INDEX

S.NO CONTENT PAGE NO.

.

1. Student profile

2. Introduction

3. History collection

4. Physical examination

5. Vital signs

6. Investigations

7. Other investigations

8. Medication

9. Nursing care plan

10. Prognosis

11. Health education

 STUDENT PROFILE

NAME : Ms. Ranjita Gaur

COURSE: M.Sc (Nursing) 1st year

SUBJECT: Obstetrics and gynecological nursing

Clinical specialty I

NAME OF THE INSTITUTION: Bora Institute of Allied Health science, Lucknow

PATIENT SELECTED FROM: Post Natal Ward (Booked )

Seva Hospital, Lucknow

⮚ STUDENT PROFILE:-

Name- Ranjita Gaur

Course- M.Sc. nursing 1st year
Subject- Obstetrical and Gynecological Nursing
Name of Institution- Bora Institute of Allied Health science, Lucknow
Patient selected from- Obs ward, Seva Hospital, Lucknow
⮚ INTRODUCTION: -
● Mrs. Nisha Sharma got admitted in the (obs ward) Seva Hospital sitapur road ,

Lucknow on 20/03/2024 at 10:30 am, with complaints of Weakness, bleeding

episodes, Increased urination since 2 days. As a part of my obstetrical and gynecology
nursing of M.Sc. Nursing requirement, I took this case for my care plan. I started care
from 21/03/24 at end. I give hygienic care to the patient and educated about post-op
care at home, diet and follow- up and medications, the patient health status gradually
improved and now she is better.

⮚ IDENTIFICATION OF DATA: -
1. Name of the patient : Mrs. Nisha Sharma
2. Age : 33 years
3. Gender : female
4. Bed no. :3
5. Educational Status : post. graduate
6. Occupation : House wife
7. Nationality : Indian
8. Religion : Hindu
9. Address : Hussainganj, Lucknow
10. Marital Status : Married
11. Family members :7
12. Addiction : no any drug addiction
13. Diagnosis : Post partum haemorrhage
14. Consultant doctor :
15. Source of information : husband
16. Date of Admission : 20-03-2024
17. Time of admission : 10:30 am
18. Obstetrical score : G2P1L1A0S0
19. LMP :20/07/2023 EDD :27/02/2024

⮚ CHIEF COMPLAINTS:-

● My client Mrs. Nisha was admitted seva hospital, Lucknow on 20/02/24 at 10:30 am

with the complaints of –

● Weakness

● bleeding episodes

● Increased urination

⮚ HISTORY OF PRESENT ILLNESS:-

Mrs. Nisha was admitted in Seva Hospital, sitapur road Lucknow on 27/02/24 with
the complain of weakness, bleeding episodes, increased urination, since 2 days after
investigation Dr.------------- diagnosed her as G2 P1 L1 39 weeks of pregnancy with
POSTPARTUM HAEMORRAGE.

⮚ PAST MEDICAL HISTORY:-

my client having no any significant of past medical history.

⮚ PAST SURGICAL HISTORY:-

my client having no any significant of past surgical history.

⮚ PERSONAL HISTORY:-
Tobacco chewing, cigarette smoking, alcohol, cola, coffee, tea : Tea
Diet: Vegetarian / Non-Vegetarian : Vegetarian
Allergies to any food item : No
No of meals and snacks /day : 3times a day
Likes & dislikes of food : Likes: Salty and Spicy , Dislikes: Sweet
Nutritional assessment 24 hours recall & recommended diet plan (for mothers on
therapeutic diet)

⮚ MENSTRUAL HISTORY:-
Age of Menarche -13 year
Duration of menstrual cycle - 28 days
Duration of menstrual cycle in days - 5 days
Regularity - Regular
Amount of flow - Normal
CONTRACEPTIVE HISTORY-

● Patient is used DEMPA injection for Contraceptive.

 ● Condom is also used for the family planning and prevention of STD.

⮚ MARITAL HISTORY:-
Age of marriage- 5 years
Type of marriage- arranged
Consanguineous marriage- no
Relationship with husband- satisfied
No. of children- 2
Any sexual disorder- no

⮚ OBSTETRICAL HISTORY: -

Year and Pregnancy Labor Method of Puerperium Baby

date event event delivery

11/5/17 Well covered Uneventful\ LSCS Uneventful Boy, wt3.3 kg,

antenatally cried at birth,
breast feeding
20/06/23 Well covered Uneventful LSCS Uneventful immunized
antenatally Girl, wt3.0 kg,
cried at birth,
breast feeding
immunized

Postnatal condition – After the birth of baby patient condition was normal in the
puerperium period.

FAMILY HISTORY-There is no any communicable and hereditary disease in the family.

Family Tree-
 KEY

Male

Female

Female patient

FAMILY COMPOSITION-

S.N NAME RELATION AGE SEX EDUCATIO OCUPATIO HEALTH

o WITH PATIENT N N STATUS

1 Mr. Ramesh Father –in-law 63 year Male Graduation Private job Healthy
2 Mrs. Geeta Mother -in - 59year Female 8th Housewife Healthy
law
3 Mr. Ankur Husband 36 year Male P.G. Private job Healthy
4 Mrs. Nisha Patient 34 year Patient 12th Housewife Unhealth
y
5 Master Ansh Son 3 year Male - - Healthy

6 Mr. Mukul Brother-in-law 27year Male P.G. Teacher Healthy

7 Baby of Daughter 3 days Female - - -

nisha

PSYCHOSOCIAL HISTORY:-

Primary language- hindi

Secondary language- hindi

House- own

Type of family- joint

Relationship of patient with family- satisfactory

 Mood of patient- normal

Position of the pt. in the society- respectable

Position of the pt. in the family- respectable

Socio- economic status of the pt. – middle class status

ENVIRONMENTAL HISTORY:-
She having clean house ,no environmental hazards, hand pump water supply,
adequate sanitation, adequate drainage system, adequate disposal method, and using public
transport service.

VITAL SIGN-

● Temperaure-101 F

● Pulse-90 beats / min

● Blood Pressure- 130/90 mmHg

● Respiratory Rate-22 breaths / min

INVESTIGATION CHART
INVESTIGATION PATIENT VALUE NORMAL VALUE REMARK
Complete Blood Count
11.4gm/dl 12-16gm/dl Normal
Hemoglobin
10900cells/mm 4000-11000 cll/mm3 Normal
TLC
Differential % Leukocytes
70% 40-80 Increased
count 26% 20-40 Normal
03% 1-6 Normal
01% 00-02 Normal
Neutrophils 2.61Lac million 1.5-4.5 Normal
Lymphocyte cells/ul
7.4-10.4 Increased
Eosinophil’s 11.9fl
3.8-4.8 Normal
Monocyte 3.94million cells/ul
27-32 Normal
Basophils 29.1pg
36-46 Decrease
Platelet count 33.7% 2.4-5.4 Normal
4.1mg/dl 10-45 Normal
19.9mg/dl 0.5-1.5 Normal
0.71mg/dl 70-110mg/dl
MPV Hyperglycemia
120mg/dl 100-140mg/dl
 148.5mg/dl Hyperglycemia
Total RBC
MCH

HCT(Hemocrit)
Serum Uric Acid
Serum Urea
Serum Creatinine

Blood sugar Fasting

Blood Sugar PP (2hours of 75

gm glucose)

MEDIACATION
DRUG DOSE ROUTE FREQUENCY ACTION

Inj. Rantac 300mg/dl IV BD Anta- acid

Inj. Perinorm 2ml IV BD Anti-emetic

Inj. Ferrous 200 mg orally OD Iron supplement

Sulphate

Tab. Calcium 250 mg Orally BD Calcium Supplement

Tab. Metformin 500 mg orally BD Anti-Diabetic

Inj. Insulin 1-2 unit subcutaneous TDS Anti-diabetic

PHYSICAL ASSESSMENT:

General examination:

● Nourishment: well nourished

● Body built: obese

● Orientation- oriented to time, place, person

● Level of consciousness- conscious

● Activity- Dull

● Behavior- Depressed

● Attitude-Co-operative

● Posture: Normal curves

ANTHROPOMETRIC MEASUREMENT-

● Height-150 cm

● Weight-67 kg

● Abdominal Girth- 90 cm

SKIN-

● Color -Fair
 ● Turgor -Normal

● Texture -Smooth

● Pigmentation -Present

● Temperature -Normal

● Sensitivity -Sensitive

● Lesion -Present

● Scar -Absent

HEAD TO TOE EXAMINATION:

HEAD-

● Shape -Normal

● Symmetry - Symmetrical

● Scalp -Not clean

● Dandruff -Present

● Pediculi -Absent

● Lesions -Absent

● Hair -Present

● Color - Black

● Texture -Normal

● Distribution -Evenly Distributed

FACE-

● Symmetry -Symmetrical

● Facial Movement - Symmetrical

● Facial Puffiness -present

 ● Sinuses -Normal

EYES-

● Eye brows -Symmetrical

● Eye lashes -Present

● Conjunctiva -Pale

● Sclera -whitish

● Style -Absent

● Cornea Transparent

● Vision Normal

● Any discharge Not present

EARS-

● Position -Normal

● Symmetry -Symmetrical

● Size and Shape -Normal

● Lesion and Lump of Pinna -Absent

● External Auditory Canal -Normal and Visible

● Mastoid Process - Normal

● Use Of hearing Aids -Not use

● Pain -Absent

● Any discharge -Not present

NOSE-

● Nasal Septum -Not deviated

● Polyps -Not Present

● Mucus Membrane -Normal

● Discharge -Not present

MOUTH-

LIPS:

● Color -Pink& Dry

● Hydration -Dry

● Symmetry -Symmetrical

● Lesion -Present

● Mucus Membrane -Moist

● Color -Pale

● Hydration -Poor

TEETH:

● No. of Teeth - 32

● Color -Yellowish

● Alignment -Normal

● Use of Denture -No

GUMS - Healthy

● Tongue - coated

● Color -Pink

● Hydration -dry

● Lesions -Absent

● Thickness -Normal

PALATE - Normal

ODOUR OF MOUTH - Normal

NECK:

● Range of Motion -Possible

● Thyroid Gland -Normal

● Trachea -midline
 ● Lymph Node -Palpable

● Jugular vein -Distended

● Lymph nodes -Not enlarged

CHEST-

INSPECTION-

● Shape -Normal

● Movement -Symmetrical

● Retraction -Present

● Respiratory Rate -22 Breaths / Min

● Location of sternum-Midline

BREAST-

● Shape -Symmetrical

● Position -Normal

● Nipple -Cracked

PALPATION:

● Axillary Lymph Node - Palpable

● Respiratory movement-Asymmetrical

● Fremitus -Normal

AUSCULATATION:

● Lung Sound -Clear

● Heart Beat -90 Beats/min

● Heart sound -Normal

ABDOMEN-

INSPECTION:

● Shape -Rounded
 ● Skin -Normal

● Distension -Present

● Peristalsis - Mild movement present

● Distended -Absent

● Umbilicus -Normal

PALPATION-

● Hepatomegaly -Absent

● Splenomegaly -Absent

● Tenderness -Present

● Mass -Absent

AUSCULTATION-

● Bowel Sound -Increased

● Character -Gurgling sound

PERCUSSION-

● Ascites -Absent

● Fluid Thrill -Absent

BACK-

● Tenderness -Absent

● Mass -Absent

GENITALIA –

● Anal opening - Clear

● Perineal fissure -Absent

● External hemorrhoids-Absent

FEMALE

● Urethral opening -clear

 ● Lesion -Absent

● Discharge - Bloody Present

EXTRIMITIES-

● Position -Symmetrical

● Gait -Normal

● Range of Motion -Normal

● Congenital deformity-Absent

● Digits - Normal (5+5,5+5)

REFLEX-

● Biceps Reflex -Normal

● Triceps Reflex -Normal

● Patellar Reflex -Normal

OBSTETRICAL EXAMINATION

INSPECTION-

● Linea Nigra is present on abdomen

● Enlarged abdomen

● Spherical shaped uterus

● Striae gravidarum is present

PALAPTION-

● Fundal Hight -39 cm

● Abdominal Girth - 90 cm

● Presentation - Cephalic Presentation

AUSCULTATION-

● Fetal Heart Sound- 144 beats /Min

NURSING DIAGNOSIS

● Hyperthermia related to bleeding.

● Fluid volume deficit related to vaginal bleeding

● Risk For infection related to bleeding.

● Ineffective tissue perfusion related to vaginal bleeding.

● Anxiety related to changes in circumstances or the threat of death.

ASSESSM DIAGNO GOAL PLANNI IMPLEMENTA EVALUAT
ENT SIS NG TION ION
SUBJECTI Hypothermi To -Assess and -Assessed and After the
VE DATA- a related to reduce monitor the monitor the body nursing
Patient bleeding. the body body temperature and note intervention
complaining temperat temperature the presence of chills client body
that she is not ure of and note / profuse diaphoresis. temperature is
feeling well the the maintained
rigt now she patient. presence of now she feels
feels her body chills / better.
warm. profuse -Adjusted and Temperature=
diaphoresis monitor 98`F
. environmental
OBJECTI -Adjust and factors like room
VE DATA- monitor temperature and bed
on observation environmen linens as indicated.
Flushed skin tal factors
with body like room
temp= 100.2F temperature -Applied tepid
Unstable B.P and bed sponge bath.
Respiration linens as -Administered
Rate= 25 indicated. antipyretics as
Breaths / min -Apply prescribed by the
Pulse Rate= tepid physician.
100 beats/min sponge
bath.
- -Provided cooling
Administer blanket as indicated.
antipyretics
as -Encouraged the
prescribed client to increase
by the fluid intake.
physician.
-Provide
cooling
blanket as
indicated.
-
Encouraged
the client to
increase
fluid
intake.
ASSESSMEN DIAGN GOAL PLANNIN IMPLEMENTA OUTCOME
T OSIS G TION
SUBJECTIV Fluid To prevent -Advice -Advised patient to After the
E DATA- volume dysfunction patient to sleep with higher nursing
Patient deficit al bleeding sleep with while the body intervention
complaining that related to and improve higher while remained supine. patient level of
she feels thirst vaginal fluid the body hydration is
and dry lips. bleeding. volume remained maintained and
supine. improved fluid
-Monitor vital -Monitored vital volume.
OBJECTIVE
Sign every 2 Sign every 2 hour.
DATA- on hour.
observation -Monitor -Monitored intake /
patient looking intake / output output every 5-10
dull . every 5-10 minutes.
● B.P..= 70/90 minutes.
-Evaluation of -Evaluated of the
mmHg
the urinary urinary bladder.
● Dry skin bladder.
-Perform -Performed uterine
● Coated lips uterine massage with one
massage with hand and the other
one hand and hand placed above
the other hand the symphysis.
placed above
the
symphysis.
-Limit vaginal -Limited vaginal and
and rectal rectal examination.
examination.
-Administer -Administered IV
IV fluid as fluid as prescribed
prescribed by by physician
physician.
ASSESSME DIAGNOS GOAL PLANNING IMPLEMENT OUTCOME
NT IS ATION
SUBJECTIV Risk For To reduce -Note the -Noted the change After the
E DATA- infection the risk of change in vital in vital signs is nursing
Patient related to infection. signs is indicative of intervention risk
complain that indicative of infection. of infection is
bleeding.
she used 5-6 infection. reduced
pads in a day & -Note the signs -Noted the signs of
coming smell of fatigue, fatigue, chills,
from the chills, anorexia, and -Maintained
discharge. anorexia, uterine hygiene.
uterine contraction.
contraction.
OBJECTIV -Monitor -Monitored uterine
E DATA- uterine involution and
On involution and lochia spending.
observation lochia
spending. -Considered the
● Fowl -Consider the possibility of
smell possibility of infection in other
infection in places, such as
discharge other places, respiratory
● Redness such as infections, mastitis
respiratory & urinary tract.
near the infections,
vagina mastitis &
urinary tract. -Instructed the
-Instruct the patient to maintain
patient to hygiene.
maintain
hygiene. -Administered
-Administer antibiotic as
antibiotic as prescribed by
prescribed by physician
physician.
 HEALTH EDUCATION-
NUTRITION/DIET:
• High in fiber
• High in fruits and in green, red and orange vegetables.
• Low in saturated fats and trans fats.
• Low in sodium and sugar
• Low cholesterol diet
PERSONAL HYGIENE
• Maintain personal hygiene.
• Clean the area and apply soframycin.
• Clean the perineum with water after every urination.
POSTNATAL EXERCISES
• Educated to perform yoga.
• Educate the client about deep breathing exercises.
REST AND SLEEP
• Take proper rest and have milk during night.
• Do deep breathing exercise and walking before sleep.
MEDICATION
• Advice to take proper medication as per doctor prescription.

OTHER INTERVENTIONS
Teach the patient regarding-

Breast Feeding-

● Wash your breasts with water daily for cleanliness

● Air dry nipples after each feeding.

● If breasts are engaged , apply warm packs and express milk.

Non- breast feeding-

● Wear well fitting bra for support.

● Use ice packs to relieve discomfort from engorgement.

● Avoid handling your breasts and do not express milk

Uterine changes-

● After pains or cramping are normal. This cramping means that the uterus is
contracting to return to its non-pregnant size. The uterus takes five to six weeks to
return to its non- pregnant size.

Vaginal Discharge-

● Usually lasts about ten days to four weeks. The color will change From bright red
to brownish to and will become less in amount and finally disappear .
● Menstruation period will resume in approximately six to eight weeks, unless
breastfeeding.

Care of Episiotomy-

● Sitzs bath-sitting in tub of warm water for 15 min , two to three minute times per
day will help relieve the discomfort.
● Stiches will dissolve in ne to three weeks.

Pain relief-

● Use a mild analgesic for breast engorgement , uterine cramps and episiotomy
discomfort.

Diet & Nutrition-

● Continue taking prenatal iron and vitamin pills until postpartum visit.

● It is important to eat a well- balanced diet and drink plenty of fluids . drink two
quarts of fluid per day if on breast feeding

Emotional changes-

● You may feel let down ,anxious and cry easily. This is normal these feeling can
begin two to three days after delivery and usually disappear in about a week or
two.

Activity –

● Rest Do not heavy housework or heavy exercise for two weeks.

● Avoid driving for one to two weeks.

 ● Avoid sexual activity until postpartum visit.

Birth control-

● It is advisable as soon as resume sexual intercourse ,Foam and condoms are safe
and east to use.

Post partum visit-

● Call obstetricians office two to three days after discharge to make an appointment
of six weeks.

DAY TO DAY PROGNOSIS

1st Day-
Patient complain- Fever

Symptom-patient is looking dull and her body is warm .

Pulse – 100 beats/min

Respiration- 22 breaths / min

B.P. - 70/90 mmHg

Temperature- 100.2`F

Implementation-

● Assess the condition of the patient

● Provide antipyretic medication as prescribed by physician.

● Monitor vital sign every 2 hourly

● Provide tepid sponge.

● Encouraged oral fluid intake.

2nd Day-
Patient complain- Patient condition is little bit better than the 1st day and her body
temperature is reduced.

Temp= 98`F

For improving the condition and maintaining the body temperature following implementation
is-

● Encouraged more Fluid intake

● Remove extra clothing.

● Provide calm and quite environment.

● Antipyretic medication.

3rd Day- After all these intervention patient body temperature is maintained . Now her
body temperature is normal.

Temperature- 98`F