Nursing care plan Of The Mother

Nursing Care Plan of the mother Prenatal Assessment Cues/Evidence SUBJECTIVE DATA: Patient verbalized that she easily wakes up whenever she hears noise. 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 Nursing Diagnosis Objective Intervention Rationale Evaluation Within our care, the client had improved sleeping pattern as evidenced by: 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

Disturbed sleep pattern r/t shortness of breath and urinary frequency

Within our care, the client will improve sleep pattern as evidenced by: Absence of dark circles under eyelids and frequent yawning, improved face expression

1. Assess vital signs especially her blood pressure level 2. Encourage the mother to void before sleeping

Elevated blood pressure is usually observed in sleep disturbed client Voiding before bedtime may limit the sleep disturbance brought about by urinary frequency

3. Provide a quiet A quiet environment conducive environment for sleeping promotes Verbalized continuation of understanding sleep without on the cause disturbances of sleep 4. Promote use of disturbance bedtime rituals such as drinking a glass of milk Promotes Report before sleeping, taking relaxation and increased a bath, reading a book readiness for

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. OBJECTIVE DATA: Sleepy eyed noted Dark circles under eyelid observed Frequent yawning 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

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

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

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. OBJECTIVE DATA: Physiologic changes: Contour of the abdomen changes Presence of linea nigra on the abdomen

associated with pregnancy

body image as manifested by: Express positive feeling towards self and others Verbalize acceptance of body image Perceived pregnancy in a positive light

2. Employ a calm, caring, confident, and non-judgmental approach. 3. Discuss with mother physiologic changes during pregnancy

Improves nurseclient relationship. Creates a sense of trust at the same time educate mother about changes during pregnancy To create a positive outlet of emotions

image as evidenced by: Expressed positive feeling towards self and others. Verbalized acceptance of body image: “Ok na man ako pagkita sa ako kaugalingon” Perceived pregnancy in a positive light and claimed she is excited to see her baby. OBJECTIVES FULLY MET

4. Allow pt to express feelings towards her pregnancy

5. Teach pt coping strategies: Help overcome maladaptive • Preparing for upcoming delivery behaviors • Provide literary articles about pregnancy

1st stage of labor Cues/ Evidence Nursing Diagnosis Objectives Interventions Rationale Evaluation

SUBJECTIVE DATA: Client verbalized excruciating pain on the abdomen and further stated that 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 Restlessness noted especially during exacerbation of contractions.

Altered comfort: pain related to increased uterine contractions and pressure on pelvic structures

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 Verbalization pain within tolerable limits throughout the duration of labor

Independent 1. Monitor vital signs every 15 minutes for 2 hours and 30 minutes until stable. 2. Assess contraction patterns, bloody show and the degree of pain and its characteristics, location, severity, duration, and frequency.

To obtain baseline data.

Within our care, the client was able to: Maintained v/s within normal range:

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

T: 37.4C PR: 66bpm RR: 16cpm BP: 110/70mmhg Verbalize pain within tolerable limits. Verbalize discomfort 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

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.

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.

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

4. Teach proper breathing technique

Proper breathing technique can prevent exhaustion, therefore preventing prolonged delivery of the fetus and prolonged pain. A full bladder contributes to discomfort and impedes fetal descent. Helps alleviate any anxiety and fears that may exacerbate pain.

5. Inspect the client’s suprapubic area and palpate for bladder distention. Encourage the client to void. 6. Provide information and update client on labor progress Dependent 7. Administer

analgesia as ordered Collaborative 8. Refer to physician any abnormalities that may be observed. 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 Independent 1. Monitor Vital Signs 2. Assess level of anxiety through verbal and nonverbal cues.

Mechanism of action is to reduce pain. To provide immediate medical intervention. At the end of our To obtain baseline care, the client was data. able to: Identify areas of concern that might interfere with the normal progress of labor. Enhances nurseclient relationship. Provides a healthy outlet of emotions and relieves anxiety. Adequate Maintained v/s within normal range: T: 37.4C PR: 66bpm RR: 16cpm BP: 110/70mmhg Claimed that she’s worried about the condition of her baby. Verbalized that she is capable of

3. Employ a calm, caring, confident, and non-judgmental approach. 4. Allow client to express fears and feelings of anxiety appropriately.

Appears preoccupied; decreased perceptual field.

Absence of facial tension and improved attention span.

5. Acknowledge normalcy of fear and provide opportunity for 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.

delivering the baby. Claimed excited to see her baby. She claimed that she trusts the nurses in the hospital. OBJECTIVES PARTIALLY MET

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.

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

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). 2. Provide frequent oral and skin care.

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 Exhibited moist mucous membrane; has good skin turgor, and prompt capillary refill.

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

OBJECTIVES PARTIALLY MET

3. Discuss

understanding of withholding food and fluids during labor Demonstrate behaviors to monitor and prevent dehydration as indicated.

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

aspiration which can lead to respiratory distress.

To prevent 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 infusion as ordered. To prevent dehydration and preserve kidney function

2nd stage of labor

Cues/ 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 Diagnosis Anxiety related to lack of knowledge about labor experience

Objectives 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.

Rationale

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

Identify areas of concern that might interfere with the normal progress of labor. Enhances nurseclient relationship. Provides a healthy outlet of emotions and relieves anxiety. Adequate explanation helps reduce anxiety, soothe fears, and provides assurance.

Verbalize awareness 2. Employ a calm, of feelings of caring, confident, anxiety and non-judgmental approach. Verbalize willingness to 3. Allow client to cooperate and express fears and follow instructions feelings of 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 control of the situation 5. Assist pt. in

This position aids in the easy expulsion of the fetus, thus

Verbalize desire to participate actively during the course of labor Acquires knowledge about childbirth and is better prepared to cope with future births

proper positioning – Lithotomy position

reducing stress and anxiety from prolonged labor

6. Promote effective second-stage pushing by instructing client to push with each contractions and rest between them Independent: 1. Assess the degree of pain and its characteristics, location, severity, duration, and frequency. 2. Employ a calm, caring, confident, and non-judgmental approach. 3. Accept patient’s description of pain Within our care, the client was able to: Claimed that she can deliver the baby. Gives pt a sense of trust and Improves nurse-client relationship. Pain is a subjective experience and cannot be felt by Perceived labor experience in a positive light and comply with the instructions of the physician effectively.

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: Verbalize pain within tolerable limits. Verbalize desire to continue with the labor process.

Provide baseline data for future interventions

Restlessness observed Profuse sweating noted

Perceive labor experience in a positive light and comply with the instructions of the physician effectively. Demonstrate use of relaxation and diversional activities as indicated (Guidedimagery, Deepbreathing).

others. 4. Support pt. paincoping activities: Offer support by staying with the patient, pating her arms, and brushing a whisp of hair off her forehead, and provide a cool cloth on her forehead as needed. Provides feeling or sense of security and trust between the nurse and the patient.

Demonstrated proper breathing techniques OBJECTIVES PARTIALLY MET

5. Instruct patient 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)

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.

SUBJECTIVE DATA: Client reported difficulty in breathing and cried for help. OBJECTIVE DATA: Hyperventilation noted RR= 31cpm Appears restless Profuse sweating noted

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

Pain can limit respiratory effort Facilitates alveolar lung expansion thus improving gas exchange To limit level of anxiety

Within our care, the client was able to: Was free from cyanosis and other signs of hypoxia Participated actively in the labor process through effective pushing Demonstrated appropriate coping behavior to promote proper breathing such as using deep breathing technique. OBJECTIVES PARTIALLY MET

RR will be within the 2. Encourage deep normal range (16breathing exercise 20cpm). Establish a normal/ effective respiratory pattern Be free from cyanosis and other signs of hypoxia Participate actively in the labor process Demonstrate appropriate coping behavior to promote proper breathing 3. Maintain calm attitude while dealing with client 4. Encourage pt. to assume various position during active labor (ex. Squatting position) Encourage rest period between bearing down

Various positions facilitates lung expansion and easy expulsion of the fetus. To limit fatigue

3rd stage of labor Cues/ 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 Diagnosis Risk for Fluid Volume Deficit related to hypovolemia secondary to excessive blood loss Objectives 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 Exhibit moist mucous membrane, good skin trugor, and prompt capillary refill. Interventions 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). 2. Provide frequent Rationale Evaluation Within our care, 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, good skin trugor, and prompt capillary refill. OBJECTIVES PARTIALLY MET To preserve skin integrity, prevent dehydration and preserve kidney

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

oral and skin care.

function. Prevent dehydration and preserve kidney function. Promotes uterine contraction which prevents uterine atony or bleeding

Dependent: 3. Assist in IV infusion as ordered. 4. Administration of 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: Report pain reduction, from a scale of 7 to 5 Demonstrate use of relaxation skills and diversional activities Exhibit absence of facial grimacing Manifest normal RR 1. Assess the level of pain experience by the client and her ability to perform normal task such as eating, breastfeeding and dressing 2. Check vital signs

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 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 Verbalize method that provide relief 3. Review client’s previous experiences with pain and methods found helpful for pain control in the past 4. Provide comfort measures ( backrub, therapeutic touch) 5. Encourage the use of relaxation technique such as deep breathing and imagery

further deterioration of the client’s condition 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 MET

To provide nonpharmacologic pain management May help decrease pain perception by interrupting the conduction of nerve pain impulse

4th stage of labor Cues/ Evidence Nursing Diagnosis Objectives Interventions Rationale Evaluation

SUBJECTIVE DATA: Client verbalized: “naa pay mga nanggawas nga dugo sa akong kinatawo” “ sakit pa e lihok ang sa akong paa dapit”

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 2. Note signs/ symptoms of fever, pallor and chills

A slight elevation in temperature suggests fever. To assess if infection is occurring

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

OBJECTIVE DATA: Method of delivery: NSVD with thick meconium staining Episiotomy area is Swollen and reddish in color.

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

Perineal area should be cleansed well to prevent the growth OBJECTIVES of microorganisms 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 2. Check clients medical record and lab findings especially platelet count, bleeding time, clotting time 3. Instruct and assist the pt. In the use of sitz bath

Detect signs and symptoms of possible infection Any deviation may suggest blood clotting/coagulation is impaired and healing will be affected. Sitz bath aids in healing process by increasing circulation to the perineum and prevent edema. 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

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

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