SANDRA SHROFF ROFEL

COLLEGE OF NURSING,VAPI.
Case Study
ON
Antenatal mother
SUBMISSION ON : /03/11

SUBMITTED TO: SUBIMITTED BY:

Mrs. Sudha pete Ms . Revathi Singireddi
Professor (Principal ) 1ST YEAR M.Sc.N.

S.S.R.C.N.;VAPI S.S.R.C.N.;VAPI

HISTORY TAKING

I. DEMOGRAPHICAL INFORMATION

Name : Mrs. Nayanaben Vinodhbhai

Age : 22Years
Sex : Female
Address : Market area , Nearbaba temple , Dharampur, valsad dt.

Religion : Hindu
Marital status : Married
Education : 2nd class
Occupation : Cooley
Income : Rs.&7000 / month
Ward : Gynec ward
Date of Admission : 10 /02/11 in to antenatal ward
I.P No : 0172- 02-11
L.M.P 15-05-10
E.D.D : 22-02-11
Gestational age : 37weeks.3days
Obstetrical score : G1 P 0L 0D 0A0

DIAGNOSIS : Antenatal mother with PROM

II. CHIEF COMPLAINT / CLIENTS REQUEST FOR CARE:

Patient came with labour pain with contractions since 7 hours. Patient is full term primi
mother. On admission 4 finger tight and PROM , liquor is clear.

III. PRESENT ILLNESS / PRESENT HEALTH STATUS:

a) Symptoms or complaints - she is having acute pain on back and abdominal area
b) Onset - Acute
c) Location - abdominal region
d) Quality - pinching in nature
e) Quantity - Continues pain
f) Associated phenomenon - physiological response to the pregnancy
g) Alleviating factors - walking
IV. PAST HISTORY:
a) No allergy to any medication and food
b) No history of, tuberculosis and Diabetes mellitus
c) Immunization – has mark and BCG scar
d) No significant past medical history
V. FAMILY HISTORY:
 She belongs to middle class family, got married 2years back and has conceived for first
time.

Sl. Name of the family Age Sex Occupatio Education Relatio Health status
No. member n n
th
1. Mr. Vinodhbhai 26 yrs Male Cooley 4 std husband Healthy
2. Mrs.Nayanaben 22yrs Femal Cooley 2nd std self Antenatal
Vinodhbhai e mother
She has the no significant family history, all the family members are healthy.
VI. PSYCHO SOCIAL HISTORY:
Economic history: He belongs to Middle class family. Her husband is the bread winner of
the family. She herself also supports the family.
Mother tongue - Gujarathi
Language known - Gujarathi.
Cultural Group - family Friends
Mood - Social
VIII. NUTRITIONAL HISTORY:
She is taking all types of foods of vegetarian. She has no history of allergy to any
foods. She used to take 3 meals per day. Her staple food is wheat, prefer to take chapatti or roti.
IX. ELIMINATION & BOWEL PATTERN:
Bowel – she has regular bowel movement once a day in the morning and no history of
constipation.
Bladder – bladder patterns are regular, voids approximately 5 times a day. No history of
dysuria, hematuria.
X. ENVIRONMENTAL HISTORY:
She lives with her family in concrete , rented house, which has three room and a kitchen
is combined. They use toilet for defecation and getting water from the boring well. She has
electricity supply and closed drainage system in his house.
XI. Menstrual history :
She attained the menarche at the age of 14 years , she had regular menstrual cycles of 28-32 days
with moderate flow for 4-5 days. There is no history of premenstrual symptoms or
dysmenorrhea.

XII. Present Obstetrical History :

First trimester : she had the complaints of nausea and vomiting. She is immunized against the
tetanus with TT 0.5ml IM. And supplemented with iron and folic acid tablets.

Second trimester: she had the complaints of leg cramps and back ache , immunized with 2nd
dose of TT. Supplemented with iron and calcium. No discharges from the vagina. Regular fetal
movements felt.
 Third trimester: she had the complaints of frequency of micturation. Fetal movements are felt,
no APH membranes ruptured in early results in PROM, she admitted with labor pains.

Clinical attendance:

Date Weight Urin Blood FHR Weeks of Fundal Position treatment

e pressur gestation height
e
14-9-10 52kg nill 120/80 ---- 17weeks 16weeks Inj.TT. 0.5ml IM
4days T.folic acid
T. ferrous sulphate
12-3-11 60Kg Nill 120/80 140 37weeks 34-36 ROA Admitted in hospital
3days weeks Cephalic with labor pains and
PROM

PHYSICAL EXAMINATION

1) GENERAL OBSERVATION:
a) Constitution : Poorly body built
b) Stature : Normal
c) State of Nutrition : Poor
d) Personal appearance : anxious
e) Posture : Good
f) Emotional stage : Anxious
g) Skin : Pallor
h) Cooperativeness : Cooperative
2) VITAL SIGNS:
Temperature : 99.8F
Pulse : 92 bpm
Respiration : 22 bpm
Blood pressure : 120 / 70 mmhg
3) HEIGHT : 149 CMS
4) WEIGHT : 40KG
5) SKIN AND MUCUS MEMBRANE:
a) Colour of skin : Pallor
b) Edema : Absent
c) Moist Temperature : Normal
d) Turgor : Poor
e) Texture : dry
6) HEAD:
a) Skull : No abnormality noted
 b) Hair : Black hair, hair distribution normal
c) Movements of the head : Full range of movements , but restricted
with central line.
d) Fore head : No scars or lesion
e) Face : Anxious looking
7) EYES:
a) Expression : Anxious & fear
b) Eye brows : Equal
c) Eye lids : No lesion
d) Lacrimation : Clear fluid
e) Conjunctiva : Pale
f) Sclera : pallor
g) Cornea : Clear and moist
h) Iris : Normal
i) Pupils : PERRLA
8) EARS:
a) Appearance : No mass
b) Discharge : No
c) Hearing : Normal
d) Lesion : Absent
9) NOSE:
a) Appearance : No Septal deviation
b) Discharge : No
c) Patency : Both nostrils are patent
d) Sense of smell : Good
10) MOUTH AND THROAT:
a) Lips : Dry
b) Tongue : dry , coated
c) Teeth : Intact in upper and lower jaw
d) Gums : Pink and moist
e) Buccal mucosa : No lesion
f) Tonsil : Normal
d) Taste : Normal
11) NECK:
a) General appearance : Normal
b) Trachea : Normal in position
c) Lymph node : No enlargement
d) Thyroid gland : Feel smooth and firm
e) Cyst and tumor : Absence
12) CHEST AND RESPIRATORY SYSTEM:
a) Inspection : Size and shape normal, chest
 expansion equal in both side and
respiration are normal
b) Palpation : No local swelling, no lymph node
enlarge
c) Percussion : Normal resonance in both lungs
d) Auscultation : Breath sounds are normal, high pitched
in both side. Respiratory rate 22 bpm,
irregular heart rate, heart rate – 92bpm.

13) ABDOMEN:
a) Inspection : No abnormality
b) Palpation :
c) Percussion : No fluid filled spaces could be found
d) Auscultation : Peristalsis present
14) BACK:
a) Spine and curvature : No abnormalities is noted
b) Movements : All range of movements are normal
c) Tenderness : No tenderness noted
15) GENITALIA:
PV findings : watery discharges are present, show is present 4 finger tight cervical dilatation,
40% effacement, vertex presentation, head is ballotable and floating. Station of the head is in
minus station and PROM , liquor is clear. No evidence of CPD.
16) UPPER EXTREMITIES:
 Normal movement
 No deformities
 No lymph node enlargement
17) LOWER EXTREMITIES:
 Normal movement
 No deformities
 No lymph node enlargement
19) INVESTIGATIONS:
Sl.
No. Investigations Patient’s Normal value Remarks
value
1) Blood
 Hemoglobin 9.2 gm/dl 14 – 16 gm/dl Anemia
 Blood group “AB” …………. …………….
 Rh Factor Positive ………….. …………..
CBC ( complete blood count )
 Erythrocyte count 4.47 mil cu.m 4.20- 5.40mil cu. M Normal
  Platelets 384000 150000-400000/cumr Normal
 Leukocyte count 12400 cu/mm 4000-11000/cu.mr Presence of
infection
Differential count
 Neutrophil 88% 40 – 75% Normal
 Lymphocytes 12% 20 – 60 % Normal
 Esinophills 0% 0– 6% Normal
 Monocyte 0% 1.10 Normal
 Basophils 0% 0 - 1% Normal

 ESR 60mm/hr 0 – 20 mm/hr Normal

 P.C.V 29.7% 37- 47 %
 M.C.V 69.6% 77- 93 % femtolitte Normal
 M.C.H 21.1% 27,
Negative …………………… Normal
 M.C.H.C
Negative . Normal
Positive …………………… Sickle cell
HbSAg- Australian antigen
Negative anemia
HIV – Spot
10ml Normal
Sickling test for sickle cells
Pale Yellow
Urine Examination
S.Turbid
Quantity
8.0
Colour
Q.N.S
Appearance
pH
Trace
Specific Gravity
Nil
CHEMICAL
Nil
EXAMINATION
Nil
Urine albumin
Nil
Urine sugar
Nil
Urine acetone
Absent
Bile salts
Bile pigments
Nil
Urobilinogen
1-2 / hpf
Occult blood
203/ hpf
MICROSCOPIC
Nil
EXAMINATION
Nil
Red blood cells ( per hpf )
Pus cells ( per hpf)
Present
Epithelial cells ( per hpf)
Absent
Casts
 Crystals Absent
Amorphous material Nil
Tricomonas vaginalis
Bacteria
Other findings
USG: single intra uterine viable fetus with vertex presentation. Placenta present at posterior
region. Liquor is adequate. No abnormality detected.
MEDICATION:

SR. NAME ROUT DOSE TIME ACTION

NO E
1. Inj. Oxytocin IV 5 units Stimulate Uterine
contraction
2. Inj. Buscopan IV 150mg TDS Antispasmodic
5. Inj.Pantop IV 40 mg Bd Proton pump inhibitor

6. Inj. Cftriaxone IV 1 gm Bd Antiinfective

Normal Physiology

Book picture Patient picture

 Single fetus is present
Definition : Pregnancy is the carrying of one or more offspring, known
as a fetus or embryo, inside the womb of a female. In a pregnancy, there
can be multiple gestations, as in the case of twins or triplets.
Present
Initiation
The initial stages of human embryogenesis. Although pregnancy begins
with implantation, the process leading to pregnancy occurs earlier as the
result of the female gamete, or oocyte, merging with the male gamete,
spermatozoon. In medicine this process is referred to as fertilization; in lay
terms, it is more commonly known as "conception". After the point of
fertilization, the fused product of the female and male gamete is referred to
as a zygote or fertilized egg. The fusion of male and female gametes
usually occurs following the act of sexual intercourse, resulting in
spontaneous pregnancy. However, the advent of artificial insemination and
in vitro fertilisation have also made achieving pregnancy possible in cases
where sexual intercourse does not result in fertilization (e.g., through
choice or male/female infertility).

The process of fertilization occurs in several steps, and the interruption of

any of them can lead to failure. Through fertilization, the egg is activated
to begin its developmental program, and the haploid nuclei of the two
gametes come together to form the genome of a new diploid organism. At
the beginning of the process, the sperm undergoes a series of changes. As
freshly ejaculated sperm is unable or poorly able to fertilize, it must
undergo capacitation in the female's reproductive tract over several hours.
This increases its motility and destabilizes its membrane, preparing it for
the acrosome reaction, the enzymatic penetration of the egg's tough
membrane, the zona pellucida, which surrounds the oocyte.

Prenatal period : Prenatal defines the period occurring "around the time
of birth", specifically from 22 completed weeks (154 days) of gestation She is on prenatal period
(the time when birth weight is normally 500 g) to 7 completed days after
birth. Legal regulations in different countries include gestation age
beginning from 16 to 22 weeks (5 months) before birth.
She is on prenatal period
Perinatal period : The perinatal period is immediately before to after
birth. Depending on the definition, it starts between the 20th to 28th week
of gestation and ends between 1 to 4 weeks after birth (the word
"perinatal" is a hybrid of the Greek "peri-" meaning 'around or about' and
"natal" from the Latin "natus" meaning "birth.").

Duration: The expected date of delivery (EDD) is 40 weeks counting

from the first day of the last menstrual period (LMP), and birth usually
occurs between 37 and 42 weeks.
 PHYSIOLOGICAL CHANGES:

Physiological and anatomical alterations develop in many organ systems

during the course of pregnancy and delivery. Early changes are due, in
part, to the metabolic demands brought on by the fetus, placenta and uterus
and, in part, to the increasing levels of pregnancy hormones, particularly
those of progesterone and oestrogen. Later changes, starting in mid-
pregnancy, are anatomical in nature and are caused by mechanical pressure
from the expanding uterus.
Present
1.Reproductive System—Breasts

 Increase of estrogen and progesterone levels: Initially produced

 by the corpus luteum and then by the placenta
 Increased blood supply to breasts. Increase of prolactin: Produced
by the anterior pituitary.
Present
Clinical Signs And Symptoms ,,
,,
 Tenderness, feeling of fullness, and tingling sensation
 Increase in weight of breast by 400 g
 Enlargement of breasts, nipples, areola, and Montgomery follicles ,,
(small glands on the areola around the nipple)
,,
 Striae: Due to stretching of skin to accommodate enlarging breast
,,
tissue
,,
 Prominent veins due to a twofold increase in blood flow
,,
 Increased growth of mammary glands ,,
 Increase in lactiferous ducts and alveolar system
 Production of colostrum, a yellow secretion rich in antibodies,
 begins to be produced by end of 16th week of gestation. Present
2. Reproductive System—Uterus

 Increased levels of estrogen and progesterone

 Enlargement of uterus to accommodate developing fetus and placenta
 Expanded circulatory volume leads to increased vascular congestion.
 Acid pH of vagina
Present
Clinical Signs And Symptoms: ,,

 Hypertrophy of uterine wall

 Softening of vaginal muscle and connective tissue in preparation for ,,
expansion of tissue to accommodate passage of fetus through the birth
canal ,,
 Uterus contractibility increases in response to increased estrogen ,,
levels, leading to Braxton-Hicks contractions. ,,
 Hypertrophy of cervical glands leads to formation of mucus plug which ,,
serves as a protective barrier between uterus/fetus and vagina. ,,
 Hypertrophy of vaginal glands leads to increase in leukorrhea ,,
 Cessation of menstrual cycle (amenorrhea) and ovulation ,,
 Increase in uterine size to 20 times that of nonpregnant uterus ,,
 Weight of uterus increases from 70 g to 1,000 g. ,,
 Blood flow to the uterus is 500–600 mL/min at term.
 Goodell’s sign: Softening of the cervix
---
 Hegar’s sign: Softening of the lower uterine segment
 Chadwick’s sign: Bluish coloration of cervix, vaginal mucosa, and
vulva
 Acid environment inhibits growth of bacteria. Present
 Acid environment allows growth of Candida albicans, leading to
increased risk of candidiasis (yeast infection).

3. Cardiovascular System:
 Decrease in peripheral vascular resistance
 Increase in blood volume by 40%–50%
 Increase in cardiac output by 30%–50%
 Increase in RBC count by 30%
 Increase in RBC volume by 17%–30%
 Increase in WBC count
 Increased demand for iron in fetal development
 Hypercoagulability Present
 Increased venous pressure and decreased blood flow to ,,
 Extremities due to compression of iliac veins and inferior Vena cava
Clinical Signs And Symptoms 14-16 beats/min increased
 Decrease in blood pressure
S1 & S2 heared
 Hypervolemia of pregnancy
----
 Increased heart rate of 15–20 bpm
-----
 Increased stroke volume of 30% Present
 Systolic murmurs, load and wide S1 split, load S2, obvious S3
 Increase in heart size
 Increase in peripheral dilation
 Physiological anemia of pregnancy
 Hemodilution is caused by the increase in plasma volume being Present
relatively larger than the increase in RBCs, which results in decreased
hemoglobin and hematocrit values.
 Values up to 15,000 mm3 in the absence of infection --------
 Iron-deficiency anemia: Hemoglobin <11 g/dL and hematocrit <33%
 Plasma fibrin increase of 40% --------
 Fibrinogen increase of 50% Absent
 Decrease in coagulation inhibiting factors ,,
 Protective of inevitable blood loss during birth
 Edema of lower extremities Present
 Varicosities in legs and vulva
 Hemorrhoids
4. Respiratory System
 Hormones of pregnancy stimulate the respiratory center and act on lung
tissue to increase and enhance respiratory function
 Increase of oxygen consumption by 15%–20%
 Estrogen, progesterone, and prostaglandins cause vascular
engorgement and smooth muscle relaxation. Present
 Upward displacement of diaphragm by enlarging uterus ,,
 Estrogen causes a relaxation of the ligaments and joints of the ribs.
Clinical Signs And Symptoms: ,,
 Increase in tidal volume by 30%–40%
 Slight increase in respiratory rate, Increase in inspiratory capacity ,,
 Decrease in expiratory volume
,,
 Slight hyperventilation
Absent
 Slight respiratory alkalosis
 Dyspnea Present
 Nasal and sinus congestion,
 Epistaxis --------
 Shift from abdominal to thoracic breathing
 Chest and thorax expand to accommodate thoracic breathing and Present
upward displacement of diaphragm.
 Slight decrease in lung capacity
5. Renal system
 Increased progesterone levels, which cause a relaxation of smooth
muscles
 Pressure of enlarging uterus on renal structures
 Alterations in cardiovascular system (increased cardiac output and
increased blood and plasma volume) lead to increased renal blood flow Present
of 50%–80% in first trimester and then decreases.
 Decreased renal flow in third trimester & Increased vascularity --------
Clinical Signs And Symptoms:
 Dilation of renal pelvis and ureters leads to increased risk of urinary Present
tract infections (UTI).
 Ureters become elongated with decreased motility, leading to increased Present
risk of UTI.
 Decreased bladder tone with increased bladder capacity --------
 leads to urinary frequency and incontinence and increased risk of UTI. Absent
 Displacement of bladder in third trimester leads to urinary frequency
and nocturia. ,,
 Increased glomerular filtration rate leads to increased urinary output.
 Increased renal excretion of glucose and protein leads to glucosuria and
proteinuria. Present
 Dependent edema
 Hyperemia of bladder and urethra --------

6. GASTROINTESTINAL SYSTEM --------

 Increase levels of hCG and altered carbohydrate metabolism Absent
 Increased progesterone levels lead to decreased muscle tone and resent
slowing of digestive processes. --------
 Increased progesterone levels lead to decreased muscle tone of
gallbladder, resulting in prolonged emptying time.
 Changes in senses of taste and smell Present
 Displacement of intestines by uterus ,,
 Increased levels of estrogen lead to increased vascular congestion of ,,
mucosa. --------
Clinical Signs And Symptoms: Present
 Nausea and vomiting during early pregnancy
 Constipation Present
 Delayed stomach emptying leads to heartburn
 Increased risk of gallstone formation and cholestasis ,,
 Increase or decrease in appetite ,,
 Pica: Abnormal; craving for and ingestion of nonfood substances such
as clay or starch Present
 Flatulence, abdominal distension, abdominal cramping, and pelvic
heaviness
,,
 Gingivitis, bleeding gums, increase risk of periodontal disease
7. Musculoskeletal System
--------
 Increased progesterone and relaxin levels lead to softening of joints and
increased joint mobility, resulting in widening and increased mobility
of the sacroiliac and symphysis pubis.
 Distension of abdomen related to expanding uterus, reduced abdominal
Present
tone, and increased breast size
 Increased estrogen and relaxin levels lead to increased elasticity and
relaxation of ligaments.
,,
 Abdominal muscles stretch due to enlarging uterus
Clinical Signs And Symptoms:
Absent
 Altered gait: “Waddle” gait , Facilitates birthing process Pelvic tilts ,,
forward, leading to shifting of center of gravity that results in change in ,,
posture and walking style, increasing lordosis
 Increased risk of falls due to shift in center of gravity and change in Present
gait and posture
 Round ligament spasm
 Increase risk of joint pain and injury
 Diastasis recti
8. Integumentary System
 Estrogen and progesterone levels stimulate increased melanin
deposition, causing light brown to dark brown pigmentation.
 Increased blood flow, increased basal metabolic rate, progesterone- Present
induced increase in body temperature, and vasomotor instability
 Increased action of adrenocorticosteroids leads to cutaneous elastic ,,
tissues becoming fragile. ,,
 Increased estrogen levels lead to color and vascular changes. Absent
 Increased androgens lead to increase in sebaceous gland secretions. ,,
Clinical Signs And Symptoms: Present
 Linea nigra
 Melasma (chloasma) Absent
 Darken of nipples, areola, vulva, scars, and moles ,,
 Hot flashes, facial flushing, alternating sensation of hot and cold Present
 Increased perspiration
 Striae gravidarum (stretch marks) on abdomen, thighs, breast, and Present
buttocks
 Angiomas (spider nevi)
 Palmar erythema: Pinkish-red mottling over palms of hands
 Increased oiliness of skin and increase of acne
9. Endocrine System
 Decreased follicle-stimulating hormone
 Increased progesterone
 Increased estrogen
 Increased prolactin
 Increased oxytocin
 Increased human chorionic gonadotropin (hCG)
 Human placental lactogen/human chorionic somatomammotropin Present
 Hyperplasia and increased vascularity of thyroid
 Increased BMR related to fetal metabolic activity --------
 Increased need for glucose due to developing fetus
 Increase in cortisol
Clinical Signs And Symptoms: --------
 Amenorrhea Present
 Maintains pregnancy by relaxation of smooth muscles, leading to ,,
decreased uterine activity, which results in decreased risk of ,,
spontaneous abortions ,,
 Decreases gastrointestinal motility ,,
 Facilitates uterine and breast development ,,
 Facilitates increases in vascularity ,,
 Facilitates hyperpigmentation
 Alters metabolic processes and fluid and electrolyte balance ,,
 Facilitates lactation
 Stimulates uterine contractions --------
 Stimulates the milk let-down or ejection reflex in response to
breastfeeding --------
 Maintenance of corpus luteum until placenta becomes fully functional
 Alters carbohydrate, protein, and fat metabolism
 Facilitates fetal growth by altering maternal metabolism; acts as an
insulin antagonist
 Enlargement of thyroid
APPLICATION OF THEORY

Name : Mrs. Nayanaben Vinodhbhai

Age : 22Years
Sex : female
Ward : female medical ward
Present complaints :
DIAGNOSIS : Antenatal mother with PROM
Theories applicable:
i) Sister Callista Roy Adaptation Model
ii) Dorothy E. Johnson Behavioral System Model
iii) Orem self care deficit theory
iv) SELYE’s stress – adaptation theory
In this case I am going to give care according to the “Sister Callista Roy Adaptation Model
The Roy Adaptation Model

Sister Callista Roy developed the Adaptation Model of Nursing in 1976. This model comprises
the four domain concepts of person, health, environment, and nursing and involves a six step
nursing process. Andrews & Roy (1991) state that the person can be a representation of an
individual or a group of individuals. Roy's models sees the person as "a biopsychosocial being in
constant interaction with a changing environment" (Rambo, 1984).
ASSUMPTIONS
Scientific

 Systems of matter and energy progress to higher levels of complex self-organization

 Consciousness and meaning are constitutive of person and environment integration
 Awareness of self and environment is rooted in thinking and feeling
 Humans by their decisions are accountable for the integration of creative processes
 Thinking and feeling mediate human action
 System relationships include acceptance, protection, and fostering of interdependence
 Persons and the earth have common patterns and integral relationships
 Persons and environment transformations are created in human consciousness
 Integration of human and environment meanings results in adaptation
Philosophical

 Persons have mutual relationships with the world and God

 Human meaning is rooted in an omega point convergence of the universe
 God is intimately revealed in the diversity of creation and is the common destiny of
creation
 Persons use human creative abilities of awareness, enlightenment, and faith
 Persons are accountable for the processes of deriving, sustaining, and transforming the
universe
PERSONS AND RELATING PERSONS

 An adaptive system with coping processes

 Described as a whole comprised of parts
 Functions as a unity for some purpose
 Includes people as individuals or in groups (families, organizations, communities,
nations, and society as a whole)
 An adaptive system with cognator and regulator subsystems acting to maintain adaptation
in the four adaptive modes: physiologic-physical, self-concept-group identity, role
function, and interdependence
ENVIRONMENT

 All conditions, circumstances, and influences surrounding and affecting the development
and behavior of persons and groups with particular consideration of mutuality of person
and earth resources
 Three kinds of stimuli: focal, contextual, and residual

 Stimulus-something that provokes a response, point of interaction for the human system
and the environment

 Focal Stimuli-internal or external stimulus immediately affecting the system

 Contextual Stimulus-all other stimulus present in the situation.

Residual Stimulus-environmental factor, that effects on the situation that are unclear.
Significant stimuli in all human adaptation include stage of development, family, and
culture
HEALTH AND ADAPTATION

 Health: a state and process of being and becoming integrated and whole that reflects
person and environmental mutuality
 Adaptation: the process and outcome whereby thinking and feeling persons, as
individuals and in groups, use conscious awareness and choice to create human and
environmental integration
 Adaptive Responses: promote the integrity of the human system. responses that
promotes integrity in terms of the goals of the human system, that is, survival, growth,
reproduction, mastery, and personal and environmental transformation
 Ineffective Responses: neither promote not contribute to the integrity of the human
system. responses that do not contribute to integrity in terms of the goals of the human
system
 Copping Process-innate or acquired ways innate or of interacting with the changing of
environment
 Adaptation levels represent the condition of the life processes described on three different
levels: integrated, compensatory, and compromised
NURSING

 Nursing is the science and practice that expands adaptive abilities and enhances person
and environment transformation
 Nursing goals are to promote adaptation for individuals and groups in the four adaptive
modes, thus contributing to health, quality of life, and dying with dignity
 This is done by assessing behavior and factors that influence adaptive abilities and by
intervening to expand those abilities and to enhance environmental interactions
NURSING PROCESS

 A problem solving approach for gathering data, identifying the capacities and needs of
the human adaptive system, selecting and implementing approaches for nursing care, and
evaluation the outcome of care provided

1. Assessment of Behavior: the first step of the nursing process which involves gathering
data about the behavior of the person as an adaptive system in each of the adaptive modes
2. Assessment of Stimuli: the second step of the nursing process which involves the
identification of internal and external stimuli that are influencing the person’s adaptive
behaviors. Stimuli are classified as: 1) Focal- those most immediately confronting the
person; 2) Contextual-all other stimuli present that are affecting the situation and 3)
Residual- those stimuli whose effect on the situation are unclear.
3. Nursing Diagnosis: step three of the nursing process which involves the formulation of
statements that interpret data about the adaptation status of the person, including the
behavior and most relevant stimuli
4. Goal Setting: the forth step of the nursing process which involves the establishment of
clear statements of the behavioral outcomes for nursing care.
5. Intervention: the fifth step of the nursing process which involves the determination of
how best to assist the person in attaining the established goals
6. Evaluation: the sixth and final step of the nursing process which involves judging the
effectiveness of the nursing intervention in relation to the behavior after the nursing
intervention in comparison with the goal established.

Physiologic-Physical Mode

 Behavior pertaining to the physical aspect of the human system

 Physical and chemical processes

 Nurse must be knowledgeable about normal processes

 5 needs (Oxygenation, Nutrition, Elimination, Activity & Rest, and Protection)

Self Concept-Group Identity Mode

 The composite of beliefs and feelings held about oneself at a given time. Focus on the
psychological and spiritual aspects of the human system.
  Need to know who one is, so that one can exist with a state of unity, meaning, and
purposefulness of 2 modes (physical self, and personal self)

Role function Mode

 Set of expectations about how a person occupying one position behaves toward a
occupying another position. Basic need-social integrity, the need to know who one is in
relation to others

Interdependence Mode

 Behavior pertaining to interdependent relationships of individuals and groups. Focus on

the close relationships of people and their purpose.

 Each relationship exists for some reason. Involves the willingness and ability to give to
others and accept from others.

 Balance results in feelings of being valued and supported by others. Basic need - feeling
of security in relationships

FIRST LEVEL ASSESSMENT

PHYSIOLOGIC-PHYSICAL MODE

Oxygenation:

 RR= 18Bpm.  Chest normal in shape. Chest expansion normal on either side.
 Apex beat felt on left 5th inter-costal space mid-clavicular line.
 NVBS. S1& S2 heard. No abnormal heart sounds.
 All other pulsations are normal in rate, depth, tension with regular rhythm.
 No abnormal heart sounds. BP- Normotensive. .
 Peripheral pulses felt-Normal rate and rhythm, no clubbing or cyanosis.

Nutrition

 She is Non vegetarian.

 She has stable digestive process.
 She has complaints of anorexia and not taking adequate food.
 No abdominal distension. Soft on palpation. No tenderness.
 No visible peristaltic movements.
 Bowel sounds heard.
 Percussion revealed dullness over hepatic area.
 Oral mucosa is normal. No difficulty to swallow food

Elimination:
  No signs of infections, no pain during micturation or defecation.
 Frequency of urination
 Stool is hard and she complaints of constipation.
 Leaking PV

Activity and rest:

 Taking adequate rest.

 Sleep pattern disturbed at night due unfamiliar surroundings.
 Not following any peculiar relaxation measure.
 Like movies and reading. No regular pattern of exercise.
 Walking from home to office during morning and evening.

Fluids and electrolytes: Drinks approximately 2000ml of water. .

SELF CONCEPT MODE

Physical self: Belongs to a Nuclear family. 2members. Stays along with her husband . Good
relationship with the neighbours. Good interaction with the friends. Moderately active in local
social activities

Personal self: Self esteem disturbed because of financial burden and staying in rented house.
she believes in god and worshiping Hindu culture.  

ROLE PERFORMANCE MODE:

she was the earning member in the family. Her role shift is not compensated. Her role clarity is
achieved.

INTERDEPENDENCE MODE:

She has good relationship with the neighbours. Good interaction with the friends relatives.  But
he believes, no one is capable of helping him at this moment, as she has to pay more credit. she
says  ”all are under financial constrains”. she was moderately active in local social activities .

SECOND LEVEL ASSESSMENT

FOCAL STIMULUS:
 Loss of appetite
 Uterine contractions
 Leaking PV
 Irregular food intake
 Missing of meals
CONTEXTUAL STIMULI: PROM may leads dry labor and risk of infecction
RESIDUAL STIMULI: Anxiety , and postnatal infections
Problems identified :
1. Acute pain ( on abdomen) related to uterine contractions secondary to onset of
labor.
2. High risk for infection related to leaking of amniotic fluid secondary to premature
rupture of membranes.
3. Imbalanced nutrition less that body requirement related to increased nutritional
requirement secondary to physiological changes and needs of the mother .
4. Activity intolerance related to leaking PV secondary to PROM
5. Potential for dry and difficult labor related to poor contractions and cervical
dilatation leaking PV secondary to PROM

CONCEPTUAL FRAME WORK BASED ON ROY’S ADAPTATION MODEL

INPUT CONTROL PROCESS OUPUT

Mrs. Nayanaben Vinodhbhai Regulators and Physiological
- Anxiety Use of positive
Internal environment cognator response
-Accept the - constipation
-Age- 22 years
- head ache coping mechanism
situation as it is
-Personal habits- habit of - loss of appetite
-Prayer to god
chewing bittel leaves
-Involve in distraction - Uterine contractions
occasionally - to husband
therapy
- Leaking PV
External environment
-Family type – nuclear -Hope things
- Irregular food intake
nd
-Education-2 class -Well get better
- Missing of meals
-Monthly income –Rs.7000/- Use of negative
-
-Friends- more Self-concept
coping mechanism
-She has fear about
-Occupation – cooly of the fore coming labor
company
Inter dependent -
- Family members- she
family is residing in
dharampur

-Health personnel-
community health nurse

Role performance
FEED BACK
 Theory
applied Assessment Diagnosis Objective Interventions Implementations Evaluation
For Mrs. sub data : Acute pain Mother will - Assess the general conditions - Assessed the general Sub
Nayanaben Mother related to have the of the mother conditions of the mother evaluation :
Vinodhbhai verbalizes physiological reduced pain - Assess the pain and - Assessed the pain and Mother
I am going changes and discomfort
that she is discomfort. discomfort verbalizes
to provide postnatal period
having acute - Provide the comfort position, - Provided the comfort position, that is felling
care by and episiotomy
applying pain over the assist in changing position and assist in changing position and comfort after
wound
Sister site of provide additional pillows. provide additional pillows. providing
Callista Roy episiotomy - Reduced the anxiety - Reduced the anxiety warm
Adaptation and body - Use diversional activities such - Used diversional activities such applications
Model pains as watching TV and listening as watching TV and listening to Objective
Obj data : to music music evaluation :
She is - Assess the bladder for - Assessed the bladder for Mother is
appearing distention and encourage to distention and encourage to doing her
restless and void every 2hr to reduce void every 2hr to reduce selfcare
discomfort discomfort discomfort activities by
- Involve the patient in making - Involved the patient in making her self
decisions about care to reduce decisions about care to reduce
the sense of powerlessness . the sense of powerlessness .
- Attend the mother`s comfort - Attended the mother`s comfort
and needs to increase her and needs to increase her trust
trust - Spend as much as time possible
- Spend as much as time with the mother to provide
possible with the mother to comfort and assistance
provide comfort and - Apply warm applications
assistance - Encourage the mother to use
- Applied warm applications the divertional therapy
- Encouraged the mother to - Encourage the mother to do her
use the divertional therapy simple selfcare activities by her
- Encouraged the mother to do self
her simple selfcare activities
by her self
 Theory
applied Assessment Diagnosis Objective Interventions Implementations Evaluation
For Mrs. Subjective Imbalanced Mother will -Assess the general conditions - Assessed the general Subjective
Nayanaben data: nutrition less take the evaluation:
of the mother conditions of the mother
Vinodhbhai Motherinlaw that body balanced Husband
I am going -Assess the pain and - Assessed the pain and
verbalizes requirement nutritional verbalizes
to provide discomfort. discomfort.
that she is related to intake. that she is
care by -Monitor the mother`s vitals . - Monitored the mother`s vitals
applying not taking increased eating food
food after caloric -Provide the comfort position - Provided the comfort position now
Sister
Callista Roy knowing sex requirement -Find out the her likes and - Found out the her likes and Objective
Adaptation of the baby as and anorexia dislikes of food dislikes of food evaluation:
Model male . secondary to -Plan for balanced diet - Planed for balanced diet She is
Objective lactation and -Educate the mother about - Educated the mother about looking calm
data: depression and taking
the importance of the dietary the importance of the dietary
On physical respectively food. Playing
examination intake during lactating period. intake during lactating with child
Mother is -Provide rest and sleep. period.
looking week -Encourage the mother to take - Provided rest and sleep.
and restless. more fluids. - Encouraged the mother to
-Reduce the anxiety take more fluids.
-Provide the psychological & - Reduced the anxiety
spiritual support . - Provided the psychological &
-Encourage the mother to spiritual support .
speak out her fears. - Encouraged the mother to
-Use the diverstional therapy speak out her fears.
-Modify the attitude of the - Used the diverstional therapy
mother and make her to - Modified the attitude of the
accept the female child mother and make her to
-Make her understand the accept the female child
needs the new born and feed - Made her understand the
her properly needs the new born and feed
her properly
 Theory
applied Assessment Diagnosis Objective Interventions Implementations Evaluation
For Mrs. Subjective Acute pain ( on Mother will - Assess the general - Assessed the general Subjective
Nayanaben data: Mother abdomen) have the conditions of the mother conditions of the mother evaluation:
Vinodhbhai verbalizes that related to comfort and - Assess the pain and - Assessed the pain and Mother
I am going she having uterine relaxed discomfort. discomfort. verbalized
to provide abdominal pain contractions during the - Monitor the mother`s - Monitored the mother`s that
care by since early secondary to labor process. vitals and FHR. vitals and FHR. somewhat
applying morning. onset of labor. - Provide the comfort - Provided the comfort accepted as it
Sister Objective position position is usual to
Callista data: - Reduce the anxiety - Reduced the anxiety bare in labor
Roy On abdominal - Collects the past history - Collected the past history Objective
Adaptatio palpations labor history. labor history. evaluation:
n Model uterus has - Change the positions - Changed the positions Mother is
contracted, - Co -relate the pains with - Co -related the pains stop the
hard and tight cervical dilation. with cervical dilation. screaming of
to touch. - Provide the psychological - Provided the pain, tried for
Duration of support . psychological support . coping with
contractions - Encourage the mother to - Encouraged the mother to pain.
45mins and speak out her fears. speak out her fears.
frequency is 4 - Use the diverstional - Used the diverstional
per 10min. therapy. therapy.
- Involve the family in the - Involved the family in the
psychological support. psychological support.
- Provide spiritual support - Provided spiritual support
and assure that everything and assure that everything
will happen good . will happen good .
- Compare and calculate the - Compared and calculate
EDD , gestational age the EDD , gestational
,weeks USG and per age ,weeks USG and per
abdominal . abdominal .
- Record the findings. - Recorded the findings.
 Theory
applied Assessment Diagnosis Objective Interventions Implementations Evaluation
For Mrs. Subjective High risk Mother - Assess the general conditions - Assessed the general Subjective
Nayanaben data: mother for infection will have of the mother conditions of the mother evaluation:
Vinodhbhai verbalizes related to the - Assess the pain and - Assessed the pain and Water is still
I am going that water is leaking of reduced discomfort. discomfort. leaking and
to provide leaking from amniotic risk for - Assess the liquor - Assessed the liquor iam washing
care by the fluid infection o amount of fluid o amount of fluid with water
applying yesterdays secondary leaking. leaking. after
Sister night. to o Color o Color toileting
Callista Objective premature o Odor o Odor Objective
Roy data: rupture of evaluation:
o Mechonium stain o Mechonium stain
Adaptation On membranes. Maintained
- Monitor the mother`s vitals - Monitored the mother`s vitals
Model perveginal the aseptic
and FHR. and FHR.
examination - Provide the comfort position - Provided the comfort position techniques
amniotic - Avoid doing PV - Avoided doing PV while doing
fluid was unnecessarily.( frequent PV) unnecessarily.( frequent PV) PV
leaking from - Follow the strict aseptic - Followed the strict aseptic
the vagina. techniques techniques
- Educate not keep hands over - Educated not keep hands over
perineum keep clean& dry perineum keep clean& dry
- Educate the mother about to - Educated the mother about to
inform if anything happen inform if anything happen
- Reduce the anxiety - Reduced the anxiety
- Provide the psychological & - Provided the psychological &
spiritual support . spiritual support .
- Encourage the mother to - Encouraged the mother to
speak out her fears. speak out her fears.
- Use the diverstional therapy - Used the diverstional therapy
- Record the findings. - Recorded the findings.
 Theory
applied Assessment Diagnosis Objective Interventions Implementations Evaluation
For Mrs. Subjective Imbalanced Mother will - Assess the general - Assessed the general Subjective
Nayanaben data: nutrition less take the conditions of the mother conditions of the mother evaluation:
Vinodhbhai Motherinlaw that body normal body Husband
- Assess the pain and - Assessed the pain and
I am going verbalizes requirement intake. verbalizes
to provide discomfort. discomfort.
that she is not related to that she is
care by taking food increased - Monitor the mother`s - Monitored the mother`s eating food
applying since leaking nutritional vitals and FHR. vitals and FHR. now
Sister started she is requirement - Provide the comfort - Provided the comfort Objective
Callista Roy fearing for the secondary to position position evaluation:
Adaptation baby. physiological She is
- Find out the her likes and - Found out the her likes
Model Objective changes and looking calm
dislikes of food and dislikes of food
data: needs of the and taking
- Plan for balanced diet - Planed for balanced diet
On physical mother . food.
examination - Educate the mother - Educated the mother
Mother is about the importance of about the importance of
looking week the dietary intake during the dietary intake during
and restless. antenatal period. antenatal period.
- Provide rest and sleep. - Provided rest and sleep.
- Encourage the mother to - Encouraged the mother to
take more fluids. take more fluids.
- Reduce the anxiety - Reduced the anxiety
- Provide the - Provided the
psychological & spiritual psychological & spiritual
support . support .
- Encourage the mother to - Encouraged the mother to
speak out her fears. speak out her fears.
- Use the diverstional - Used the diverstional
therapy therapy
 Theory
applied Assessment Diagnosis Objective Interventions Implementations Evaluation
For Mrs. Subjective Activity Client will - Assess the general - Assessed the general Subjective
Nayanaben data: intolerance have effective conditions of the mother conditions of the mother evaluation:
Vinodhbhai related to activity on the - Assess the pain and - Assessed the pain and
I am going Objective leaking PV bed Objective
to provide discomfort. discomfort.
data: secondary to evaluation:
care by Physician PROM - Monitor the mother`s vitals - Monitored the mother`s vitals She is on
applying suggested to and FHR. and FHR. bed rest
Sister not move - Provide the comfort position - Provided the comfort position frequently
Callista from the bed - Educate the mother about the - Educated the mother about the positions
Roy and lift are
importance of the less importance of the less activity
Adaptation weights changed.
Model activity during PROM during PROM
- Provide rest and sleep. - Provided rest and sleep.
- Encourage the mother to take - Encouraged the mother to take
more fluids. more fluids.
- Reduce the anxiety - Reduced the anxiety
- Provide the psychological & - Provided the psychological &
spiritual support . spiritual support .
- Encourage the mother to - Encouraged the mother to
speak out her fears. speak out her fears.
- Use the diverstional therapy - Used the diverstional therapy
- Educate the mother how to - Educated the mother how to
bear down during labor. bear down during labor.
- Monitor the PV with regular - Monitored the PV with regular
intervals intervals
- Inform the findings to the - Informed the findings to the
physician. physician.
 Theory
applied Assessment Diagnosis Objective Interventions Implementations Evaluation
For Mrs. Subjective Potential for Mother will - Assess the general - Assessed the general Subjective
Nayanaben data: dry and have safe conditions of the mother conditions of the mother evaluation:
Vinodhbhai Mother difficult labor delivery Mother
- Assess the pain and - Assessed the pain and
I am going verbalized related to poor verbalizes
to provide that she is not discomfort. discomfort.
contractions that she
care by feeling pain and cervical - Monitor the mother`s - Monitored the mother`s feeling pain
applying on abdomen dilatation vitals and FHR. vitals and FHR. Objective
Sister leaking PV - Provide the comfort - Provided the comfort evaluation:
Callista Objective secondary to position position On PV
Roy data: PROM examination
- Educate the mother about - Educated the mother about
Adaptation On pelvic cervical
Model the importance of the less the importance of the less
examination dilatation is
activity during PROM activity during PROM
no cervical present 3-4
dilatations - Start the induction of - Started the induction of fingers
and poor labor with cervibrim with labor with cervibrim with loose
contractions , physician order. physician order.
leaking PV - Monitor the mother - Monitored the mother
continuously to find out continuously to find out
any abnormality , Inform any abnormality , Inform
the findings to the the findings to the
physician. physician.
- Provide rest and sleep. - Provided rest and sleep.
- Encourage the mother to - Encouraged the mother to
take more fluids. take more fluids.
- Reduce the anxiety - Reduced the anxiety
- Provide the psychological - Provided the psychological
& spiritual support . & spiritual support
- Encourage the mother to - Encouraged the mother to
speak out her fears. speak out her fears.
Nurses record:

DAY-1

 Assessed the general condition of the patient. Patient came with labour pain with contractions
since 7 hours. Patient is full term primi mother. On admission 4 finger tight and PROM , liquor is
clear. she is having acute pain on back and abdominal area
 bed red.
 Monitored the vitals & FHR
 Done antenatl examination
 Monitored the blood glucose levels
 Monitored the PV finidings
 Administered the medications like analgesics, anticoagulants and by the physician
 IV fluids administered periodically
 Maintained the input –output chart
 Maintain the aseptic techniques.

DAY-2

 She delivered the male baby.

 Allowed the mother to feed the baby.

 Routine care is given

DAY-3

 Routine care is given

DAY-4

 Remarkable progress, she able to perform her ADL.

 Routine care is given
Diet plan :

Sr.no Name Time menu Amount Calori CHO Protei Fat Iron Calcium
age,sex e n
1. Mrs.Shubash 6am Tea 100ml 36 6.5g 0.7g 0.8g ----- 0.03g
ini 7am Idili 2-nos 130 27.6 4.6g 0.2g 0.6g 0.02g
(136)
10am Milk 1cup 216 9.2g 8.4g 16g 0.8g 0.24g
(200ml)
1pm Jowar 2nos 168 52.5g 7.5g 1.3g 4.5g 0.02g
roti (150g)
Cabbag ½ plate 56 6.1g 1.5g 5.6g 0.9g 0.04g
eand (56g)
carrot
curry
4pm Tea 100ml 36 6.5g 0.7g 0.8g ----- 0.03g
6pm Milk 200ml 216 9.2g 8.4g 16g 0.8g 0.24g
9pm Jowar 2nos 168 52.5g 7.5g 1.3g 4.5g 0.02g
roti (150g)
Cabbag ½ plate 56 6.1g 1.5g 5.6g 0.9g 0.04g
eand (56g)
carrot
curry
Plain 1serving 118 26.8g 2.4g 0.2g 0.00 1.0g
rice (100g) 4g
Bengal ½ cup 284 25.2g 9.0g 16.4 0.14 5.5g
gram (150g) g g
dal.
10pm Milk 200ml 216 9.2g 8.4g 16g 0.8g 0.24g
Summary :

 My Patient has Patient came with labour pain with contractions since 7 hours. Patient is full
term primi mother. On admission 4 finger tight and PROM , liquor is clear. she is having acute
pain on back and abdominal area. she delivered a male baby. Bothe mother and baby are healty.
After providing 5 days care, Patient was maintaining good nutritional status. Patient is maintaing
stable vital parameters.

Conclusion :

During my clinical posting in Dharmapur gynec ward , I got chance to provide care to , Mrs.
Nayanaben Vinodhbhai with diagnosis of Antenatal mother with PROM by this study I learn in detail
about PROM and its management. I thank my client for his cooperation and my clinical
coordinator for her valuable guidance .

Bibliography:
1. D.C.Dutta, Textbook of obstetrics, Sixth Edition,India:published by new central book
agency,Page no.148-150.
2. O.P.Ghai, Essential paediatrics, Sixth Edition, India: published by Dr. Ghai Delhi-92, Page
no.95-99.
3. Potter A.Patrica.Perry Anne Griffin.Fundamentals of nursing.1st ed. St. Louis :Mosby; 2006.
P.17-18.
4. www.elesvier journal support world breastfeeding week.com, 2010
5. www.international breastfeeding.