Appendix 4b

Applied Science Private University

Faculty of Nursing
Maternal and Neonatal Health Nursing
Post-natal Nursing Care Plan

Upon successful completion of this nursing care plan students will

be able to:
ILO 1: Demonstrate the role of Competent Nurse in providing quality
nursing care for individuals, families and groups
ILO 2: Integrate updated knowledge and findings of scientific research
in the application of evidence-based practice
ILO 3: Connect effective professional communication skills and
attitudes with individuals, families, groups and health care providers.
ILO 4: Demonstrate the leadership roles in various health care
settings.
ILO 5: Utilize critical thinking and problem-solving skills while
providing care for individuals, families and groups.
ILO 6: Prioritize safety measures and risk management plans to
improve the quality of care.
ILO 7: Outline population focused care incorporating concepts of
global health perspectives, health promotion, restoration, maintenance
and disease and injury prevention
ILO 8: Provide cost-effective care incorporating concepts of health
economic issues.

Student name:

University Number Clinical area: Postpartum

Date: 20/4/2025
Post Natal care Record 3 marks

Mother name A.H.M Age: 36 Years Old

Occupation: house wife Education: 12 th Grade

Patient diagnosis :Post C/S Labour Date of admission :

20/4/2025
Gyn & Obstetric History: 4 marks

Gravida 2 .… Para…2 Living ………3Abortion …………0.

PIH……No PIH…………………………PPH…………No PPH……………………..

Blood transfusion &reaction………No blood

transfusion……………………………

PPD………No PPD……………………………………………………………………………

Past pregnancies (Last six) 2

marks
Date GA Leng Birth Se Type Place Preter complications
wks th of weigh x of of m
labor t M birt birth labor
/F h Yes/
No
2.600 F C/S YES NO
15/3/20 37we Mothe kg Alama
22 eks r l
doesn’ hospit
t al
know

F C/S Al YES NO
20/4/20 37we Mothe 2.500kg Bashe
25 eks r er
doesn’ Hospi
t tal
know

F C/S Al YES NO
37we Mothe 2.700kg Bashe
20/4/20 eks r er
25 doesn’ Hospi
t tal
know
 Medical History 2 marks
Diabetes NO Pulmonary (TB, Asthma) NO
Hypertension NO Thrombo-embolic disorder NO
Heart disease NO Allergies NO
Kidney disease/ UTI NO Depression / PPD NO
Neurologic/epilepsy NO History of blood transfuse NO
Psychiatric NO Infertility NO
Hepatitis/liver disease NO Drugs NO
Thyroid dysfunction Tobacco
***Relevant Family History
Her father and her grandfather from her mother and father side has DM
and HTN ,but they don’t have heart disease, kidney disease , pulmonary
disease ,liver disease and any of the chronic diseases

Habits 1.5 marks

Diet No specific diet Smoking AMN/D Exercise
while pregnant NA Walks every day for
Regular diet half an hour

History of recent delivery 3.5 marks

Date of delivery:20/4/2025
Mode of delivery C/S
Place of delivery Al Basheer hospita
Newborn 2 female babies ,they look good, pink, no cyanosis or
jaundice, they were sleeping beside their mother in the postnatal
room
Episiotomy No Epistomy
Estimation of blood loss Nearly 800mL
Psychological status stable, the mother was so happy, cannot take
her eyes off them. Well-oriented and not depressed
 Laboratory tests & procedures 2 marks
Test name Result Normal Nursing Implications
Range for Abnormal
result.
Blood tests - Monitor fluid intake/output.
Blood type A - Encourage adequate hydration
Rh type Positive Normal (oral or IV fluids if needed).
CBC - Monitor for signs of
dehydration (dry mucous
HB 17.4g/dl Abnormal membranes, tachycardia).
- Educate on importance of
4.59 10’6/ ul Normal fluid intake during pregnancy.
RBC
21.5 10’3/ul Monitor maternal temperature,
WBC Abnormal
pulse, and fetal heart rate.
- Assess for signs of infection
Platelet 215 10’3/ul (e.g., dysuria, uterine
Normal
Blood chemistry tenderness, foul-smelling
discharge).
Random blood 90 mg/dl - Administer prescribed
sugar Normal
antibiotics if infection
7mg /dl
BUN Normal confirmed.
- Educate patient on hygiene
0.51mg/dl
Creatinine and infection prevention.
- Notify physician for further
4.02 mmol/l Normal
Potassium assessment
Normal

Sodium 139 mEq/l

2,3 mmol/l Assess dietary intake
Normal
Calcium (especially B12 and folate
Normal
15 u/l sources).
ALT - Collaborate with dietitian.
11 u/l - Monitor for symptoms of
AST Normal
anemia (fatigue, pallor).
49.3 % - Request further testing (serum
PCV Normal B12, folate levels).
Normal - Administer supplements as
MCH 36.9
ordered.
Abnormal
 Monitor blood glucose levels.
- Assess for signs of
hyperglycemia (polyuria,
polydipsia, fatigue).
- Notify physician – possible
indicator of diabetes mellitus or
gestational diabetes.
- Educate patient on low-sugar
diet and follow-up testing.
Urine test Monitor capillary blood glucose
▪ Albumin Negative levels as ordered.
▪ WBCs 1-3. - Educate patient on
1-2. Normal signs/symptoms of
▪ RBCs
Negative Normal hyperglycemia and
hypoglycemia.
▪ Sugar Moderate - Provide dietary counseling
▪ Acetone Normal (low sugar, complex carbs).
- Refer for oral glucose
Abnormal tolerance test (OGTT).
- Collaborate with healthcare
provider to manage GDM if
diagnosed.
Others
▪ …….. …………..
▪ …….. …………..
▪ …….. …………..

Mothers conditions for the first six hours 4 marks

Uterus
1st hr Regular, Firm, midline not deviated,
contracted ,uterine fundus at 1cm below
2nd hr umbilicus

3rd hr The uterus is still firm and contracted. Fundal

height is 1 cm under the umbilicus.
 1st hr She had foly catheter I measured the level of the
urine in the bag and it was empty
2nd hr
Bladder
3rd hr She had foly catheter I measured the level of the
urine in the bag and it was 250cc, yellow and
clear no blood

1st hr the pad for the first time 1 hours after delivery:
Lochia Rubra lochia – no foul odor – some small clots.
2nd hr
I checked the pad, Rubra lochia, no foul odor- no
3 hr
rd
clots just small ones. The amount is normal they
change the pad every 2 and a half to 3 hour

Perineum 1st hr I didn’t assess the c/s surgical site because the wound was
covered

(REEDA) 2nd hr I didn’t assess the c/s surgical site because the wound was covered
3rd hr I didn’t assess the c/s surgical site because the wound was covered
4th hr I didn’t assess the c/s surgical site because the wound was covered
5th hr I didn’t assess the c/s surgical site because the wound was covered
6th hr I didn’t assess the c/s surgical site because the wound was covered

Postnatal care record 5 marks

Items 1st. Hour 2nd. Hour 3rd. Hour
Date/time
Vital signs: 85 bpm 92bpm 96bpm
Pulse 118/75 mmHg 115/80 mmHg 120/81 mmHg
BP 36,7 C 36,5 C 36.6 C
15bpm 20bpm 18bpm
Temp
R.R
Breast &
nipples Nipples inverted outward- no Nipples inverted outward- Nipples inverted
hotness or redness- no discharge- no hotness or redness- no outward- no hotness or
striae laterally – no cracks discharge- striae laterally – redness- no discharge-
no cracks striae laterally – no
cracks
Laceration in NA NA NA
breast and
Nipples

Uterus Firm Fundal height is 1cm Firm Fundal height is Firm Fundal height
Consistency under 1cm under is 1cm under
Fundal height the umbilicus the umbilicus the umbilicus

Abdominal. I didn’t assess the c/s surgical I didn’t assess the c/s I didn’t assess the
Surgical site because the wound was surgical site because the c/s surgical site
wound covered wound was covered because the wound
was covered

Bowels Bowel sound: exist Bowel sound: exist Bowel sound: exist
Bowel movement: 1/ day Bowel movement: 1/ Bowel movement: 1/
No blood, no diarrhea, no day day
constipation- no gases No blood, no diarrhea, No blood, no
no constipation- no diarrhea, no
gases constipation- no
gases

Legs:
Cramps No redness or cramps No redness or cramps No redness or cramps
Edema skin temperature and color are skin temperature and color skin temperature and
even and normal are even and normal color are even
Homan’s test
No edema No edema and normal
No edema
Drainage No Drainage No Drainage No Drainage
(Surgical
drain)
I.V Site Right dorsal hand Right dorsal hand Right dorsal hand

Anti D No need the mother is No need the mother is No need the mother
positive positive is positive

Nursing Diagnoses and Interventions ( 8 marks -2 marks

for PRIORITY)

# Nursing Diagnosis Nursing

 Interventions
1 Acute Pain related to -Administer pain
Comfort disruption of skin, tissue, medications as prescribed
and muscle integrity - Encourage
secondary to Cesarean relaxation, distraction
section as evidenced by techniques
patient stating a pain -Assess the wound for any
level of 5 out of 10 redness or discharge or
pus drainage that
indicates infection
-Provide measures to
relieve pain, ex:
encourage the patient to
use relaxation techniques
such as deep breathing
exercise

2 Risk for infection related Assess and monitor vital

Safety protection to invasive procedures signs; fever, tachycardia,
causing traumatized low pelvic pain
tissue
-If symptoms of infection
appeared, check lab test:
WBC.
-Teach the mother about
the importance of keeping
the wound clean and dry,
and clean it with running
water.
-teach the mother about
signs and symptoms of
infection

3 Risk for constipation  Assist the mother

Elimination exchange related to decreased in doing physical
mobility and effect of activity and
using opioid exercise
analgesics  Encourage the
mother to increase
fluid intake
 Encourage toilet
schedule or bowel
 ‫‪training as‬‬
‫‪appropriate‬‬
‫‪ Advice the mother‬‬
‫‪to increase fiber‬‬
‫‪intake‬‬
‫‪If not contraindicated,‬‬
‫‪using osmotic laxatives‬‬
‫‪(such as lactulose and‬‬
‫)‪polyethylene glycol (PEG‬‬
‫‪as prescribed‬‬

‫‪Postnatal discharge summary 2.5 marks‬‬

‫‪- Date of discharge‬‬

‫‪22/4/2025‬‬
‫‪- Discharge address‬‬

‫‪-‬‬ ‫‪At her mother’s house.‬‬

‫‪- Summary of condition on leaving hospital‬‬

‫تم ادخال المريضة الجراء عملية قيصرية في تاريخ ‪20/4‬‬
‫التشخيص الحالي هو النفاس مابعد العملية القيصرية الناجحه‬
‫‪ :A+‬فصيلة الدم‬
‫حالة طفلتيها ممتازة وبصحة جيدة‬
‫لم يتم تسجيل االدوية التي تم إعطائها ماقبل وخالل العملية‬
‫تم إعطائها خالل فترة تواجدها بقسم النفاس القيصري‬
‫‪ Clexan‬‬
‫‪ Perfalgan‬‬
‫‪ Oxytocin‬‬
‫نتائج عالماتها الحيوية والتحليل المختبري طبيعية‬
‫تم تثقيف االم حول طريقة االرضاع الصحيحة والحفاظ على منطقة الصدر والحلمة‬
‫وتم تثقيفها حول العناية بالجرح الناتج عن العملية القيصرية‬
 ‫وتم إعطائها إجازة امومة‬

Health education based on mother and newborn needs

 Rest when you feel tired.
 Be active. Walk frequently.
 Don't move quickly or lift anything heavier than your baby until you are
feeling better
 Breastfeeding is the most important source of the baby’s nutrition, so feed
the baby frequently until she feels full (to avoid hypoglycemia and to reduce
jaundice if occurred)
 Wash your breasts before and after feeding the baby, to avoid infections
 Drink much fluid
 Increase your activities bit by bit.
 Plan your activities so that you don’t have to go up or down stairs more than
needed.
 Don’t lift anything heavier than your baby until your healthcare provider tells
you it’s OK.
 Educate the pt about how to clean and handle the surgical wound
 Educate pt about signs of infection in the wound
Warning condition for necessary arrival
 Pus draining from the incision
 You feel sad, anxious, or hopeless for more than a few days.
 You are having problems with your breasts or breastfeeding.
 Your baby is breathing heavily and poorly sucking the nipple
Your baby’s temperature is high and not decreasing with medications
Medication explanation (if prescribed)
▪ New

Clexan
Perfalgan
Oxytocin

▪ Old

No prescribed medication

Planning for the next arrival

The mother should come to the appointment after one week, to check her
health status, uterus condition, and if there are any infections in the
abdominal wound. And to check on the baby’s health, assess the vision and
hearing of the baby, and start the vaccination program
 Condition of the baby ( /2.5 marks)

Alive she is alive still birth no Macerated no

Color pink

Apgar score: First min: 7/10

Fifth min: 9/10 Wt. : 2.600 Length: 45cm
H.C:34cm
Any abnormality/specify no abnormalities baby is healthy
Newborn follow-up
General Condition
• Activity :Active /Sluggish/Limp: Active Sluggish Limp
• Breast Feeding Initiated: (Yes/No)
If Yes, how many hour after birth? ... 2hrs after giving
birth
If No, why breast feeding was not initiated?
………………………………………
What method of feeding was used? Breast feeding
……………………………………………….
• Condition of the umbilical cord ( moist, dry, foul smell)
clean dry no bleeding no foul odor