. DATA- Acute pain r/t  Assess level, intensity, duration of  Level, intensity, Patient’s pain
Patient complains child birth pain using pain scale. duration of pain is level is reduced to
of backache . discomfort. assessed some extent.
 Provide comfortable position.
OBJ. DATA-  comfortable position
Patient’s facial  Encourage early ambulation within provided.
expression 24 hours of delivery.
express pain and
she is looking  Early ambulation
restless., pain  Administer analgesics , as encouraged.
intensity 4 on prescribed.
visual analogue  Analgesics
scale. administered as
ordered.( tab voveron
50 mg)

2. SUBJ. DATA: Fatigue r/t  Monitor nutitional status and  Dietary pattern and Patient’s level of
Patient c/o decreased weight of client. weight of client fatigue is reduced
weakness even haemoglobin recorded. to some extent.
while doing and
simple physical diminished  Assist the client/caregivers in  Daily activity and rest
tasks and iron carrying developing a schedule for daily schedule planned and
anorexia. capacity of activity and rest. implemented.
blood.
OBJ. DATA: Pale
skin (pallor),  Importance of frequent
 weakness  Stress the importance of frequent rest told to client.
rest periods.
 Complete blood count
 Monitor hemoglobin, hematocrit,
monitored.
RBC count, and reticulocyte
counts.
 Oral iron tablet given
 Encourage patient to continue iron to client. Once a day
for 6 weeks on
therapy for a total therapy time
discharge.

3. SUBJ. DATA: Risk of  Assess patient’s risk factors for  Patient’s personal and Patient’s risk for
Patient c/o infection r/t developing infection like perineal hygiene infection is
itching in perineal inadequate inadequate personal and perineal assessed. decreased to
area. personal and hygiene. some extent .
perineal  Vitals monitored and
OBJ. DATA: Client hygiene.  Monitor vital signs. are normal.
has not
maintained her  Provide perineal care
personal as well  Perineal care given.
as perineal  Stress the importance of well
hygiene as balanced diet including iron rich  Health education given
evidenced by food and iron tablet. on importance of well
unclean balanced diet.
perineum and  Antibiotics
dirty and long  Administer antibiotics as ordered. administered as
finger and toe ordered.
nails.
 NURSING CARE PLAN FOR BABY:
SNO ASSESSMENT DIAGNOSIS PLANNING IMPLEMEMTATION EVALUATION
1 SUBJ DATA: Risk of  Monitor vital signs.  Vitals monitored and Risk of
mother says that ineffective are normal. hypothermia is
baby is feeling thermoregulation  Place infant in warmer or reduced to some
cold on touching. r/t immature provide proper clothing  Baby kept warm, dry extent
CNS, poor clean.
OBJ. DATA: metabolic
temperature is reserves and  Keep baby warm,dry,clean
normal however inadequate  Proper mummification
presence of less subcutaneous  Ensure proper mummification. done.
subcutaneous fat. fat.
 Kangaroo mother care
 Teach mother kangaroo mother taught to mother and
care. given to baby.

 Bathing should be delayed until

24 hours after birth

2. Subj data: Risk of infection  Observe general condition,  General condition, Baby’s risk for
mother c/o r/t immature vomiting,colour, cry,activity, vomiting,colour, infection is
redness over immune system, passing of urine and meconium. cry,activity, passing of reduced to some
body and fragile skin. urine and meconium extent.
diificulty in  Special care of umbilical cord. observed.
sucking milk . Do not put anything on the  Mother told for Special
stump. care of umbilical cord.
Obj data: And not to put anything
inadequate on the stump.
primary defences
secondary to  Advise Exclusive breast feeding
prematurity. for 6 months. Avoid top feeds or
solids for 6-8 months.
 Feed frequently and on
demand.
 Inform about Immunization as
per schedule.
 Teach about Care of eyes
,cord,mouth,skin.
 Explain dangers signs for the
newborn like difficulty in
breathing or indrawing, fits,
fever, bleeding from cord or any
other area, not feeding
,diarrhoea.
 Encouraged Exclusive
breast feeding for 6
months and also
instructed to Avoid top
feeds or solids for 6-8
months.
 Feed frequently and on
demand.
 Mother told about
Immunization as per
schedule.
 Care of eyes
,cord,mouth,skin taught
 dangers signs for the
newborn like difficulty in
breathing or indrawing,
fits, fever, bleeding from
cord or any other area,
not feeding ,diarrhoea
told to mother and also
to report S.O.S.