NURSING CARE PLAN

S. Nursing Goals Planning Implementation Evaluation

No Diagnosis
1. Acute pain To reduce -Assess the level of -Level of pain is Pain of the
related to the pain of the pain with the assessed with the patient is
surgical the patient. help of pain scale. help of pain scale. reduced.
procedure. -Provide diversional -Diversional therapy
therapy to the is provided to the
patient, e.g. T.V. patient.
-Provide the -Comfortable
comfortable position position is provided
to the patient i.e. to the patient i.e.
straight lying straight lying
position. position.
-Provide comfortable -Comfortable
devices to the patient devices are provided
such as extra set of to the patient such as
pillows. extra of pillows.
-Administer -Analgesics such as
analgesics to the injection voveran are
patient as prescribed administered to the
by the physician patient as prescribed
such as Injection by the physician.
voveran.

2. Risk of To reduce -Assess the amount -Amount of blood Risk of

fluid the risk of of blood loss during loss during surgery fluid
volume fluid surgery. is assessed. volume
deficit volume -Monitor and record -Vital signs of the deficit is
related to deficit in the vital signs of thepatient is monitored reduced in
blood loss the patient. patient especially especially pulse and the patient.
during pulse and blood blood pressure every
surgery. pressure. half hourly.
-Monitor and record -Intake-output chart
the intake-output of the patient is
chart of the patient. maintained.
-Regularly assess -Signs and
the patient for signs symptoms of the
and symptoms of shock are regularly
shock. assessed in the
patient.
-Administer the -Fluids are
fluids to the patient administered to the
E.g. dextrose 5% and patient as prescribed
ringer lactate. by the physician.
-Administer -Injection methergin
injection methergin is administered to
to the patient helps the patient as
to control the prescribed by the
 bleeding. physician.

3. Altered To improve -Collect the history -History of sleeping Sleeping

sleeping the sleeping of sleeping pattern of pattern of the patient pattern of
pattern pattern of the patient such as is collected such as the patient
related to the patient. hours of sleeping in hours of sleeping in is
pain due to day and night. day and night. improved.
surgery. -Provide cool and -Cool and calm
calm environment to environment is
the patient. provided to the
patient.
-Provide dim light to -Dim light is
the patient. provided to the
patient.
-Restrict the number -Number of visitors
of visitors in the is restricted to the
patient’s room. patient’s room.
-Involve the patient -Patient is involved
in daily activities in daily activities
such as maintaining such as maintaining
personal hygiene. her personal
hygiene.
-Administer -Sedatives are
sedatives as administered to the
prescribed by the patient as prescribed
physician to the by the physician
patient such as such as alprazolam.
alprazolam.

4. Risk of To reduce -Assess the vaginal -Vaginal discharge, Risk of

infection the risk of discharge, colour, colour, odour and infection is
related to infection. odour and incision incision site are reduced.
surgical site. assessed.
procedure. -Check the vital -Vital signs are
signs of the patient. checked.
-Use the aseptic -Aseptic techniques
technique during are used during
performing any performing any
procedure. procedure.
- Maintain the -Personal hygiene of
personal hygiene of the patient is
the patient. maintained.
-Advise the patient -Patient is advised
not to touch the not to touch the
incision site. incision site.
-Advise the patient -Patient is advised
clean the perineal clean the perineal
area with water after area after each
each urination and urination and
defecation. defecation.
 -Administer -Antibiotics are
antibiotics to the administered to the
patient as prescribed patient as prescribed
by the physician by the physician
such as Gentamycin. such as Gentamycin.

5. Deficit To enhance -Assess the Knowledge of the Knowledge

knowledge the knowledge of the patient regarding of the
related to knowledge patient regarding caesarean section patient is
hysterectom of the caesarean section and care of the enhanced.
y and post- patient. and care of the newborn is assessed.
operative newborn.
self care. -Instruct the patient -Patient is instructed
to observe the to observe the
incision site daily for incision site for any
any purulent purulent discharge.
discharge.
-Instruct the patient -Patient is instructed
to avoid any to avoid any
strenuous exercise, strenuous exercise,
heavy work and heavy work and
sexual activities until sexual activities until
physician advised. physician advised.
-Educate the patient -Patient is advised to
to report any vaginal report any vaginal
discharge, excessive discharge, excessive
bleeding and bleeding and
elevated elevated
temperature. temperature.
-Advise the patient -Patient is advised to
to take more oral take more oral
fluids. fluids.
-Educate the mother -Mother is educated
to breastfeed her to breastfeed her
baby every one baby every one
hourly or demand hourly or demand
feed helps to provide feed helps to provide
immunity to the immunity to the
neonate. neonate.
-Educate the mother -Mother is educated
regarding regarding
immunization immunization
schedule helps to schedule helps to
prevent the newborn prevent the newborn
from six-killer from six-killer
disease. disease.
-Educate the patient -Patient is advised
for regular follow- for regular follow-
up. up.
 IDENTIFICATION DATA OF PATIENT
NAME OF THE PATIENT- Shubhlata
AGE- 29 yrs
SEX- Female
EDUCATION- 10th
OCCUPATION- House wife
RELIGION- Hindu
MARITAL STATUS- Married
ADDRESS- Basai
NAME OF THE WARD- Postnatal ward-I
DATE OF ADMISSION- 04/02/19
DATE OF DISCHARGE:-12/02/19
DATE OF DELIVERY - 04/02/19
TYPE OF DELIVERY- Caesarean Section
DOCTOR INCHARGE- Dr. Bindu
DIAGNOSIS- 38th week of pregnancy.

CHIEF COMPLAINTS

 Fetal distress

PRESENT HISTORY’

 Patient Shubhlata is admitted in SGT Hospital having a pregnancy of 38th weeks with
fetal distress. Patient has delivered a male baby with caesarean section and having
complaints of pain at the incision site.

PAST MEDICAL HISTORY

 Patient having no any significant past medical history

PAST SURGICAL HISTORY

 Patient having no any significant past surgical history.

FAMILY HISTORY

Name of Relationship Age/sex Marital status Occupation Health Educational

the family with patient status background
member
Subash Husband 31yrs/M Married Pvt. job Healthy B.A.
Preeti Daughter 3yrs/F Unmarried Student Healthy Pre-nursery
Newborn Son 1 day Unmarried Nil Healthy Newborn
HEALTH FACILITY NEAR HOME:-

Dispensary near the sector, and transport facility is by car, bus

SOCIO ECNOMIC STATUS:-

Housing-Pucca house, 3 room set, 1 bathroom, 1 toilet, 1 kitchen.

Water supply- Tap water and they drink filter water
Sanitation- Environmental hygiene is maintained
Income-Rs1,80,000 per annum

PERSONAL HISTORY

Hobbies- Watching T.V. and cooking.

Dietary Habits- Vegetarian
Addiction- Not present

PERSONAL HYGIENE

Oral hygiene- Maintains oral hygiene with toothpaste and brush 1 times a day
Bath- Takes bath daily
Diet- Vegetarian
No. of meals per day- 3 times per day.
Food preference- Homemade food
Fluid- 10-12 glasses/day
Tea & coffee- 2 cups/day
Sleep & rest- 2 hours in afternoon and 6 hours in night

ELIMINATION

Bowel per day- Regular, frequency – 1 to 2 times.

Urine frequency day- 4 to 5 times, light yellow color, night-2 times.

MOBILITY AND EXERCISE

Exercise / Activity- No
Joints- No pain and movements of joints are normal.

MENSTURAL HISTORY

Regular, 4 days duration, 28 days cycle, moderate dysmenorrhea present.

MARITAL HISTORY
Spouse Health- Good
Spouse occupation- Pvt. Job
Substance use- No history of any substance use
Addiction- No
OBSTETRIC HISTORY

G2P2L2A0

SEXUAL HISTORY

Frequency of sexual activity- 1-2 times/week

Method of contraception- Condom
Dyspareunia- Present
Relationship- Satisfactory
PHYSICAL ASSESSMENT

General appearance and behaviour

Build- Normal
Nutrition- Good

Anthropometric Measurement
Weight-76 kg
Height-5’4’’

Physical Assessment

Subjective data Objective data

Head
Vision
Hearing
Speech &orientation
Respiratory system
Circulatory system
Lymphatic system
Gastrointestinal system
Nutrition/hydration
Urinary system
Reproductive system
Psycho-social aspect
Neurological system
No dandruff present, hairs black, texture-dry
Normal
Normal
Fluency of speech is normal; patient is well
oriented to their surroundings.
On inspection- normal symmetry
On percussion- no fluid present
On auscultation- normal breath sounds
Pulse –80/min
Blood pressure-110/70mm Hg
On palpation- no lymph nodes present
On inspection-normal shape and symmetry
On percussion- no taped fluid present
On auscultation-normal bowel sounds
Adequate nutrition and hydration
Light yellow colour urine, blood and pus
cells are not present in urine.
Increase in the size of uterus than the normal
i.e.13 cm and Lochia Rubra is present.
Normal mental status
Memory
Recent-intact
Remote –intact
Well oriented
Insight and judgment present
Normal speech
Normal behaviour

VITAL SIGNS

DATE TEMPERATURE PULSE RESPIRATION BP REMARKS

08/02/12 98.6 F 78/min 22/min 110/80mmHg Normal
09/02/12 98.6 F 82/min 22/min 110/80mmHg Normal
10/02/12 98.6 F 82/min 22/min 110/70mmHg Normal
ROUTINE INVESTIGATIONS

S.No. TEST PATIENT’S NORMAL REMARKS

VALUE VALUES
1. Hemoglobin 12.4 gm/dl 12-15 gm/dl Decreased
2. TLC 8600/cumm 4000-11000/cumm Normal
3. DLC; N 69% 40-70% Normal
4. L 26% 20-40% Normal
5. M 03% 1-6% Normal
6. E 06% 2-10% Normal
7. BT 4.4 min. 3-7 min. Normal
8. CT 7.8 min. 4-10 min. Normal
9. Blood Sugar 92 mg/dl 70-110 mg/dl Normal
10. HIV -ve --------- Normal
11. VDRL -ve --------- Normal
12. Blood AB+ve --------- ----------
Group

MEDICATIONS

S.NO. DRUG SALT DOSE ROUTE FREQUENCY ACTION

1. Ciplox Ciprofloxacin 100 ml I/V BD Antibiotic
2. Metrogyl Metronidazole 100 ml I/V TDS Antibacterial
3. Monocef Cefotaxime 1 gm I/V BD Antibiotic
Sodium
4. Genta Gentamycin 80 mg I/V BD Antibiotic
Sulphate
5. Voveran Diclofenac 25 mg I/V BD Analgesic
Sodium
6. Fortwin & Pentazocine 30 mg I/V BD Sedative
7. Phenergin Lactate 25 mg I/V BD Sedative
Promethazine

INTAKE –OUTPUT CHART

S.No. INTAKE OUTPUT BALANCE REMARK

08/02/2012 4,000 ml 3,000 ml 1,000 ml Normal
09/02/2012 3,000 ml 2,000 ml 1,000 ml Normal
10/02/2012 2,400 ml 1,600 ml 800 ml Normal
SHORT TERM GOALS

 To relieve pain.
 To prevent infection.
 To prevent further complication.
 To maintain personal hygiene.
 To provide comfort.
 To enhance the physical mobility of the patient.
 To enhance the knowledge of the patient.

LONG TERM GOALS

 To rehabilitate the patient after surgery.

 Teach the patient family about medication, their frequency, dose, action and adverse
effect.
 Teach the patient about postnatal exercises.
 Teach the patient about the dietary pattern i.e. high protein diet and low cholesterol
diet.

NURSING DIAGNOSIS

 Acute abdominal pain related to soft tissue injury as evidenced by verbal complaints.

 Imbalance nutrition less than body requirement related to insufficient intake to meet
metabolic demands as evidenced by verbal report of abdominal pain.

 Self-care deficit related to immobility as evidenced by surgical incision on the lower

abdomen.

 Risk of infection related to inadequate primary defences as evidenced by incision on

the abdomen.

 Deficit knowledge related to incomplete information as evidenced by inadequate

performance of procedure.
 HEALTH EDUCATION

Diet
 Advice regarding fat free diet.
 Advice patient to take protein rich diet.
 Advice to take 3 meals a day and in between snacks.
 Advice patient to take more fluids per orally.
 Advice regarding intake of haematinic and calcium supplement

Exercise

 Encourage the patient to perform light exercises of arms and legs without putting
stress on stitches.
 Teach the patient to avoid activity that tenses the muscles such as weight lifting
exercises.
 Avoid heavy exercises after taking meal.

Hygiene
 Teach the patient about maintaining proper personal hygiene.
 Educate the client to change her vulval pad every 6 hourly.
Medication

 Educate the patient about medication regimen, route, dose, frequency and adverse
effects.
Rest and sleep

 Advice the patient to do alternate exercises with period of rest.

 Advice the patient to take proper rest and sleep.
 Avoid activity which initiates pain and fatigue.
Immunization

 Educate the parents of the newborn about immunization according to the age.

Breast feeding

 Educate the mother about proper breastfeeding technique and its importance.
 Educate the mother to breastfeed her baby every one hourly.

Follow-up care
 Advise the patient for regular medical check-up so that if any complication occurs can
be detected at right time.
 BIBLIOGRAPHY

 Dutta DC. Textbook of obstetrics; Central publisher, 6th ed. 2004.

 Jacob annamma. A comprehensive textbook of midwifery and gynaecological
nursing; Jaypee publisher, 3rd ed. 2012.