Nursing Process

1. 1
GRT COLLEGE OF NURSING
GRT Mahalakshmi Nagar, Tiruttani
MIDWIFERY NURSING PROCESS – NORMAL ANTENATAL
S. No. Nursing Diagnosis Goals Nursing Interventions Rationale Evaluation
1. Discomfort related
to pain secondary
to unpleasant
sensory and
emotional
experiences arising
from actual or
potential tissue
damage as
evidenced by
physiological
changes
Mother use
appropriate
self-care
activities to
reduce
discomfort's
a. Assess respiratory status a. As the uterus compress on the diaphragm,
respiratory capacity reduces resulting in
dyspnea
Mother uses
appropriate
self care
activities to
reduce
discomforts
b. Suggest use of low-healed shoe's,
pelvic rock exercises, heat application
and massage techniques for relief of
back pain and altered gait
b. Effects of hormones relaxing and
progesterone on pelvic articulations and shift
in the center of gravity as the uterus
enlarges causes lordosis and muscle strain
and multiple interventions are more useful
to alleviate discomfort
c. Encourage mother to extend leg's
and turn foot upward in dorsiflexion
and change position frequently in case
of leg cramps
c. Pressure from enlarging uterus compressing
nerves supplying the lower extremities
d. Assess for presence and frequency of
Braxtons Hicks contractions and
provide information regarding
Physiology of uterine activity
d. These contractions may create discomfort’s
for the mother in 2nd and 3rd trimester's
e. Encourage mother to remove
constrictive jewelry if noted any
paresthesia of toes and fingers and
maintain adequate intake of prenatal
vitamins
e. Reduces effects of extreme lordotic posture
strains brachial nerves and compresses nerve
roots and femoral veins
f. Encourage mother to take high fiber
rich foods in her diet if Constipated
persists
f. High fibre diet increases the bulk of the bowel
where increasing displacement of bowel
problems to elimination
g. Encourage mother to take shower with
problem of leukorrhea and use cotton
underwear and loose clothing
g. As oestrogen levels increases secretions of
cervical glands create an acid medium that
encourages proliferation of organisms
h. Suggest to mothers having diaphoresis h. Increased metabolism and body temperature

2. 2
to use light clothing, frequent bathing
and cool environment
caused by progesterone activity and excess
weight gain may create a constant feeling of
being overheated and may increase
diaphoresis
2. Deficient
knowledge
regarding birth
process related to
lack of experience
as evidenced by
request for
information
Mother will
recognize
that
increased
knowledge
and skill will
help her cope
better with
birth process
a. Establish a trusting relationship with
mother and develop mutual goal for
learning
a. These measures enhance learning Mother
verbalizes
increased
knowledge to
cope with
labour and
delivery
b. Provide information about normal
physiological changes associated with
third trimester
b. Understanding the normalcy of such changes
reduces anxiety and fosters adoption of self-
care activities
c. Review information about signs of
labour onset and difference between
false and true labour
c. Helps mother to recognize onset of labour
to ensure timely arrival in hospital and to
cope with labour and delivery process
d. Teach information and skills needed
for understanding and coping during
birth
d. Decreases the mothers anxiety and
increases her sense of competence
3. Disturbed sleep
pattern related to
changes in level
of anxiety as
evidenced by
interrupted sleep
Mother will
report
increased
sense of well-
being and
feeling rested
a. Review changes in normal sleep
requirements associated with pregnancy
and determine current sleep pattern
a. Helps to identify need for establishing
different sleep pattern
Mother
reports
increased
sense of well-
being and
feeling rested
b. Suggest side lying position with pillow
between legs for support
b. Back discomfort may necessitate change in
position and use of multiple pillows
c. Encourage mother to rest 1-2hrs during
daytime and obtain 8hrs of sleep at
night
c. Adequate sleep reduces fatigue
d. Suggest the mother to sleep in semi
fowler position in case of breathing
difficulty
d. Semi fowlers position allows the
diaphragm to descend fostering optimal lung
expansion
e. Encourage the mother to take a warm
shower at bedtimes
e. Warm bath increases vasodilation and
enhances adequate muscle relaxation thus
improves sleep
4. Impaired Urinary
elimination
related to uterine
enlargement
Mothers
urinary
function will
remain
a. Provide information about urinary
change's associated with pregnancy
a. Uterine enlargement reduces bladder
capacity resulting in frequency
Mother
maintains
normal
urinary
b. Encourage mother to assume lateral
position while sleeping
b. A left or right lateral position increases
glomerular filtration rate and renal blood
flow in order to enhance renal perfusion and

3. 3
secondary to
presence of
discomfort as
evidenced by
Urinary
frequency
normal mobilizes dependent oedema function
c. Advice mother to avoid long periods in
upright or supine position
c. These position potentiate venacaval
syndrome and reduces venous return
d. Provide information regarding need for
fluid intake of 6 to 8 glasses and
reduction of intake 2-3hrs before
retiring and moderate use of salt or
sodium containing foods
d. Maintains adequate fluid levels and renal
perfusion
5. Ineffective
breathing pattern
related to
impingement of
the diaphragm
by the enlarging
uterus as
evidenced by
shortness of
breath
Mother will
demonstrate
behaviours
that Optimize
respiratory
function
a. Explain the importance of taking
prescribed vitamins and iron daily
a. Increased plasma levels dilute hemoglobin
levels resulting in possible anaemia and
decreased oxygen carrying capacity
Mother
appears more
relaxed and
less anxious
b. Provide information about rationale
for respiratory difficulties and realistic
activity and exercise program
b. Reduces the likelihood of respiratory
symptoms caused by overexertion
c. Encourage rest periods, providing extra
time for certain activities and
participation in mild exercise such as
walking
c. Promotes maximum lung expansion and
improves breathing
d. Use modified semi fowlers position for
sitting and sleeping
d. Semi upright position may increase lung
expansion as the gravid uterus descends
6. Risk for
ineffective role
performance
related to
maladaptive
coping in
pregnancy period
The mother
will verbalize
acceptance of
changing role
a. Evaluate mothers response to pregnancy
and family stressors
a. Mother's ability to adapt positively to Crisis
depends on support system and coping
mechanism developed in the past
Mother
develops
realistic goals
and accepts
the pregnancy
b. Ascertain from mother how stressors
have been dealt with in the past
b. Learned coping methods either positive or
negative tend to be used in subsequent crises
c. Explain emotional liability as
characteristic of pregnancy
c. Helps mother to understand mood swings
d. Discuss normalcy of ambivalence d. Helps spouse realize the need to offer
support and affection at those times
e. Provide information about the
physiology of pregnancy and child birth
e. Provides information about mothers ability
to deal with stress and the need for
intervention
7. Risk for Mother will a. Discuss with mother the need to
maintain usual pregravid elimination
a. Increasing progesterone level relaxes
smooth muscles within the GI tract, resulting
Mother

4. 4
constipation
related to smooth
muscle relaxation
maintain
normal
pattern of
bowel
function
pattern as much as possible in reduced peristalsis reports
changed food
habits to help
reduce
problems of
constipation
b. Explain the physiologic change's that
cause constipation and hemorrhoids
b. Varicosities of rectum frequency develops
as a result of prolonged constipation and due
to hormonal relaxation of blood vessels
c. Provide dietary information about fresh
fruits, vegetables, fibre, roughage and
adequate fluid intake
c. Adequate bulk and consistency in diet
choices help promote effective bowel pattern
d. Encourage regular, non-strenuous
exercise program such as walking
d. Promotes peristalsis and assist in prevention
of constipation
8. Risk for urinary
tract infection
related to
Urinary stasis
and poor hygienic
practices
Mother will
be free of
signs and
symptoms of
infection
a. Provide information about signs and
symptoms of urinary tract infection and
instruct to avoid self-medication
a. Maternal UTI is associated with preterm
labour and it respond well to treatment
Mother
remains free
of urinary
tract infection
in the
prenatal
period.
b. Teach the need for proper hand
washing before meals, food handling
and after toileting
b.Causative organisms can possibly be
transmitted through poor hygienic practices
c. Provide information about other
hygienic measures including wiping
vulva from front to back after voiding,
defecating and after intercourse
c. Helps prevent rectal E. Coli contaminants
from reaching the vagina
d. Recommend that mother drink 6-8
glasses of non-caffeinated liquid daily
d. Helps to prevent stasis in the urinary tract
e. Encourage practice of kegal exercises
(tightening of perineum) several times
each day
e. Strengthening and increasing the elasticity of
the pubococcygeal muscle provides more
control over urination
f. Suggest use of cotton underwear and
adequate shower
f. Wearing synthetic fabrics can potentiate for
exposure of infection
g. Administer prescribed antibiotics as
appropriate
g. Treats infection as indicated
9. Risk for
maternal injury
related to pre-
existing or newly
developed health
Mother will
verbalize
understanding
of potential
individual
risk factors
a. Evaluate preexisting or newly
diagnosed high risk factors
a. Potential high risk situations often becomes
problematic and necessitate interventions
Mother asks
for
clarification
of potential
risks factors
and seeks
b. Assess for infections such as Candia
trichomonas, gonorrhea, herpes simplex
virus, etc and if present refer for
appropriate treatment
b. Untreated vaginal infections or STDs create
intense discomfort for the mother and risk for
the fetus either through placental
transmission or at the time of delivery
c. Verify the mother is following c. Detects anaemia with potential problems

5. 5
problem prescribed daily iron and prenatal vitamin
intake and check reports of hemoglobin
and hematocrit
of hypoxaemial anaemia for mother and fetus medical help
d. Provide information about signs and
symptoms of labour onset,review history
of PROM or preterm labour
d. Positive history increases likelihood of
similar problems in subsequent pregnancy
e. Inform physician for appropriate
treatment of mothers who have vaginal
bleeding, presence of ecchymotic area's and
signs of Disseminated intravascular
coagulation
e. Presents an obstetrics emergency with
reduction in fluid volume and decreased
oxygen carrying capacity posing a threat to
maternal organs, placental circulation and fetal
systems