ILIGAN MEDICAL CENTER COLLEGE

San Miguel Village, Pala-o, Iligan City

Tel. No. 221-4661 – Fax No. 221-6584
www.imcc.edu.ph
PACUCOA ACCREDITED
(Level II 1st Reaccredited Status)

NURSING CARE PLAN

CASE METHOD APPROACH
MATERNAL HEALTH CARE ANALYSIS FORM

STUDENT : ___________________________________ YEAR LEVEL : ________________________________ GROUP NO. : _________________

HOSPITAL / WARD : __________________________ INCLUSIVE DATE OF EXPOSURE: ______________

CLINICAL INSTRUCTOR: _____________________ RATING: ______________________________________

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 REVIEW OF ANATOMY AND PHYSIOLOGY

I. GENERAL INFORMATION

Name : __________________________________________ Discharge Date & Time : _____________________________________

Age : __________________________________________ Initial Diagnosis : _____________________________________

Sex : __________________________________________ Final Diagnosis : _____________________________________

Nationality : __________________________________________ Attending Physician : _____________________________________

Civil Status : __________________________________________ Source of Information : _____________________________________

Birth Date : __________________________________________ Relationship to Child : _____________________________________

Chief Complaint : __________________________________________ Reliability of Historian : _____________________________________

Address : __________________________________________ Language / dialect spoken : _____________________________________

Inclusive Date of Confinement: _________________________________________ Rank in the Family : _____________________________________

Admission Date & Time : __________________________________________ Insurance : _____________________________________

II. HEALTH HISTORY

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 MATERNAL ASSESSMENT

GENERAL SURVEY

A. Breasts and Nipples

 Contour and size (describe)

 Lumps _________ presence _______ absence
 Secretions _________ colostrums _______ secretions other than colostrums specify ____________________.

B. Abdomen

 Contour and size (describe)

 Changes in skin color and characteristics _______ linea nigra ________ striae gravidarum _______ scars _______ rashes

C. Fundal Height

_________ measurement in centimeters

_________ fundus palpable just above symphysis at 8-10 weeks
_________ halfway between symphasis and umbilicus at 16 weeks
_________ umbilicus at 20-22 weeks

D. Perineum ______ scars ______ moles _______ rashes ________ warts _______ discharge

Baseline Data Day 1 Day 2 Day 3 Day 4 Day 5

1. Weight
2. Vital Signs Blood pressure _____ _____ _____ _____ _____
Temperature _____ _____ _____ _____ _____
Pulse Rate _____ _____ _____ _____ _____
Respiration _____ _____ _____ _____ _____

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 3. Laboratory Findings Urine Hematocrit _______ Pap smear _______
sugar _______ Hemoglobin _______ VD smears and screening _______
protein _______ Blood type _______
albumin _______ Rh factor _______

ANTEPARTUM ASSESSMENT

1. Weight _______ First trimester (3 – 4 lbs.)

_______ Second trimester (12 – 14 lbs.)
_______ Third trimester (8 – 10 lbs.)
Total _______ (Minimum weight gain during pregnancy: 24 lbs)

2. Blood pressure _______ First trimester _______ Second trimester _______ Third trimester
(average)

3. Fundal Height _______ large fundal growth, specify ___________________

_______ small fundal growth, specify ___________________

4. Fetal position (Leopold’s maneuver) _______ Vertex presentation

_______ Breech presentation / transverse lie

5. Fetal heart rate _______ bpm

_______ quadrant & location

6. Edema _______ lower extremities ________ upper extremities _______ face

7. Urine _______ presence of sugar

_______ presence of protein
_______ presence of albumin

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8. Major discomforts

______ abdominal distress _______ cramps in legs _______ frequency voiding ______ nausea & vomiting ______ vaginal discharge
______ backaches _______ edema of legs & feet _______ heartburn ______ pain in thighs or aching of perineum ______ varicosities, legs & vulva
______ breast soreness _______ fatigue _______ hemorrhoids ______ shortness of breath
______ constipation _______ flatulence _______ insomnia ______ supine hypotensive syndrome

INTRAPARTUM ASSESSMENT

1. Lightening and dropping

______ several days to weeks before onset of labor
______ multipara: may not occur until onset of labor
______ no lightening or dropping

2. Mucous plug ______ expelled from cervix prior to onset of labor

3. Bloody show ______ clear, pinkish, or blood-tinged vaginal discharge as cervix begins to dilate, efface

4. Ruptured membranes ______ before labor ______ during labor ______ after labor ______ meconium staining

5. Amniotic fluid ______ clear, straw color amount: ______ less than 500 ml. ______ odor
______ greenish brown ______ 500 – 1000 ml.
______ yellow-stained ______ 1,000 – 2,000 ml.
______ over 2,000 ml.

6. Fetal heart rate ______ bpm _______ > 160 bpm ______< 120 bpm ______ absent

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LABOR AND DELIVERY ASSESSMENT

1. First Stage

 Frequency (mins.) _______

 Duration (seconds) _______
 Intensity (mmHg) _______ latent ______ active ______ transitional phase
(cm) (cm) (cm)
 Bloody show ______ absent ______ present
 Nausea & vomiting ______ absent ______ present
 Perineum beginning to bulge ______ absent ______ present
 Urge to bear down ______ absent ______ present

2. Second Stage

 Caput ______ visible ______ non – visible

 Presenting part
 Fetal heart rate
 Fetal heart rate tracing
 Breathing
 Pain and anxiety
______ vertex ROA / LOA presentation _______ occiput posterior, breech, face or transverse lie
______ bpm ______< 120 bpm _______> 160 bpm ______ absent
______ short term variability _______ long term variability
______ controlled _______ heavy / excessive
______ medication required _______ no medication

3. Third Stage

 Placental separation ______ duration (mins.) _______ failure of separation

4. Fourth Stage

 Temperature _______
 Pulse rate _______
 Respiration _______
 Blood pressure _______

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POST PARTUM ASSESSMENT

1. Vital signs every 15 mins. (average) every 30 mins. (ave.) every hour (ave.) every 4 hrs. (ave.) every 8 hrs. (ave.)\

 Temperature ______ ______ ______ ______ ______

 Pulse rate ______ ______ ______ ______ ______
 Respiration ______ ______ ______ ______ ______
 Blood Pressure ______ ______ ______ ______ ______

2. Fundus ______ firm in midline 4 at or slightly above umbilicus

______ return to prepregnant size in 6 weeks (descending at rate of 1 fingerbreath / day)
______ boggy fundus
______ misplaced fundus

3. Lochia

 Color ______ rubia (1 – 3 days) ______ serosa (4 – 10 days) ______ alba (10 – 21 days) others, _______ spurts ______ heavy bright red
“dark red” “clear pink” “white” “yellow brown” ______ No lochia
 Quantity ______ moderate ______ heavy
 Odor ______ minimal ______ foul

4. Breasts and Nipples

______ soft, intact, secreting colostrums (day 1 – 2)
______ engorged, tender, full, tight, painful (day 2 – 3 )
______ secreting milk (day 3 & 4)
______ increased pains as baby sucks
______ sore or cracked
______ milk does not “let down”

5. Perineum
______ episiotomy intact ______ no discoloration
______ no swelling ______ bruising / swelling

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6. Bladder
_______ voiding every 4 hours with no pain
_______ voiding regularly with pain
_______ not voiding

7. Bowels
_______ spontaneous bowel movement 2 – 3 days after delivery ______ no BM

8. Mother-infant bonding

_______ touches infant ______ discussing care about baby

_______ talks to infant ______ discussing role of being a parent

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 STEPS IN LEOPOLD’S MANEUVER

First Maneuver To determine part of fetus presenting into pelvis.

Second Maneuver To locate the back arms & legs (fetal heart heard best over fetal back)

Third Maneuver To determine part of fetus in fundus.

Fourth Maneuver To determine degree of cephalic flexion and engagement

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MAJOR DISCOMFORT AND RELIEF MEASURES

DISCOMFORT TRIMESTER MOST RELIEF MEASURES

PROMINENT
1. Nausea & 1st Eat five/six small, frequent meals. Between meals have crackers without fluid.
vomiting Avoid foods high in carbohydrates, fried and greasy or with a strong odor.
1st Take frequent rest periods during the day.
2. Fatigue 1st, 3rd Wear perineal pads if there is leakage.
3. Frequency 2nd, 3rd Avoid fatty, fried & highly spiced foods.
voiding Small frequent feedings.
4. Heartburn Avoid sodium bicarbonate.
1st, 2nd, 3rd Eat slowly, chew food thoroughly, take smaller helpings of food.
2nd, 3rd Maintain daily BM. Avoid gas – forming foods.
5. Abdominal 2nd, 3rd Drink sufficient fluids. Eat fruits and foods high in fiber & roughage. Exercise moderately. Do not use mineral
distress 3rd oil.
6. Flatulence 3rd Apply ointments, suppositories, warm compresses. Avoid constipation.
7. Constipation 3rd Exercise moderately to promote relaxation & fatigue.
8. Hemorrhoids Rest and improve posture; use a firm mattress. Use a good abdominal support; wear comfortable shoes.
9. Insomnia 3rd Do exercises: squatting, sitting & pelvic rock.
10. Backaches Avoid long period of standing or sitting with legs crossed. Sit or lie with feet and hips elevated. Move about
3rd while standing to improve circulation. Wear support hose; avoid tight garters. Wear peripads with vulva
11. Varicosities, 3rd varicosities.
legs & vulva 3rd Elevate feet while sitting or lying down. Avoid standing or sitting in one position for long periods.
12. Edema of legs 3rd Extend cramped leg and flex ankles, pushing foot upward with toes pointed toward knee. Increase calcium
& feet 1 , 2nd, 3rd
st
intake.
13. Cramps in legs 3rd Alternate periods of sitting and standing. Rest.
14. Pain in thighs or 3rd
aching of perineum Sit up. Lie on back with arms extended above bed.
15. Shortness of Wear brassiere with wide adjustable straps that fits well.
breath Change position to left side to relieve pressure of uterus on inferior vena cava.
16. Breast soreness
17. Supine Practice proper cleansing and hygiene. Avoid douche unless recommended by physician.
hypotensive Observe for signs of vaginal infection common in pregnancy.

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 syndrome
18. Vaginal
discharge

PHILOSOPHY OF MATERNAL AND CHILD HEALTH NURSING

1. Maternal and child health nursing is family centered: assessment data must include family as well as individual assessment.
2. Maternal and child health nursing in community centered: the health of families both depends on and influences the health of communities.
3. Maternal and child health nursing is research oriented because research is the means whereby critical knowledge increases.
4. Nursing theory provide a basis for nursing care.
5. A maternal and child health nurse serves as an advocate to protect the rights of all family members including the fetus.
6. Maternal and child health nursing uses a high degree of independent nursing functions because teaching and counseling are so frequently required.
7. Promoting health is an important nursing role because this protects the health of the next generation.
8. Pregnancy or childhood illness are stressful because they are crises. The alter family life in both subtle and extensive ways.
9. Personal, cultural and religious attitudes and beliefs influence the meaning of illness and its impact on the family. Circumstances such as illness or pregnancy are
meaningful only in the context of a total life.
10. Maternal and child health nursing is a challenging role for the nurse and is a major factor in promoting high – level wellness in families.

TERMS RELATED TO PREGNANCY STATUS

TPAL - T – the number of full – term infants born (37 weeks or after).
- P – the number of pre – term infants born (before 37 weeks).
- A – the number of spontaneous / induced abortions.
- L – the number of living children.

PARA – a live birth.

GRAVIDA – a pregnant woman.
PRIMIGRAVIDA – a woman who is pregnant for the first time.
PRIMIPARA - a woman who has delivered a live born child.
- a woman who is pregnant for the first time.

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MULTIGRAVIDA – a woman who has been pregnant previously.
MULTIPARA – a woman who has delivered 1 or more live-born children previously.
NULLIGRAVIDA – a woman who has never been pregnant.

Guidelines for Working Women With Normal Pregnancies (Pilliteri)

(From Ringler – Barman, M. (1984). Advising pregnant and post operative working patients.

TRY TO ALL JOBS AVOID

1. Take frequent breaks. Exhaustion

2. Rest on left side at lunch hour. Discomfort
3. Stop working when fatigued. Strenuous exercise
4. Elevate legs periodically. Extreme temperature
5. Take walks. Smoking areas
6. Perform stretching exercise, especially for back and legs. Ladder climbing
7. Wear support hose. Lifting more than 10, 15, or 25 lb (different responses)

JOBS THAT REQUIRES STANDING / WALKING AVOID

1. Reduce activity; work part time or most in 8-hour shifts. Heavy lifting or pushing
2. Take naps or rest periods morning or afternoon. Exercise stair climbing
3. Stop or reduce work 2 – 4 weeks before EDC. Running

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 In flight airline work in final month

JOBS THAT REQUIRE PHYSICAL EXERTION AVOID

1. Use common sense. Heavy lifting & straining

2. Stop when short of breath. Jogging and contact sports.
3. Sleep on left side. Prolonged standing or walking.
4. Empty bladder every two hours. Horseback riding, skiing, rough hiking after 7 months.
5. Get extra rest on weekends. Trauma to abdomen from heavy equipment
6. Exercise great caution around hazardous equipment such as machinery with Overtime
moving parts.
7. Work part time (20 hrs / wk) for 2 – 4 weeks before EDC.

FACTORS THAT CREATE A HIGH-RISK STATUS: (PILLITERI)

1. Abnormal fetal presentation / position.

2. Age 35 years or younger than age 15 years.
3. Bleeding during pregnancy.
4. Drug or alcohol dependence.
5. Hydramnios
6. Hypertension of pregnancy
7. Infection in mother
8. Maternal illness.
9. Past history of difficult delivery.
10. Post ceasarean birth.

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 11. Potential for blood incompatibility.
Classification of NANDA Nursing Diagnoses by Gordon’s Functional Health Patterns
Health Perception-Health Management Pattern
Health maintenance, altered
Noncompliance (specify)
Infection, potential for
Injury, potential for
Injury, potential for: trauma
Injury, potential for: poisoning
Injury, potential for: suffocating
Nutritional-Metabolic Pattern
Nutrition, altered: potential for more than body
requirements
Nutrition, altered: less than body requirements
Swallowing, impaired
Tissue integrity, impaired: oral mucous membrane
Fluid volume deficit: potential
Fluid volume deficit: actual (1)
Fluid volume deficit: actual (2)
Fluid volume excess
Skin integrity, impaired: potential
Skin integrity, impaired: actual
Tissue integrity, impaired
Body temperature, altered: potential
Thermoregulation, ineffective
Hyperthermia
Hypothermia
Incontinence, total
Urinary retention
Activity-Exercise Pattern
Activity intolerance: potential
Activity intolerance
Mobility, impaired physical
Self-care deficit: bathing/hygiene
Self-care deficit: dressing/grooming
Self-care deficit: feeding
Self-care deficit: toileting
Diversional activity, deficit
Home maintenance management, impaired
Airway clearance, ineffective
Breathing patte4rn, ineffective
Gas exchange, impaired
Cardiac output, altered: decreased
Tissue perfusion, altered: renal, cerebral,
cardiopulmonary, gastrointestinal, peripheral
Growth and development, altered
Sleep-Rest Pattern
Sleep pattern disturbance
Cognitive-Perceptual Pattern
Comfort, altered: pain
Comfort, altered: chronic pain
Sensory/perceptual alterations: visual, auditory,
Powerlessness
Self-concept, disturbance in: body image
Self-concept, disturbance in: personal identity
Self-concept, disturbance in: self-esteem
Role-Relationship Pattern
Grieving, anticipatory
Grieving, dysfunctional
Role performance, altered
Social isolation
Social interaction, impaired
Family processes, altered
Parenting, altered: potential
Parenting, altered: actual
Communication, impaired verbal
Violence, potential for: self-directed or directed at
others
Sexuality-Reproductive Pattern
Sexual dysfunction
Sexuality, altered patterns
Rape trauma syndrome
Rape trauma syndrome: compound reaction
Rape trauma syndrome: silent reaction
Coping Stress Tolerance Pattern
Coping, ineffective individual
Adjustment, impaired
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Elimination Pattern
Bowel elimination, altered: constipation
Bowel elimination, altered: diarrhea
Bowel elimination, altered: incontinence
Urinary elimination, altered patterns
Incontinence, functional
Incontinence, reflex
Incontinence, stress
Incontinence, urge
Pilliteri, Maternal and Child Nursing.
Wong, Pediatric Nursing.
kinesthetic, gustatory, tactile, olfactory Post-trauma response
Unilateral neglect Coping, family: potential for growth
Knowledge deficit (specify) Coping, ineffective family: compromised
Thought processes, altered Coping, ineffective family: disabled
Self Perception-Self-Concept Pattern Value-Belief Pattern
Fear Spiritual distress (distress of the human spirit)
Anxiety
Hopelessness
BIBLIOGRAPHY
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 LABORATORY DATA/DIAGNOSTIC STUDIES

A. LABORATORY EXAMINATIONS RESULTS NORMAL SIGNIFICANCE

VALUES

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B. DIAGNOSTIC EXAMINATIONS RESULTS NORMAL SIGNIFICANCE
FINDINGS

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 COLLABORATIVE PLAN OF CARE

MEDICATIONS

Standing Orders
Brand Name/Generic Dose/Dosage/Frequency Indications Action/Mechanism of Action Side Effects Nursing Precautions
Name

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NURSING DIAGNOSES DEVELOPED IN CARE PLAN

CUES PATHOPHYSIOLOGIC NURSING PLAN/OBJECTIVE INTERVENTION RATIONALE EVALUATION

BASIS DIAGNOSIS (INDEPENDENT/DEPENDENT
INTERDEPENDENT

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 CUES PATHOPHYSIOLOGIC NURSING PLAN/OBJECTIVE INTERVENTION RATIONALE EVALUATION
BASIS DIAGNOSIS (INDEPENDENT/DEPENDENT
INTERDEPENDENT

PROGNOSIS/CURRENT STATUS OF PATIENT

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