NURSING CARE PLAN
ON
CAESAREAN DELIVERY
SUBMITTED TO
Mrs.RAJBIR KAUR
LECTURER
OBSTETRIC & GYNECOLOGICAL NURSING
SUBMITTED BY
RAJDAWINDER KAUR
MSC. (N) Ist YEAR
OBSTETRIC AND GYNAE. (N)
Identification of the patient
Name of patient: Baljit kaur
Husband’s name: Darshan singh
Age: 35 years
Sex: Female
C.R. No. 208064
Ward: Maternity
D.O.A: 27.03.16
Educational status: Middle
Religion: Jatt Sikh
Language: Punjabi
Occupation: House-wife
Husband’s occupation Agriculturist
L.M.P: 27-06-15
E.D.O.D: 3-04-16
Address: Rasulpur kalan
Diagnose: Placenta praevia
D.O.D 05-04-16
Gravida G2P1A0L1
Chief complaints at the time of admission:
Bleeding per vagina since morning.
History of present illness: patient came to hospital at 7am on 27-03-16with H/O bleeding per vagina
Chief findings at the time of admission:
B.P. 110/70 mmHg.
Pulse 74/min
Pallor +
P/A 34-36 weeks
Cephalic
FHS + regular
Uterine contractions +
History of past illness: No H/O enteric fever
No H/O T.B
No H/O D.M
No H/O STDs
No H/O H.T
Obstetrical history:
G2 P1
Duration of marriage: 12 years.
No. of living children: 1
Menstrual history:
Menstrual cycle 28-30 days
Menarche: 16years.
Duration: 4-5 days
Amount of blood flow: normal
Contraceptive history: No any contraceptive devices used
Immunization history
Patient has undergone TT immunization at 4th month and 5th month of pregnancy.
Trimester history
Ist Trimester
H/O nausea
No H/o Hyper emesis Gravidarum
No H/o leg cramps with back ache
No H/o x-ray exposure
H/o Constipation
IInd Trimester
No H/o constipation
No H/o Oedema on ankles
H/O good fetal movements
IIIrd Trimester
No H/o oedema
No H/o burning micturation
No H/o polyhydraminios
H/O frequency of micturation
Personal history: Vegetarian, Non Smoker, Non-Alcoholic
Family history: No any family H/O PIH, bronchial asthma, Tuberculosis, diabetes.
Both mother-in-law and father-in-law of the patient are suffering from hypertension
Family tree: joint family
Father-in-law mother-in-law
(70 years) (68 years)
Husband Brother in law
daughter
Vital signs
On 02.04.16 at 9 am
Temperature 100.2oF
Pulse 90/ min
Respiration 22/min
Blood pressure 130/90 mm of hg
GENERAL PHYSICAL EXAMINATION :
General Appearance
Body built - Well built
Nourishment - Well nourished
Weight - 70 Kg
Height - 5.7”
CNS :
She is conscious, oriented
All the reflexes are present
Speech is clear
Gait is normal
Respiratory System
Respiratory rate - 20 / mt
Air entry - equal and bilateral
Auscultation - breath sounds clear
CVS
Pulse - 76 / mt
B.P. - 120 / 80 mm of Hg
Auscultation - S1 & S2 heard
There is no oedema
Gastrointestinal system
Tongue - Clean
Teeth - No abnormality
Neck - Lymph nodes not palpable.
She does not have constipation and heart burn.
Urinary System
Urine output is good.
No burning micturition
Breast
Inspection - Secondary areolar present
- No Montgomery’s tubercle
- Nipple are not cracked.
Palpation - There is no tenderness or any other abnormalities.
Abdominal examination
Inspection - Linea Nigra is present
- Strae gravidarum present
- There are no incision marks
- Size of the uterus longitudinal.
Palpation - Not done due to placenta praevia
Fundal height - 34 cm
Auscultation - FHS – 142 / mt.
Per Vaginal Examination: There was bleeding per vaginum at the time of examination.
LAB INVESTIGATIONS: On 27-03-16
Test Patient Value Normal Valve
Hb 10 gm% 12-14gm%
TLC 4800/ mm3 4000-11000mm3
DLC N 52% 40-75%
L 40% 20-45%
M 4% 2-10%
E 2% 1-6%
BT 3'-5" 1'-6"
CT 5'-2" 3'-10"
B. urea 28mg/dl 10-46 mg/c
S. Ceratinne 1.0 0.6-1.4
RBS 109 mg% 100-180mg%
BLOOD GROUP O +VE
ULTRASONOGRAPHY: Ultrasonography showing a single viable fetus with 33 wk gestation with major degree of placenta Praevia.
Diagnosis
Grade –II, Posterior Placenta Previa
Treatment received:
Drug Chemical Dose Route Time Action
constitution
Inj. Cefotaxime 1gm IV BD Antibiotic
Gramocef
Inf. Metronidazole 300 ml IV 8hly for 3 Anti microbial
Metrogyl days
Inj Voveron Diclofenac 50 mg IM SOS Analgesic
sodium
Inj. Aciloc Ranitidine 150mg IV BD Antacid
Short term goal:-
To reduce the anxiety level.
To reduce the pain.
To correct the anaemia.
To maintain the vital signs.
To provide the comfort.
Long term goal:-
To reduce the complication.
To maintain the health of the mother.
To educate the mother regarding baby care & feeding.
To educate the mother regarding correction of anaemia.
To rehabilitate the client as soon as possible.
Nursing diagnosis
Anxiety related to caesarean delivery
Acute pain related to surgical procedure
Risk for infection related to traumatized tissue
Risk for ineffective parent/infant attachment related to interruption in bonding process.
NURSING CARE
PLAN
Sr. Nursing Nursing Expected Nursing
Nursing Planning Implementation Rationale
No. Assessment Diagnosis Outcome Evaluation
1. Subjective data: Anxiety Reduce To assess the anxiety Level of anxiety is For reducing Anxiety
client says, “ I am related to anxiety at level of the client. assessed. anxiety. reduced at
some some extent.
feeling caesarean Explain the reason for
extent. Explained the
lonlinessis”. delivery. caesarean delivery.
procedure to theclient.
Answer every
Objective data:- .
questions the woman Answered the question
Client looks and her support person of the client
stressed. may have regarding a
caesarean delivery
Explain that a sensation
of pressure will be felt Explained all
during the delivery, but procedure before
that little pain will doing.
occur. Instruct that any
pain should be reported
to the nurse.
Encourage use of
relaxation technique
after medication has
Demonstrated
been given for the pain
relaxation technique &
encouraged to do so.
Use a back rub and a
quite environment to
promote the
2. Subjective Data:
Acute pain effectiveness of the Provided quiet & For providing
Client verbally related to Reduce pain relaxed environment. comfort. Reduced pain
medication.
complaint about at some at some extent
surgical Support and splint the
pain & discomfort. extent. -
procedure. abdominal incision
Objective Data:-
when moving or
Client is placing
coughing or deep
hand repeatedly Applied abdominal
on abdomen. breathing
binder
Encourage frequent rest
periods and plan for
them after activities.
To reduce the pain
Encouraged her
caused by the gas,
Encouraged for early
encourage ambulation,
ambulation.
use of rocking chair
and lying on stomach
as much as possible
and tolerated.
Observe wound
condition & urine
catheter.
Use aseptic technique
when changing
dressing.
Provide catheter care
Risk of along with vital signs Observed condition of For control of
3. Subjective Data:- To reduce Client’s
infection the risk of every 4 hour or as the wound . infection. condition is
Patient says, “ I infection. normal.
related to needed.
am feeling Followed aseptic
bodyache”. Traumatized Provide routine post precaution while
tissue & operative care doing dressing
Objective Data:-
tubings. measures to prevent
Temperature is
slightly raised urinary or pulmonary Provide catheter care
infection. & vitals are monitored
Encourage the woman
to discuss her feelings Advised early
regarding breast ambulation & plenty
feeding. of liquids.
Demonstrate the
woman the shoulder
hold for breast feeding
so the infant not lying
on her abdomen & to
Ineffective do so frequently for Encouraged the client For improving
Subjective Data:- breast feeding. To motivate early initiation. to Verbalized the the lactation Improved
the mother lactation at
Client says ,” I am for breast Teach the woman for feeling. & breast
some extent.
not able to feed feeding. exclusive breast feeding.
the baby”.
feeding for 6 months.
Objective Data:- Demonstated the
Client is not able shoulder method of
to put the baby on breast feeding.
breast.
Taught the client for
exclusive breast
feeding for 6 months.
HEALTH EDUCATION
1. Educate the patient to take deep breath and perform active & passive exercises of
upper & lower extremities..
2. Ask the client to move her legs. Encourage her for early ambulization.
3. Oral liquids are started as soon the peristalsis returns.
4. Plain water, electrolyte water & tea can be given to the patient.
5. Encouraged patient to take well balanced diet.
6. Encourage patient to take roughage diet to prevent constipation.
7. Ask mother to take milk and fruit juice in large amount for more production of breast
milk.
8. Advice mother to put the baby on breast as early as possible.
9. Advice mother about family planning methods for adequate spacing between two
children.
10. Advice patient to report if any sign of infection arises.
11. Educate patient about follow up care.
12. Educate mother about proper rest.
13. Educate mother about neonatal care.
CARE OF NEW BORN
Educate mother about breast feeding.
Educate mother to keep the baby warm.
Educate her to wash her hand before touching the baby.
Educate her about immunization
Educate regarding KMC
FOLLOW UP CARE
Advice women about follow up after a week or earlier if any problem arises
Educate her to get the full immunization of the baby as scheduled.
References
Dutta D.C,”Textbook of obstetrics including perinatology and contraception”, 6th
edition, published by new central book agency. Pp 588-589
Fraser M Diane and Margret A cooper’s, “textbook of midwifery”,14 th edition,
published by Churchill livingstone, Pp 581-590.
Lippincott’s,”Nursing Management-Clinical practice”, published by Williams and
wilikins, Pp 1298-1300.
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