1.

IDENTIFICATION DATA OF CLIENT

a. Mother’s name - Mrs kajol

b. Wife of - Mr. Kapil Verma
c. Age in years - 23 years
d. Address - Yamunangar Haryana
e. Registration number- 1711080102
f. Educational status- 12th
g. Occupation- House Wife
h. Religion- Hindu
i. Duration of marriage- 3 years
j. Obstetric score G3P1L1A1
k. LMP- 20/2/2019
l. EDD- 27/11/2019
m. Date of admission- 19/11/2019 at 11 :32 am
n. Diagnosis- G3P1L1A1 with Period of gestation 39 weeks ±1days with cephalic presentation with gestational diabetes mellitus with
vaginitis.

STUDENT DATA

a. Name of student- Nadiya Rashid

b. Class- M.Sc. Nursing II year
c. Date of care started- 21/11/2019
d. Date of care ended- 23/11/2019
e. Number of days care provided- 3 days
CHIEF COMPLAINTS AT THE TIME OF ADMISSION

Mrs Kajol MMIMS&R hospital’s OPD on 19 November 2019 with the chief complaints of:

 Amenorrhea 9 months
 Pain lower abdomen last 2-3 days
 Anxiety since 2 days
 Fatigue since 2 days
 Foul vaginal discharge from 2 days

2. HISTORY COLLECTION

History of present illness

 HISTORY OF PRESENT ILLNESS- client came to MMIMSR hospital’s outpatient department on 19 November 2019 with the chief
complaint of Amenorrhea since 9 months, and pain in lower abdomen from last 2-3 days ,foul vaginal discharge from last 2day After the
examination and investigation the patient is diagnosed as G3P1L1A1 with Period of gestation 39 weeks with ± 1days with false labour pains
, vaginitis and gestational diabetes mellitus with cephalic presentation and after that client was admitted in labour room.
 PAST MEDICAL HISTORY- There is no significant past medical history of hypertension, asthma, tuberculosis, pneumonia, hyper or
hypo thyrodisim , any drug allergy, jaundice etc., But mother have history gestational diabetes in present pregnancy .which is
diagnosed at 8th month of pregnancy.
 PAST SURGICAL HISTORY- Patient is having no past surgical history of general and gynecological.
 PRESENT SURGICAL HISTORY- Mrs kajol is not having any significant present surgical history.

History of prenatal period

 First trimester- pregnancy confirmed by urine pregnancy kit at home at 15days overdue. There is no history of nausea, vomiting, and
urine incontinence and no history leakage per vaginum, or bleeding per vaginum. Ultrasonography was done in third month and it was
normal .history of folic acid intake. Injection tetanus toxoid first doses covered 2nd month.
 Second trimester- quickening felt at 5th month. Injection tetanus toxoid 2nd doses covered 4th month. No history of leakage per
vaginum, or bleeding per vaginum, blurring of vision, fever, rash, pedal edema, heart burn. Ultrasonography done and was normal
according o mother .History of iron and calcium intake.
 Third trimester- there is no history of burning micturition, blurring of vision, pedal edema or deep vein thrombosis increase blood
pressure breathless ness History of iron and calcium intake and ultrasonography done which shows normal findings . No history of x-
rays exposure. At 28th weeks mother is having history of gestational diabetes.

a) Family history
No significant family history of any illness in family members like hypertension and tuberculosis etc. But kajol,s mother and father
both have history of diabetes from last 5-6 years.
 No of family members- there are total 5 members in the family.
 Monthly income- Rs 20000/ month
 Income per capita- Rs 4000/ member

NAME RELATIONSHIP AGE SEX OCCUPATION HEALTH STATUS

S.NO WITH PATIENT

1. kirparam Father in law 60 years Male Business man Healthy

2. Kiran jeet Mother in law 53 years Female House wife Healthy

3. Kapil Verma Husband 28 years Male Business man Healthy

4 Mrs kajol wife 23 years Female House wife Healthy

5 Anjali Daughter 3 years Female Student healthy

 FAMILY TREE:

Kirparam, 60 years kiranjeet 53 years KEYS

Kapil 28 years kajol 23 years

Male

Anjali 2 years Female

Female patient

b) Menstrual history
 Age of menarche- at 13 years
 Regularity- regular
 Cycle- 28-30 days
 Duration- 3-4 days
 Flow- average blood flow (2 pads daily)
 LMP- 20/2/2019
c) Marital history
 Age of marriage- client got married 8 years back at the age of 16.
 Years of married life- 3 years.

d) Obstetrical history
Obstetrical score: -G3P1L1A1

S.NO YEAR NATURE OF NATURE OF LABOR NATURE OF SEX REMARKS

PREGNANCY PUERPARIUM
G1 2015 Normal Full term normal vaginal Normal and healthy Female Baby was
delivery with right medio healthy and
lateral episiotomy. cried
immediately
after the birth
and
immunized
till date

G2 2016 ---------------- 4 months spontaneous ----------------------- Dead male -----------

miscarriage.

G3 2019 Present pregnancy with POG 39 weeks± 1 day with vaginitis and with cephalic presentation with gestational diabetes
with vaginitis.
 Present pregnancy period
 Period of gestation- period of gestation is 39 weeks± 1days.
 Immunization during pregnancy- TD1 and TD2 covered in second and fourth month.
 Folic acid, iron and calcium, supplements- history of folic acid, iron and calcium intake.

e) Personal history
 Hobbies- watching TV and listening music
 Likes/dislikes- client likes to cook.
 Veg/non-veg- Mrs kajol is vegetarian
 Alcoholic/ smoker- client is nonsmoker and nonalcoholic.
 Sleeping pattern- Mrs kajol is having sleeping disturbance at night.
 Any allergy- mother is having no evidence of allergy.
 Mother is having adequate rest and sleeps 2-3 hours during day.

f) Diet pattern
DAY BREAKFAST LUNCH EVENING SNACKS DINNER

Day 1 chapatti with tea Roti.,rice with dal Tea with biscuits Roti with Sabji

Day 2 bread with tea Sabji with roti Tea with bread Roti with Sabji

Day 3 Bread and milk Khichaddi with curd Tea with biscuits Roti with sabji

g) Socio-economic status
 Type of house- client lives in pucca house.
 No. of rooms- there are total 3 rooms in client’s house.
 Electricity facility- there is proper electricity facility in client’s house e.g. tubes and bulbs.
 Drainage facility- there is closed drainage system.
 Water supply. Water is supplied by tap.
3) PHYSICAL EXAMINATION

a) General examination

Date: 21 November 2019

Time: 10:00 am

 Height- 5 feet
 Weight- 50 kg.
 BMI- 21.5 Kg/m3
 Age- 22 years.
 Race and sex- Asian and female.
 Body type- mesomorphic
 Body movements- client was having normal body movements and there were no tics or tremors.
 Hygiene and grooming- well-groomed and hygiene is maintained.
 Mood and effect- Mrs kajol was having appropriate effect as that of mood.
 Speech- client was having normal speech and there was no slurring or stammering of speech.
 Mental status- client was conscious and oriented to time place and person.

b) Vital signs

 Temperature- normothermic, 98.2o f

 Pulse- 88 beats/ min.
 Respiration- 20 breaths / min.
 Blood pressure- 130/80 mmhg

Head and Foot Examination:

Integumentary

 Skin- client was having dark complexion with chloasma gravidarum present and no rash or redness present.
  Nails- client was having pinkish nails with no clubbing and normal nail capillary refill.
 Hair and scalp- client was having black hair with rough texture with normal distribution of hair and there was no pediculosis or dandruff
present.

Head and face examination

 Head- head was normal in shape and size.

 Face- client was having oval shape and chloasma was present.
 Eyes
 Vision- Mrs kajol is having normal vision, and there is no history of double vision or blurring of vision.
 Eyelids- eyelids were symmetrical, and meet completely when eyes are closed. No ptosis is present in eyelids.
 Conjunctiva-in palpebral conjunctivae no pallor seen (anemia) and bulbar conjunctivae no icterus seen (jaundice).Conjunctiva is moist
with no ulceration or foreign object is object.
 Sclera- sclera is white in color and there is no yellowish discoloration of the sclera.
 Pupils- pupil is round, equal and reactive to light and accommodation.
 Eyebrows and eyelashes- the eyebrows and eyelashes are symmetrical with normal hair distribution and there is no eyebrow or lash
loss present.

 Ears- ears are normal in shape in size, and hearing is normal and there is no discharge, pain or redness.
 Nose- nose in normal in shape and size, nasal mucosa is moist and no discharge or deviated nasal septum present.

 Mouth and pharynx

 Buccal mucosa- buccal mucosa is reddish pink in color and is moist. Gums are healthy and no bleeding is present
 Teeth- teeth are white in color and hygiene is maintained, no discoloration present.
 Lips- reddish pink and dry in texture
 Dentures- client is not having any dentures.
 Helitosis- not present

 Neck
 Range of motion- normal range of motion present as client is able to move her neck.
 Normal position of trachea- trachea is centrally located.
  Normal size, shape and symmetry of thyroid gland, no lymph node- thyroid glands are normal in shape and size and there is no thyroid
or lymph node enlargement or tenderness present.
 Genitalia- normal in shape and size, the mucosal membrane is moist and there was redness, itching dysuria,discharge (due to vaginitis)
was present. No valval edema was present.
 Rectum and anus- the rectum and anus are normal and no hemorrhoids present.
 Extremities- extremities are normal in shape and size and symmetrical and range of motion is present.
 Motor system- motor system is normal and no abnormal findings present.
 Sensory system- sensory system is normal as patient is able to feel all the sensations like touch, and differentiate between cold and hot
temperature.

D. OBSTETRICAL EXAMINATION-

 Antenatal breast examination:

Inspection: breast is normal in shape and size and symmetrical, primary and secondary areola present with Montgomery tubercles
and no cracked or inverted nipples are present.

Palpation: breast is soft and no tenderness or engorgement present. No lymph enlargement or abnormal mass present.

Any discharge: not present.

Milk secretion: colostrum present

 Abdominal examination:
Inspection: abdomen is oval in shape and linea nigra and striae gravidarum ,stria gravidarum are present, no suture marks an itching or
rashes present.

Measurements: symphysis fundal height- fundal height was 32 cm

Abdominal girth- abdominal girth was 95 cm
Weeks of gestation according to fundal height(finger method)- 34 weeks .

 Obstetric Grips:
  Fundal palpation- smooth, soft and globular mass was felt suggesting of buttocks at the fundus,
 Lateral grip- on the left side knob like irregular parts were felt suggesting extremities whereas on the right side smooth curved
resistant mass was felt indicating presence of spine/ back of the fetus hence lie is longitudinal

 Pelvic grip 1 - presenting part is head and is outside the pelvic brim, ballottement of head is not present

 Pelvic grip 2- As the hands were conversing or meeting while assessing the foetus hence engagement is not present

 Auscultation- the foetal heart rate was 146 beats/ min.

CONCLUSION

 Gestational age- 39 weeks+1day

 Lie- longitudinal lie
 Presentation- cephalic presentation.
 Presenting part- vertex.
 Position- right occipital anterior.
 Attitude- flexion
 Denominator - vertex
 Engagement- not engaged.
4. INVESTIGATION:

S.NO. DATE INVESTIGATION PATIENT VALUE NORMAL VALUE REMARKS

 Haematological
Investigations

1. 21/11/2019 Bleeding time 2.15 min Up to 6 min Normal

2. 21/11/2019 Clotting time 6.15 min Up to 10 min Normal

3. 21/11/2019 LFT
Total bilirubin 0.24 mg/dl 0.00-1.20 mg/dl Normal
Direct bilirubin 0.17 mg/dl 0.00-0.20 mg/dl Normal
SGOT 25 U/L 2-31 U/L Normal
SGPT 27 U/L Up to 45 U/L Normal
Alkaline phosphate 193 U/L 54-119 U/L Increased
Total protein 7.6 g/dl 6.60-8.70 g/dl Normal
Albumin 2.9 g/dl 3.50-5.20 g/dl Decreased

4. 21/11/2019 RFT
Urea 13m g/dl 13-43 mg/dl Normal
Createnine 0.59 mg/dl 0.60-1.10mg/dl Decreased
Uric acid 7.3 mg/dl 2.50-6.80mg/dl Elevated
134 mmol/l 135-155 mmol/l Normal
HIV
5 21/11/2019 Negative

6 22/11/2019 Hb 9.9mg/dl Mild degree

10-14g/dl anemia is
present

-
7. 22/11/2019 VDRL Negative -
 -
8 22/11/2019 HbsAg Negative Normal

9. 22/11/2019 Glucose(PP) 190mg/dl 120-140mg/dl gestational

diabetes
mellitus
10 Urine
30ml
Volume
Pale /Yellow
Colour Normal
Nil
Albumin
Nil
Urine fasting
Nil
Sugar
Nil
RBC
6-8
Pus cells
2-4/ HPF
Epithelial
-
Casts
-
Crystals

11. 22/11/19 Blood group O+ve Normal

12. 22/11/2019  Radiological USG shows single live intra uterine pregnancy with gestational age 39 week/± 1days
Investigations with cephalic presentation.
Liquor adequate
USG Placenta located at anterior upper segment of uterus
No congenital anomaly.
5. MEDICATION:

S. DRUG CHEMICAL DOSE ROUTE FREQUENC ACTION NURSING RESPONSIBILITY

NO NAME NAME Y
.
 Lab test : obtain baseline and
1. Tablet Metformin 500mg Orally BD Anti diabetic periodic kidney and liver function
Gluformin tests
 Drug contraindicated in presence of
hepatic and renal insufficiency.
 Monitor cardio pulmonary status
throughout course of therapy
 Cardiopulmonary insufficiency may
predispose to lactic acidosis.
 Be aware that hypoglycaemia is not
a risk when drug is taken in
recommended therapeutic dose.
 Report to physician immediately
when sign and symptom of infection
is present. Which increase the risk of
keto acidosis?
 Do not breastfeed while taking this
drug without consulting physician

2. Tablet Calcium and 500mg Orally BD Calcium  Advice patient to take medication as
Cipcal- vitamin D3 supplement directed. Take missed doses as soon
500 as remembered that day, unless
almost time for next dose; do not
double up on doses.
 Review diet modifications with
patient.
 Encourage patient to comply with
dietary recommendations of health
care professional. Explain that the
 best source of vitamins is a well-
balanced diet.
 Educate about the importance of
sunlight.
3. Tablet Capsules of 100mg Orally BD Iron supplement  Explain the purpose of iron therapy.
Cofol- Z carbonyl iron  Encourage patient to comply with
with zinc and medication regimen.
folic acid  Advise client that stools may
become dark.
 Instruct patient to have diet rich in
iron
4. Candid Clotrimazole 100 mg vaginally OD Antifungal  Evaluate effectiveness of treatment.
vaginal tab  Report any sign of skin irritation and
pecessary. dermal preparation.
 Anticipate signs of clinical
improvement with in 1st week of
drug use
FAMILY EDUCATION
 Use Clotrimazole as directed.
 Report to physician if condition
worsens.
 If receiving the drug vaginally your
partner may experience burning and
irritation of penis refrain from sexual
intercourse during therapy of wear
condom during intercourse.
 Wash hands before inserting tab
vaginally
 Clean applicator
 Before inserting tab pass urine and
don’t move from bed for 1 hour after
inserting tab
THERAPUTIC MENU PLAN FOR MOTHER WITH GESTATIONAL DIABETES TYPE- 2
CALORIES 1800
TOTAL CHO SERVINGS 13

MEAL PATTERN NO OF CARBOHYDRATE NO CARBOHYRATE MENU

CHOICE CHOICES
Breakfast 1 1 large egg omelet

1 1slice whole grain toast

2 tsf butter

Morning snack 2 1 1 cup chai(2%milk)

1 3/4oz veggie sticks

Noon meal 4 1 ½ cup toor dal cooked

1 ½ cup red kidney beans(rajma)

2 2 rotties

Afternoon snacks 1 1 1 cup sprouted moong salad

10 almonds

Evening meal 3 1 300grams chicken curry

1 1 roti
1 1/3cup cooked white rice.

Evening snacks 2 1 1 cup 2%milk

 1 6 saltine –type crackers
1 tbsp almond butter

183.3g carb (40.5% of total calories), 107.7g protein(23.6% total calories) ,74.3g fat =1820 calories.

Note- 15 mint post noon and post night meal walk.

7. NURSING DIAGNOSIS:

1. Acute pain related to burning micturition and vaginal itching as evidenced by client verbalization.
2. Acute lower abdominal and back pain related to false labor pain as evidenced by irritable uterus.
3. Sleep disturbance related to frequent micturition as evidenced by client verbalization.
4. Knowledge deficit about diabetic condition, prognosis and treatment measures need related to lack of information and do not know
the source of information
5. Risk for fetal injury related to maternal glucose level ,and changes in the circulation as evidenced by fluctuations in blood glucose
level
6. Risk for maternal injury related to inadequate diabetic control, abnormal blood profile, tissue hypoxia and changes in general response
as evidenced by anaemic look of the mother.
7. Risk for imbalanced nutrition less then body requirement related to inability to digest nutriments are less precise as evidenced by
mothers’ verbalisation of GI disturbance.
8. Risk for trauma of fetal gas exchange related to the inadequate maternal diabetic control, macrosomia or IUGR.
9. Risk for unstable blood glucose level related to lack of adherence to diabetic management as evidenced by blood glucose level below
or above normal level.
10. Risk for infection related to decreased leukocyte function and circulatory changes due to high blood glucose level.
 8. NURSING CARE PLAN:

NURSING NURSING GOAL INTERVENTIONS RATIONALE IMPLEMENTATION EVALUATION

ASSESSMENT DIAGNOSI S
S
Subjective Acute pain To cure  Assess the general  To know the  Client general Day 1: pain is little
data: related to the condition of the client baseline data condition is bit reduced.
Client said that, burning vaginitis to know the condition assessed Mild pain is there.
she is having micturition and of the client
vaginal itching, and vaginal provide
white curdy itching as relief  Inspect the vaginal area  To check any
discharge and evidenced by from for symptoms of deviation from  P/S examination is
red ness on client pain. vaginitis the normal done
vulva. verbalization. Day 2: no pain and
white discharge is
 Wash labia and vulva  To maintain  Perineal area is reduced
with v-wash lotion the hygiene cleaned

 Dry the external  To remove  Perineal area is

genitals and perineum moistness  dried well
thoroughly
Objective  Wash hands before and  To prevent the  Asepsis is Day 3: Itching,
data: after inserting cross infection maintained redness and swelling
It was observed antifungal pecessary is minimised.
during per  Avoid deodorant’s
speculum powders, perfumed  To prevent the  Chemicals are
examination toilet paper. vaginal area avoided
that client is from strong
having white chemicals
curdy discharge  Wear cotton under
,vulva is red clothing. Avoid tight  To provide soft  Soft underclothes
,swollen and fitting clothing and good are wearied
sensitive to ventilation for
touch.  Eat well balanced diet. perineal Ares.
According to diet plan. Well balanced diet is
 To make the maintained.
tissue healthy

.
NURSING NURSING GOA INTERVENTIONS RATIONALE IMPLEMENTATIONS EVALUATION
ASSESSMEN DIAGNOSIS L
T
Subjective Acute To  Assess the level of  To know the level  Assessed the level of Day 1:
data: abdominal mini pain by pain rating of pain. pain with pain rating abdominal was
Client said pain related to mize scale. scale, and the score decreased to
that” I’m false labor the  Advise client to take  To maintain was 4. some extent as
having lower pain as pain rest with legs elevated normal venous evidenced by
abdominal and evidenced by on the pillow. return  Advised the client to facial expression
back pain” verbalization take rest with legs of the client.
of mother and  Advise the client to lie  To provide elevated on the pillow Pain score 3
Objective irritable down in a comfortable comfort
data: uterus . position.  Advised the client to Day 2: backache
It was observed lie down in a was decreased as
that the client  Educate client about  To divert and comfortable position evidenced by
uterus was relaxation therapy. relax the mind facial expression
irritable and  Educated the client of the client and
slightly tender.  Provide diversional  To divert the about relaxation pain rating scale:
therapy to the client. mind of the client techniques like deep 1
and controlled
 Provide back massage  To provide breathing.
relaxation  Provided diversional Day 3: No
 Hot compression with  To get relief from therapy by abdominal and
hot water bottle. pain communicating with back pain
the client. evidenced by
 Avoid visitors at the  To avoid  Advised the family facial expression
time of rest or sleep. disturbance members to avoid of the client .
during resting visitors during uterus was
hours sleeping and resting relaxed on P/A
hours. examination.
 Try to provide a calm  To provide and  A calm and soothing
and soothing promote comfort environment was
environment to the provided to the client
client. by avoiding visitors
and switching off the
extra lights.
 NURSING NURSING GOAL INTERVENTIONS RATIONALE IMPLEMENTATIONS EVALUATION
ASSESSMEN DIAGNOSI
T S
Subjective Knowledge To improve  Assess readiness to  To make sure that  Readiness to learn Day : 1-patient
data: deficient the learn and individual client is physically and learning needs to have knowledge
Client said thatregarding knowledge learning needs. mentally and be assessed. regarding diet
“ I’m having disease regarding Determine clients emotionally and treatment as
lack of proper process, disease readiness as well as capable for the evidenced by
knowledge treatment and process, his barrier to teaching patient have less
related to individual treatment learning programme. quarries
treatment and care needs and  Identify clients  To provide proper  Client s support
diet plan. related to individual support person that information person is identified Day 2: Level of
unfamiliarity care needs. may also need regarding knowledge is
Objective data: with information about treatment to the improved as
It was observed information the planned diabetes support person evidenced by
that the client ,lack of recall regimen because they are client is having
was not having evidenced by also providing regular
regular regimen verbal  Create objectives care to the client. treatment
of medicine statements of clearly in clients  To meet the client  Objectives are regimen
intake and diet concerns or term need and no the created and clarified
plan. misconceptio instructor need
n  Provide written  The written  Written information Day 3: Level of
information’s related information is provided related to knowledge is
to treatment and helpful for the diet and treatment. improved as
diabetic diet plan client if he needs evidenced by”
 Provide information clarification. that patient is
how to contact  For concern and  Information related to informing
health care provider clarification after health care provider herself that my
after hospitalization. discharge is provided blood sugar
 For health care  Client is taught about sampling time is
 Educate about resource post nearby community due now when
nearby community discharge. health resources nurse is doing
resources.  Simplifies the diet  Diet and medication the medication
 Discuss one topic at plan and regimen is taught to of mother.
time avoid jumping medication the mother in simple
into different topics. regimen. way.
NURSING NURSING GOAL INTERVENTIONS RATIONALE IMPLEMENTATIONS EVALUATION
ASSESSMENT DIAGNOSI
S
Subjective Risk for To  Assess the general  To know the  General condition of Day 1: Normal
data: Decreased maintain condition of the baseline data. client is assessed by cardiac output is
Client said that, cardiac the client. monitoring vital signs. maintained as
she is feeling output normal  Observed the skin evidenced by
fatigued and related to cardiac  Observe skin color,  To know any early colour, moisture, monitoring
weak. poor venous output moisture, temperature signs of shock and temperature and blood pressure.
return as and capillary refill haemorrhage capillary refill time  BP 120
evidenced by time /70mmhg
monitoring
blood  Provide calm and  To provide comfort  Provided calm and Day 2: Normal
pressure soothing and rest soothing environment cardiac output is
environment and and try to minimize the maintained as
try to minimize the environmental noise by evidenced by
environmental avoiding extra visitors. monitoring
Objective data: noise. blood pressure
On observation  Taught the client about and pulse.
it was observed  Teach the client  To divert and relax relaxation techniques  BP/110/70m
that patient is about relaxation mind and body. and guided imaginary. mhg
feeling fatigued techniques and  Pulse -80
related to guided imaginary.  Asked the client to lie beats /mint
decreased  To improve venous down in a comfortable
cardiac output.  Ask the client to lie return. position with legs
down in a elevated on a pillow. Day 3: Normal
comfortable cardiac output is
position with legs  Frequently monitored maintained as
elevated on a the blood pressure of evidenced by
pillow.  To keep a check the client and kept a monitoring
 Frequently monitor over blood pressure record of it. blood pressure.
the blood pressure and to know any  BP:120/80m
of the client and deviation from the mhg
keep a record of it. Normal
 Advise the client to  To maintain normal  Advised the client to
avoid any strenuous cardiac activity. avoid any strenuous
activity. activity.

 Advise the client to  To avoid stress and  Advise the client to

avoid over thinking maintain normal avoid over thinking and
and stress cardiac activity stress

 Talk to the client  To gain confidence  Communicated with the

and try to answer to and solve queries of client and answered to
their queries. the client their all of the
questions.

 Advice patient  To maintain normal  Advised the client about

about sodium blood pressure. sodium restricted diet.
restricted diet.
9. PROGRESS NOTES:

DATE DAY GENERAL ANY SPECIFIC MEDICATION VITAL SIGNS CARE PROVIDED/
CONDITION OF COMPLAINTS ADVICES
CLIENT
21/11/2019 1st day General condition Client was having Tab clitrimazole Temperature- 98.2  Educated the client about
was fair and client acute pain during 100 mg vaginally f the personal; hygiene
was calm, conscious micturition and given Pulse rate-  Educated the client about
and oriented to time vaginal itching. Tab calcium 500 78beats/min hand washing.
place and person. mg Respiration- 20  Advised the client to wear
Hygiene was Tab iron 60 mg breaths/min loose cotton underwear.
maintained and client Tab metformin BP- 130/80 mmhg.  Educated the client about
was well groomed. 500 mg delivery and postnatal
nd
22/11/2019 2 changes.
day General condition Acute lower Temperature- 98.6  Advised the client about
was fair and client abdomen pain and Tab clitrimazole f postnatal exercises.
was calm, conscious backache 100 mg Pulse rate-  Educated the client about
and oriented to time Calcium 500 mg 78beats/min breastfeeding and its
place and person. Iron 100 mg Respiration- 20 benefits.
Hygiene was Tab metformin breaths/min
 Educated the client about
maintained and client 500mg BP- 120/70 mmhg
care of new-born.
23/11/2019 was well groomed.
rd  Educated the client about
3
self-hygiene
day General condition Tab clitrimazole Temperature- 98 f
was fair and client 100mg Pulse rate-  Educated the client about
diabetic diet menu plan
was calm, conscious Calcium 500 mg 74beats/min
and oriented to time Iron 100 mg Respiration- 20
place and person. Tab metformine breaths/min  Educated the client about
Hygiene was 500 mg. BP- 130/80 mmhg glucose monitoring and
maintained and client treatment regimen’
was well groomed
10. ANTENATAL ADVICES:

DO’S DON’Ts WARNING SIGNS

 Sleep sideways with a pillow  Sleep on your back  Bleeding per vaginum
 Prepare yourself for breastfeeding  Don’t slump or slouch  Leakage per vaginum
 Be aware of your baby’s movements  Don't go more than two to three hours  Increased blood pressure
 Learn about the stages of labor without eating  Pedal edema
 Do kegel exercise  Avoid heavy lifting  Anaemia (less than 6gm %)
 Have positive mind and outlook  Avoid Heavy household chores  Pre rupture of membrane
 Continue antenatal exercise  Avoid heavy exercising  Febrile ailments
 Talk to your health care provider  Don’t over think things or take stress  Bad obstetrical history
 Maintain perineal hygiene  Avoid travelling.  History of APH or PPH
 Uterine size less than period of gestation
 Blurry or impaired vision
 Unusual or severe abdominal pain or
backaches
 Frequent, severe, and/or continuous
headaches

HEALTH EDUCATION-
DIET-
 Mother advised to take 1800 kilo calories /day
 Mother advised to take small and frequent, easily digestive and rich in protein, minerals and vitamins rich diet.
 Mother advised to follow therapeutic diet menu plan.(diabetic diet plan)
HYGIENE-
 Mother advised to avoid the strenuous work and start prenatal exercises as long as she feels comfortable.
 Mother advised to take bed rest 8hours at night and 2 hours at noon.
 Mother advised to take plenty of fluids, vegetables, fruits and stool softeners to get relief from constipation.
 Mother advised to take daily bath but be careful against slipping in bathroom.
 Mother advised to wear loos and comfortable garments, avoid high heels.
 Mother advised to wear well-fitting brassiere to get relief from breast engorgement.
 Mother advised to avoid travel.
  Mother advised to stop smoking and alcohol intake.
EXERCISES
 Advised mother for active and passive exercises after demonstrating the exercises.
GENERAL ADVICE
 Mother advise to come hospital at painful uterine contractions, sudden gush of watery fluid, active vaginal bleeding.

SUMMARY:

My self Nadiya Rashid student of Msc nursing II year. I was posted in antenatal ward where Mrs kajol a 23 years old female with diagnosis
of G3P1L1A1 with POG 39 weeks + 1 day of pregnancy with cephalic presentation GDM was assigned as a patient to me by our teacher Mrs
Simarjeet ma’am (Assistant professor). The client came to the hospital with the chief complaint of lower abdominal pain, white discharge from
vagina and mild backache and difficulty in sleeping, so I cared her for three days and provided health education to the client for preparing her
for the delivery. Along with nursing care and medical treatment the client was feeling better than before.
BIBLIOGRAPHY

 Dutta’s D.C. Textbook of obstetrics. 9th edition. Published by New central book agency (P) ltd. Chintamoni das lane, Kolkata
India.2013.
 Rama AV. Textbook of Maternity nursing. 19th edition. Published by wolters kluwer. New Delhi. 2014.
 Howkins and Pourne. Shaw’stextbook of gynecology. 16th edition. Published by reed Elsevier. New Delhi. 2015.
 http://www.momjunction.com/articles/indian-diet-during-pregnancy_00372727/#gref
 Lippincott and Wilkins.” Drug handbook’’. 32nd edition. Published by wolter and kluwer. New York. 2012.
 https://nurseslabs.com/6-hypertension-htn-nursing-care-plans/4/
 https://nurseslabs.com/pregnancy-induced-hypertension-nursing-care-plans/3/
 M.M. COLLAGE OF NURSING,
MULLANA

NURSING CARE PLAN

ON
ANTENATAL MOTHER

SUBMITTED TO SUBMITTED BY
Ms Simarjeet ma’am Ms Nadiya Rashid
Assistant Professor M.Sc. nursing II year
OBG Department 1918721