INTRODUCTION:
As a part of our clinical posting. I was posted in postnatal ward and I was assigned to write
care plan. So I choose a patient by the name Karabi Sharma, 19 years old. She was diagnosed
with retained placenta. At the time of collecting history I introduced myself to the patient and
ask her to co-operate with me while collecting her history and other required information.
DEMOGRAPHIC DATA
Name : Mrs. Karabi Sharma
Age : 25 years
Educational level : BA
Husband’s name : Mr. Moloy Sharma
Religion : Hindu
Address : Jalukbari
Occupation : housewife
Marital status : Married
Admitted on : 22/ 2/2021
H no : 32177
Ward : Post-natal ward
Obstetric score : G2 P1 L1 A0
LMP :
EDD :
Diagnosis : Retained placenta.
CHIEF COMPLAINS
Placenta was not being expelled after delivery
1ST PREGNANCY:
PRESENT OBSTRETICAL HISTORY –
1ST TRIMESTER: There is cessation of menstruation. She complaints of multiple respond of
nausea and vomiting. There is no history of bleeding of per vagina, no history of fever. Tab-
Folic acid and calcium was taken.
2ND TRIMESTER: There is gradual enlarged of abdomen. She perceives her first fetal
movement in her 5 months of gestation. No history of swelling of legs, headache, Blurred
vision and no bleeding per vagina. 2 doses of TT is taken.
3RD TRIMESTER: There is gradual enlargement of the abdomen, She has increased frequency
of micturition, swelling of legs, fatigue and breathing difficulty.
HISTORY OF PRESENT ILLNESS
She was referred from PHC as she delivered the baby but placenta was not being
expelled and was admitted in the hospital.
PAST MEDICAL AND SURGICAL HISTORY
There is no significant past medical history of hypertension, asthma, tuberculosis, preumenia,
jaundice etc.
There is no significant past surgical history of accidents, falls appendectomy etc.
FAMILY HISTORY
PEDIGREE CHART: - key:-
Male
Female
60 yrs 56yrs baby
Patient
28 yrs 19 yrs 29 yrs
FAMILY HEALTH HISTORY:-
There is no significant family history of hereditary diseases
SL NAME AGE SEX RELATIONSHIP OCCUPATIO HEALTH
NO (YEARS) N STATUS
1 Montu 60 M FATHER CARPENTER HEALTHY
Sharma
2 Baby 56 F MOTHER SHOPKEEPER HEALTHY
Sharma
3 Paresh 28 M BROTHER BUSINESS HEALTHY
Sharma
4 Karabi 25 F PATIENT HOUSEWIFE UNHEALTHY
Sharma
5 Moloy 29 M HUSBAND DRIVER HEALTHY
Sharma
SOCIO ECONOMIC HISTORY:-
She is living in a joint family. She is living in a house, which consists of all the
adequate facilities such as water supply, drainage and ventilation.
PERSONAL HISTORY:-
She is a non-vegetarian & not allergic to any foods. She takes habit of drinking tea
and coffee. She sleeps 6 hours at night. Her bowel and bladder habits are normal, no
habit of smoking and tobacco chewing.
MENSTRUAL HISTORY:-
Age at menarche : 14
Menstrual cycle : Regular
Days : 30 days
Dysmenorrhea : absent
MARITAL HISTORY:-
Marital Status : Good
She is married since 11 months.
Type : Arranged marriage
Her marriage is a non- consanguineous marriage
Relationship with husband : The patient is maintaining a good relationship with her
husband
Used any Contraceptive method : No
PARTNER’S HISTORY:
Name : Moloy Sharma
Age : 29 years
Educational Status : Class 12 Passed
Occupation: driver
Genetic Disorder : Absent
Health Problem : Healthy
Habits: Use to Smoke and chew Bettle Nuts.
Blood Group : B+
PAST OBSTETRICAL HISTORY:-
S. YEAR ABORTI TYPE COMPLICA SEX BIR CONDIT HEAL
NO ON OF TION TH ION TH
. PRETE DELIV DURING WT. AT STAT
RM ERY PUERPERIU BIRTH US
M
PRIMI
PRESENT OBSTETRICAL HISTORY:-
S. YEAR ABORT TYPE OF COMPLIC- SEX BIRTH CONDITION HEALTH
NO. -ION DELIVERY ATION WT. AT BIRTH STATUS
PRETE- DURING
RM LABOUR
1 2021 - FTNVD RETAINED M 3.1 GOOD HEALTHY
PLACENTA
PHYSICAL EXAMINATION.
Appearence : Builds thin, healthy, and fair in complexion.
Mental status : conscious and oriented.
Health status : Healthy and mildly nourished.
S.L. ASSESSMENT PATIENT FINDINGS
NO.
1. Hair Black, shinny hair present equal distribution
2. Scalp Infection absent, normal
3. Eyes Normal vision, no any other problems. Sclera is white in colour&
conjunctiva looks very pale.
4. Ears Normal hearing capacity present. Absence of other problems.
Normal placement, airway patency; No obstruction and congestion.
5. Nose
6. Neck Thyroid glands normal, lymph node enlargement. Range of
movements normal.
7. Lips Pale in colour, dryness present.
8. Tongue coated tongue and dry not hydrated, taste buds are normal.
Normal teeth, Absence of dental carries, flurosis absent.
9. Teeths
Normal
10. Tonsil
Absent
11. Lymph nodes
12. Chest Symmetrical chest wall movements bilateral air entry normal,
Normal vesicular breathe sounds pulse rate regular.s1 s2 heard
13. Breast
Normal in size, Soft in consistency, Primary and secondary areola
prominent, Montgomery tubercles evident, Nipples erect
14. Abdomen
Soft bowel movements heard
Fundal height -20 cms
15. Extremities Range motion is normal. Reflexes are normal, no oedema or
varicose veins.
16. Genitalia Clean ,bleeding present
17. Lochia amount 70-75 ml fishy odour of lochia
18. vulva No oedema present
VITAL SIGNS
Temperature : 98.40F
Pulse : 82 beats / min
Respiration : 24 breathes / min
Blood pressure : 100/80 mm/hg
Pain : 5/10
Height : 162 cm
Weight : 5o kg
INVESTIGATIONS
TEST DONE PATIENT VALUE NORMAL VALUE REMARKS
Haemoglobin 8.4gms 13.5 mg | dl Anaemia
Pvc 26% 45 % Anaemia
Platelet 1.6 lakh 1.5 – 5 lakh | mm Normal
Blood area 24 mg | dl 20 – 40 mg | dl Normal
Sugar 92 mg | dl 70 – 150 mg | dl Normal
Serum creatinine 0.8 mg | dl 0.8 – 1.4 mg | dl Normal
OGCT 9.2 mg |dl 70 – 120 mg | dl Normal
Urine:- Normal
Sugar Nil Normal
Albumin Nil Normal
MEDICATIONS
Name of the Dose Route Action Side effect Nurses
drug Responsibilities
Tab. Folic 5mg P|o Vitamin Hypervitaminosis Nurse has to motivate
acid supplement& to take medicine
maturation of Regularly
blood cells Advice to drink more
Tab Vit – c 250 mg P/O Hypervitaminsis
Synthesis of water
collagen
maintenance
of connective
Tab. Calcium 200 mg tissue
P/O Hypercalcemia Check serum
Formation of electrolyte level
bone and
Inj. Metrogyl maintainance
100mg IV of coagulation Nausea Maintain intake output
mechanism vomitting chart
[Link] antibiotic Allergic
reactions
100 ml IV Check for i/o and
Nausea
vomitting weight daily
antibiotic
NURSING ASSESSMENT
Assess the patients Bleeding episodes (amount, duration)
Assess the patients Abdomen soft/hard when palpated
Assess the patient’s body weakness
Assess the patients’ blood pressure
Assess the patient’s heart rate
Assess the patients respiratory rate
Assess the patients urine output
Assess the patients urine concentration
Assess the patients Pale, cold, clammy skin
NURSING DIAGNOSIS
Deficit fluid volume related to disease condition as evidence by excessive
blood loss
Ineffective tissue perfusion related to hypovolemia as evidence by low
haemoglobin level.
Anxiety related to the disease condition as evidence by frequently asking
questions, restlessness.
Imbalanced nutrition related to inadequate food intake of iron.
Risk for infection related to an inadequate secondary defenses.
ASSESS DIAG GOAL PLANNING IMMPLIME RATIONA EVALU
MENT NOSI NTATION LS ATION
S
Subjectiv Deficit To Monitor intake Monitored Provide maintain
e data: fluid improve output chart and intake output baseline ed
Mother related the fluid hydration status chart data Hydrati
says that to volume on
she is hypov
very tired olemia Document the Documentation To know the
as blood loss of blood loss actual blood
Objectiv eviden done by loss
e data: ce by weighing pads
Client fatigue Monitor vital Monitored To rule out
looks dull , weak. signs vitals for shock
T-98.4 F
P-70/min
R-20/min BP-
100/70mmhg
To improve
hydration
Administer iv
fluids and Administered
crystalloids as RL and NS
per doctors
order
Subjectiv Ineffec Mother Assess the Assessed Provide Mothers
e data: tive will mother’s mother baseline Hb level
Mother tissue achieve knowledge level knowledge. data is
verbalize perfusi normal maintain
d that she on blood ed.
is feeling related volume. Monitor vital Monitored vital Provide
so tired to signs signs further
Objectiv retaine information
e data: d Place mother in Placed in Encourages
Mother placent Trendelenburg Trendelenburg venous
looks dull a as position position return and
and eviden
prevent
restless ce by
bleeding
excessi
ve To increase
blood the
loss Provide oxygen Provided
as needed oxygen as saturation
needed level
Record BP BP- 90/70 Stable BP is
mmHg neededto
keep
sufficient
tissue
perfusion
Reassess the Reassessed the To evaluate
client client the nursing
intervention
Subjectiv Anxiet To Monitor anxiety Mother anxiety Provide Mothers
e data : y decrease level level assessed. basic for level of
Mother related anxiety care anxiety
told that to the level planning is
she is disease Provide positive Provided decrease
afraid of conditi information positive d.
her on as reinforcement To decrease
Monitor ,weight anxiety
disease eviden
intake and Intake output
condition. ce by
output and weight was Provide
Objectiv restless
assessed information
e data: ness.
Mother Support the
looks mother Supported the To decrease
restlessne mother anxiety
ss , Provide
increased information Decrease
pulse rate Provided anxiety after
information discharge
Reassess the about iron rich
client diet
Evaluate the
intervention
Reassessed the
client
PROGNOSIS:
1ST DAY: On the first day when I met the patient Mrs. K Sharma was looking tired, weak and
having anxiety about her health condition. I explained to the patient about her disease
condition and also about the treatment needed.
2nd DAY: On the 2nd day, as we had our conversation, she was comfortable, and relaxed, she
looks a bit okay compared to the day before.
HEALTH EDUCATION
FOR MOTHER
Regarding diet
Advised the mother to take plenty of oral fluids
Advised the mother to start with light diet and shift to balance diet later on
Advised mother to take green leafy vegetables
Advised mother to take gram and jiggery
Advised to take vitamin-c rich diet.
Regarding hygiene
Advised the mother to maintain personality
Advised the other to pay more attention to perineal and breast care
Advised the mother to daily clean the cloths and wash and dry them in direct sunlight
Advised the mother to perform hand washing such and every time before handling the
baby
Advised the mother to daily perform postnatal exercises like deep breathing exercises,
pelvic floor exercise etc.
Miscellaneous
Advised the mother to take adequate rest and sleep
Advised the mother to frequently breastfeed the baby
Advised the mother to avoid tight fitted bras and instead wear nursing bras
Advised the mother to avoid lifting heavy weight
Advised the mother to avoid sexual intercourse for 6-8 weeks.
Mother is advised to use contraceptive method for birth spacing
For Baby
Advised the mother to observe for cord bleeding, color, general condition, cry,
feeding pattern and passage of urine and bowel
Advised the mother that clothing should be according to the season
Advised the mother to pay special attention towards the care for card
Advised id mother to maintain a daily weight record of the baby
Advised the mother to observe for sign and symptoms of jaundice
Advised mother to maintain an immunization card for baby
Advised the mother to give exclusive breastfeeding for 6 months
Advised the mother to expose baby to the sunlight for 10-15 min
Advised the mother to strictly avoid any customs like giving honey to baby.
CONCLUSION:
Retained placenta means that all or part of the placenta or membranes are left behind in your
uterus (womb) during the third stage of labour. The third stage is delivery of the placenta and
membranes. The placenta is considered retained if it remains undelivered after 30 minutes of
an actively managed third stage and 60 minutes of a physiological third [Link] a part of a
care plan. I have studied about Retained placenta through which I have gained adequate
knowledge about the disease and I hope and believe that this study will help me and brought
up more knowledge for further studies.
BIBLIOGRAPHY
(1) DUTTA DC “TEXT BOOK OF OBSTETRICS” , PUBLISHED BY NEW
CENTRAL BOOK AGENCY(P) LTD, 6TH EDITION, PAGE 462-468.
CPMS COLLEGE OF NURSING
POSTNATAL CARE PLAN
ON
RETAINED PLACENTA
SUBJECT: OBSTETRICS & GYNAECOLOGY NURSING
SUBMITTED TO SUBMITTED BY
MAAM SANGEETA PAUL THOLEH LALRAMDINI JONGTE
ASSISTANT PROFESSOR ROLL NO.-10
OBSTETRICS & GYNAECOLOGY NURSING [Link] (N) 2nd YEAR
CPMS COLLEGE OF NURSING CPMS COLLEGE OF NURSING
