KHALSA COLLEGE OF NURSING
AMRITSAR.
NURSING CARE PLAN
ON
LSCS ( CAESEREAN
SECTION)
Submitted To: Mrs. Harleen Kaur
Assistant Professor
Msc.(N), OBG
Submitted By:
Anupamdeep kaur
M. Sc. Nursing
(1st year)
PATIENT'S IDENTIFICATION DATA:
Name of Patient: Manpreet kaur
Age / sex: 24yrs / female
Education: Matriculation
Occupation: House wife
Blood Group: A +ve
Marital status: Married
Religion: Sikh
Name of Husband: Rohit
Education: Graduate
Occupation: factory worker
Total Income: 30,000 per month
Address: Sarai Sant Ram,Amritsar
Date of admission: 19-04-2025
C.R. No.: 1505
Obstetrical Score: G-1, P-1, A-0, L-1
Doctor In charge: Dr. Prabhjot Kaur Warraich
Diagnosis: lower segment cesarean section
CHIEF COMPLAINTS:
The chief complains of the patient is pain at incision site, disturbed sleep pattern and slight
increase in body temperature.
HISTORY OF PRESENT ILLNESS:
1) MEDICAL HISTORY: Patient has admitted in postnatal ward after ceasarean section.
with the chief complains of fever, pain and disturbed sleep pattern due to pain at incision site.
Now she is under treatment in J.B.M.M Civil Hospital, Amritsar.
2) SURGICAL HISTORY: patient is undergone cesarean section due to related birth
complications.
HISTORY OF PAST ILLNESS:
PAST MEDICAL HISTORY: No any significant of past medical history.
PAST SURGICAL HISTORY: No any significant of past surgical history.
FAMILY HISTORY: Patient lives in nuclear family with her husband. All the family
members are good & healthy. No any medical or congenital disorder present in family.
FAMILY MEMBERS:-
S. NAME OF AGE/ RELATIONSHI EDUCATION OCCUPATION HEALTH
NO FAMILY SEX P WITH STATUS
. MEMBERS CLIENT
1. Mr. Rohit 26y/M Husband graduate shopkeeper Healthy
2. Mrs. 24y/F Patient Matriculation House-wife Unhealthy
Manpreet
kaur
3. Harpal singh 52 y/ M Father-in-law _ Nothing Healthy
4. Amarjot Kaur 50/F Mother-in-law _ Nothing Healthy
FAMILY TREE
Harpal singh Amarjot kaur
Rohit Manpreet kaur ( Patient)
Keys:
Male
Female patient
Female
MENSTRUAL HISTORY:
Age of menarche: 13 years
Duration of cycle: 30 days
Number of days: 5-6 days
Flow: Normal
Discomfort during menstruation: Mild Dysmenorrhoea
MARITAL HISTORY:
Age of Marriage: 22 years
Nature of marriage: Arranged marriage
OBSTETRICAL HISTORY:
Number of living children : NONE
Health status of babies : -
Immunization : -
Last Issue : No any last issue
DELIVERY NOTES:
Type of delivery : LSCS
Date of delivery : 19-04-2025
SOCIO-ECONOMIC STATUS:
Type of house : Cemented house
Number of Rooms : 3 rooms
Total income per month : 30,000 from all sources
Latrine facility : Available
Drainage facility : Good
PERSONAL HISTORY:
Sleeping pattern : About 7 hours
Diet Habit : Good (Three times in a day)
Bowel and bladder Habit : Good
Allergic to diet : No any significant
Personal hygiene : Good
Amount of water intake :10-12 glasses per day
PHYSICAL EXAMINATION:
GENERAL APPEARANCE:
Nourishment : Well Nourished
Body Build : Good
Health : Unhealthy
Activity : Dull
VITAL SIGNS:
Temperature : 100.2 F
Pulse : 110/min
Respiration : 24/min
B.P :110/80mm (Hg)
MENTAL STATUS:
Consciousness : Conscious
Look : Depressed
POSTURE:
Body curves : Normal
Movement : Allowed
HEIGHT & WEIGHT:
Height : 5’4”
Weight : 70 kg
SKIN CONDITION:
Colour : Fair
Texture : Normal
HEAD:
Hair Colour : Black
Texture of hairs : Rough
Dandruff : Present
Scalp : Clean
EYES:
Eye brows : Symmetrical
Conjunctiva : Normal
Eye Lids : No infection present
Pupillary reaction : Reacting to light
Vision : Normal
Sclera : White
NOSE:
Nasal drainage : Absent
Nostrils : Normal
Epistaxis : Absent
MOUTH:
Lip colour : Pink
Lip Texture : Rough
Teeth : Pale yellow in colour (Normal)
Colour of teeth : Pale yellow
Dental carries : Absent
Gums : No inflammation
TONGUE:
Colour : Pink
Pharynx : Normal
EAR:
Alignment : Normal (Symmetrical)
Discharge : Absent
Hearing : Normal
NECK:
Range of motion : Normal
Lymph nodes : Not palpable
Thyroid glands : Normal, no enlargement
CHEST:
Chest measurement : Normal
Respiratory rate : 24 per minute
Breath sound : Normal, no wheezing sound
Heart sound : S1 and S2 sound present
BREAST:
Shape : Round
Axillary lymph nodes : Not palpable
Nipples : Symmetrical, not cracked and not inverted
Discharge : Adequate
Tenderness : Present
Pain : Present
NAILS:
Shape : Round
Texture : Smooth
Colour : Pink
ABDOMEN:
Inspection:
Skin colour: Fair
Linea nigra: Present
Umblicus: -
Striae gravidarum: Present
Palpation : Abdominal organs are normal.
Auscultation : -
BACK:
Back ache : Present
Lesions : Absent
EXTREMITIES:
Deformities : No any deformity present
Edema : Present
Range of motion : Altered
Homan’s sign : Absent
GENITALIA:
Lesions : Absent
Inguinal lymph node : Present
Anal patency : Good
Vaginal discharge : Lochial discharge
Colour of lochia : Red
Odour of lochia : Foul smell, fishy
VITAL SIGNS:
S. VITALS PATIENT NORMAL REMARKS
No VALUE VALUE
1 Temperature 100.2 F 98.6F pyrexia
2 Pulse 90/Min 72-80/ Min tachycardia
3 Respiration 24/min 16-24/ Min Normal
4 B.P 110/80 mm(Hg) 120/80 mm (Hg) Normal
INVESTIGATIONS:
S. NO TEST PATIENT VALUE NORMAL VALUE
1. TLC 10,000/cu mm 4-11000/cu mm
2. DLC :
Polymorph 39% 50-60%
Neutrophils 43% 40-70%
Eosinophil 2% 1-6%
Basophils 1% 0-1%
3. Blood group A +ve -
4. Hb% 11gm 12-16mg/dl
5. Blood sugar R-100mg/dl 70-130mg/dl
6. Serum potassium 3.7 g 3.5-4.5g/day
7. S. Sodium (Na+) 12 g 135-145g/day
8. S. Creatinin 0.4mg/dl 0.2-1.2 mg/dl
9. HIV Negative -
10. HbsAg Negative -
11. Bleeding time 1’-6” min -
12. Clotting time 4’-16” min -
MEDICATIONS:
S.NO DRUG DOSE ROUTE FREQ ACTION
1. I/V Fluids 1 pint I.V slow OD Caloric agent
2. Inj. cefotaxime 1 gm IV BD Antibiotic
3. Inj. diclofenac 200mg orally BD Analgesic
a. Inj.Ranitidine 150mg IV BD Antacid
4. Inf. metronidazole 300ml IV 8hrly for 3 Anti microbial
days
NURSING MANAGEMENT:
Nursing Assessment:
To note the patient’s general symptoms( fever, chills, rapid breathing etc.)
to review the medical history of the patient(existing infection, compromised immune
system).
To perform a systemic assessment to identify any systematic changes.
To assess for progression to shock(delayed capillary refill, thready pulses, diaphoresis
etc).
Observe intravenous lines for the signs of infection and thrombophlebitis such as
swelling, redness or drainage.
Goals :
Short term goals:
To reduce the anxiety level
To reduce the pain
To correct the anaemia(if present)
To maintain vital signs
To provide the comfort
Long term goals:
To reduce the complications
To maintain the health of the mother
To educate the mother regarding baby care and feeding
To educate the mother regarding correction of anaemia
To rehabilitate the client as soon as possible
Nursing diagnosis;
Acute pain related to surgical incision as evidenced by patients facial expression.
Risk for infection related to traumatized tissue and tubings as evidenced by client’s
vital sign and CBC profile.
Impaired skin integrity related to surgical incision .
Imbalanced nutrition less than body requirements related to meet metabolic demands
as evidenced by decreased oral intake or lack of oral intake.
Sno. Assessment Diagnosis Goal Planning Intervention Rationale Evaluation
1 Subjective Acute pain To Assess the Assessed Aids in Level of
data: related to decrease location and location and differential pain and
Client says surgical the level of nature of nature of diagnosis discomfort
that she is incision as pain and discomfort discomfort of tissue decreased
having pain evidenced discomfort. or pain, or pain, rate pain to some
stitches. by facial involvement involvement on a 0-10 extent.
Objective expression in infectious in infectious scale.
data: and process. process.
Facial restlessness.
expression Provide Provided Promotes
shows that instruction instruction sense of
client is regarding regarding well being
having pain and assist and assisted and
on with the with enhances
abdomen( i maintenance maintenance healing.
ncisional of of
site) cleanliness cleanliness
and warmth. and warmth.
Provide Provided Refocuses
positive positive client’s
diversionary diversionary attention
activities activities and
such as such as enhances
radio, radio, comfort.
reading, reading,
music. music.
Analgesics Analgesics It act on
such as given to the pain
diclofenac client as receptors
sodium prescribed. and
should reduced
given to the level of
client as pain.
prescribed
by the
doctor.
Sno Assessment Diagnosis Goal Planning Intervention Rationale Evaluatio
. n
2 Subjective Risk for Prevent Review Reviewed Identifies risk Risk of
data: infection spreadin prenatal , prenatal, factors for infection
Client says related to p g of intranatal intranatal and development is reduced
that I am traumatize infection and postnatal postnatal of postnatal to some
feeling d tissues record. record. infection. extent.
body ache. and tubings Helps
as Demonstrate Strict hand prevent cross
Objective evidenced and maintain washing infection.
data; by patients strict hand demonstrated
Patient’s vital signs washing and hand
temperatur and CBC policy for washing
e is slightly profile. staff, client policy
raised. and visitors. maintained Prevents
for all. spread of
Provide for Client infection.
and instruct instructed in
client in proper
proper disposal of
disposal of contaminated
contaminate dressings and
d dressings peripads.
and peripads.
Demonstrate Correct Cleaning
correct perineal removes
perineal cleaning after urinary/fecal
cleaning voiding and contaminants
after voiding defecation .
and and frequent Changing
defecation changing of pads removes
and frequent peripads moist
changing of demonstrated medium that
peripads. . favors
bacterial
growth.
Administer
antibiotics Antibiotics Prevents the
such as administered growth of
cefitriaxone to client . microbial
should be organisms.
given to
client.
Sno. Assessment Diagnosis Goal Planning Intervention Rationale Evaluation
3 Subjective Imbalanced Maintain Encourage Encouraged It helps Normal
data: nutrition less the normal choice of choice of promote nutritional
Client says than body nutrition foods high foods high healing level is
that she is requirements level. in in protein, regeneratio maintained
not feeling related to proteins, iron and n of new to some
hungry. meet iron and vitamin C. tissue. extent.
metabolic vitamin C.
Objective demands as
data: evidenced Promote Promoted Provides
Decreased by decreased intake of intake of at calories and
intake of oral intake at least least 2000 other
food. or lack of 2000 ml/day of nutrients to
oral intake. ml/day of soups and meet
soups and other metabolic
other nutritious needs and
nutritious fluids. replaces
fluids. fluid losses.
Encourage Encouraged Reduces
adequate adequate metabolic
sleep/rest. sleep/rest. rate,
allowing
nutrients
and oxygen
to be used
for healing
process.
HEALTH EDUCATION:
Regarding Diet:
Instruct the client to take meal thrice in a day.
Instruct the client to avoid more spicy & fatty food.
Instruct client to take plenty off fluids.
Regarding Activity:
Teach the client to take the proper rest & sleep.
Regarding Hygiene:
Instruct the client to change vaginal pad time to time.
Instruct the client & family members to maintain proper personal & environmental
hygiene.
Teach the client & family members about hand washing methods.
Regarding Treatment:
Instruct the client to complete her full course of medications.
Instruct the client about every procedure done on client.
Regarding Follow-up:
Instruct the client for follow up visits.
Instruct the woman to notify her health care provider if the experiences respiratory
distress.
SUMMARY:
I have taken the patient Mrs. Simranjeet kaur, 26 years old diagnosed with Puerperial sepsis.
She came in hospital with the chief complaints of fever, pus formation in sutures and foul
smell from vagina since 1 week. Advised is given to take proper rest, nutritious diet and
plenty of fluids.
