POSTNATAL CARE PLAN

OF
MRS ANJANA SURESH
WITH
BREAST ENGORGEMENT

SUBMITTED TO, SUBMITTED BY,

[Link] Jose Arathy Unnithan

Associate professor 2nd year MSc Nursing

TMM college of Nursing TMM College of Nursing

Thiruvalla Thiruvalla

Submitted on

21/11/2023
IDENTIFICATION DATA

Name of the patient : Mrs. Anjana Suresh

Age : 26 years

Address : Aparna bhavan

Puliyoor p.o chenganoor

Religion : Hindu

Income : 1,00000/month

Husband name : Mr. vaishak

Blood group of the mother : A positive

Blood group of the father : A positive

Date of admission` : 30/06/2023

Date of discharge : 5/07/2023

Date of study started : 03/07/2023

Date of study ended : 05/07/2023

Obstetrical score : G1P1L1A0

LMP : 27/09/2022

EDD : 04/07/2023

Reason for admission : For safe confinement

Mode of delivery : Normal vaginal delivery

DIAGNOSIS : Breast engorgement

 OBSTETRICAL HISTORY

 PRESENT OBSTETRICAL HISTORY

Mrs Anjana Suresh 26 /F primigravida mother got admitted in TMM hospital Thiruvalla for
safe confinement. On examination no pallor, per abdomen uterus is firm and relaxed, visible
fetal movements are perceived. Fetal heart rate is normal 142 beats per minutes.

1st TRIMESTER

The pregnancy was planned and confirmed by the urine pregnancy test. Her first scan was
done on 5th week which should confirm the pregnancy. She started to take tab. flovite 5mg
OD from the fifth week onwards. During the first trimester she had increased frequency of
micturition ,weakness and morning sickness such as nausea and vomiting. She completed
first dose of T.T on 12th week.

II nd TRIMESTER

Morning sickness was increased and frequency of micturition was decreased. The mother
was more active. She started [Link] 500 mg in the morning. She gained all the antenatal
[Link] scan was performed at 20th week of pregnancy, it was normal. She
completed her second dose of T.T at 18th week.

3rd TRIMESTER

She gained 5 kg weight. She had increased urinary frequency, mild itching, over the abdomen
and backache due to the overstretching of the abdomen. She underwent all the regular
antenatal checkups.

INTRANATAL HISTORY

Mrs Anjana was delivered a male baby weighing 2.820kg through normal vaginal delivery.
The baby cried immediately after the birth. the baby and mother having no complications
during the intranatal period.
POST NATAL HISTORY

During the immediate postnatal time she was conscious and oriented and has minimal
bleeding. vitals are checked and recorded. Temperature -98.6, pulse-98 beats per minute,
respiration 24 breaths per minute, bp-130/80 mm of Hg. During the second day of post-
partum period she feels pain on the breast and consulting the doctor and doctor advised to the
patient feed the baby in every two hours and advised to use breast pumb in case of severe
pain. Educate the patient regarding proper position and breastfeeding technique.

PAST OBSTETRICAL HISTORY

Mrs. Anjana has no significant past obstetrical history.

PAST MEDICAL HISTORY

Mrs. Anjana has no significant past medical history.

PRESENT AND PAST SURGICAL HISTORY

Mrs. Anjana has no significant past and present surgical history.

FAMILY HISTORY

Mrs. Anjana belongs to a high-class family. Her husband is the bread winner of the family.
All the family members are healthy and are free from all the communicable diseases.

Name of the family Age Relation Education occupation Health status

member

Mr. Suresh Kumar 58 Father 10th nil Healthy

Mrs. Bindu Suresh 54 Mother 10th nil Healthy

Mr. Vaishak 30 Husband degree engineer Healthy

Mrs. Anjana 26 Patient degree Pharmacist Healthy

Miss. Aparna 21 Sister degree nil nil

suresh
PEDIGREEE

Mr Suresh

-56yrs Mrs. Bindu 54 yrs.

Miss. Aparna, 21 years

Mr. Vaishak, 30 yrs Mrs Anjana 26yrs

PERSONAL HISTORY

Mrs. Anjana Suresh lives with her husband. She is well nourished and likes non vegetarian
food. She has adequate rest and sleep but sometimes sleeping pattern is disturbed due to
hospitalization. She maintains good personal hygiene. Her Bowel and bladder pattern was
regular. She has no any bad habits like smoking, chewing.

MENSTRUAL HISTORY

Age of menarche : `13 Years

Frequency and duration : 30 days and 4-5 days

Amount of blood : 3-4 pads/ day

Any Abnormalities : no any abnormalities in menstruation

MARITAL HISTORY

Age of marriage : 25 years

Type of marriage : non consanguineous marriage

Years of marriage : 1 years

Use of contraceptives : nil

SOCIO ECONOMIC STATUS

Place of housing : rural

Occupation : pharmacist

House : own

She is living in a pucca house with adequate supply of water, electricity and good sanitation
and maintenance a good relationship with all family members.
 INVESTIGATIONS

Date Name of the Patient value Normal value remarks

investigations

Hemoglobin 13.9 11.5-16.5

PCV 36.9 35-45
WBC count 9900 5000-10000
RBC count 4.24 4.35-5.65
million cells
40-75%
Poly 68
20-40%
Lymph 26
0-6%
Esino 2
1-3%
Mono 1
80-100
Mcv 89
27-32
Mch 39
32-36
Mchc 34
9/08/2023 11.5-14.5 Normal
RDW 16
100-400
Platelet count 224
URINE
EXAMINATION
Colour
Light yellow
Apperence
Clear
PH
5.5
specific gravity
1.030
glucose
Neg
protein
Neg
ketones
+
bilirubin
Negative

USG FINDINGS (22/6/23)

Single live intrauterine gestation with cephalic presentation with 34 weeks +/_ 3 weeks .
PHYSICAL EXAMINATION

General examination

Body build : good

Nourishment : moderate

Height : 162 cm

Weight : 78 kg

BMI : weight in kg/height in m2 * 100

78/1.62*1.62 = 29.7 kg/m2

VITAL SIGNS

Temperature : 98.6-degree F

Pulse : 78beats per minute

Respiration : 24 breaths per minute

Blood pressure : 110/70 mm of hg

Head

Scalp : clean and no dandruff

Hair : equally distributed

Color : normal

Pediculosis : absent

Face

Facial puffiness : present

Cholasma : present

Eyes
Eye brows : symmetrical

Eye lashes : symmetrical

Eye lids : no edema

Sclera : white

Conjunctiva : pink in color

Vision : normal

Ear

Pinna : equally distributed

Hearing : normal

Discharge : absent

NOSE

Nasal septum : midline

Nasal pathway : patent

Nasal pathway : absent

Rhinorrhea : absent

Mouth and Pharynx

Halitosis : absent

Dental caries : absent

Mucosal skin : not ulcerated

Gums : no bleeding

Tounge : not coated

Neck and axilla

Range of motion : possible

Thyroid gland` : not enlarged

Trachea : Midline

Lymph node : not enlarged

Breast

 Inspection

Size : enlarged

Symmetry : Symmetrical

Veins : not visible

Nipples : no abnormalities like cracked nipples or flat nipples

Areola : secondary areola

Montgomery’s tubercle : present

Discoloration : absent

 Palpation

Consistency : hard

Engorgement : present

Colostrum : present

Pain : pain present due to breast engorgement

Extremities

 Upper extremities

Symmetry : symmetrical

Range of motion : possible

Edema : absent

Cyanosis : absent
 Lower extremities

Symmetry : symmetrical

Range of motion : possible

Edema : absent

Cyanosis : absent

Genitalia and back

Vulva : slight edematous

Genital warts : absent

Varicosities : absent

Discharge : Lochia rubra present

Pain : pain present on episiotomy wound

Physical examination findings

 Facial puffiness present

 Chloasma present
 Breast engorgement present
 Edema present
 Lochia rubra present
 Pain present on episiotomy wound
POSTNATAL ASSESMENT

 Vital signs
Temperature : 98.6-degree F
Pulse : 74 beats per minute
Respiration : 20 breaths per minute
Blood pressure : 120/80 mm of hg
 Breast
*Inspection
Size and shape : large in size and normal shape
 Symmetry : symmetrical
Nipples : erect enlarged more pigmented and adequate for
feeding

Skin changes : primary and secondary areola present

 *Palpation

Tenderness : Absent

Warmth : absent

Colostrum : present

Axillary lymph nodes : no enlarged

 ABDOMEN

*INSPECTION

Size and shape : flattened and smaller

Pigmentation : linea nigra and straie gravidarum present

*PALPATION

Position : in the midline below the umbilicus

Consistency : firm and contracted

Fundal height : 14 cm

 BOWEL

Bowel sound : present in all four quadrents of abdomen but

hypo active
Bowel movements : present

Distension : absent

 BLADDER

Bladder : not palpated

 Urine output : adequate

Urgency : absent

Colour : pale yellow

 LOCHIA

Colour : bright red

Odour : no foul smell

Amount : slight amount (3 PADS PER DAY)

 EPISIOTOMY

Redness : Present

Edema : absent

Eccymosis : absent

Discharge : absent

Approximation : approximated

 HOMAN SIGN
Negative for both legs
 EMOTIONAL STATUS
On observation no significant signs of postpartum blues, depression and psychosis.
she seems happy, she started to exhibit passive dependent behavior and spend time to
touching and talking to the baby.
 NEWBORN ASSESMENT
Name of the baby : B/O of Anjana
Age : 2 days
Sex : male
Weight : 2.820 kg
Apgar score : 8/10 in 1min and9/10 in 5 min
 ANTHROPOMETRIC MEASUREMENT
Length : 49 cm
 Weight : 2.820 kg
Head circumference : 33 cm
Chest circumference : 32 cm
 GENERAL ASSESMENT
Apperence
Activity : active
Cry : good cry
Colour : pink in colour
Cyanosis : absent
 EYES
Eye brows : symmetrical
Eye lashes : equally distributed
Pupils : PERRLA
Conjunctiva : no discoloration
Discharge : absent
 HEAD
Hair : equally distributed
Injury : absent
Caput succedenum : absent
Cephal hematoma : absent
Frontanalles : soft and palpable
 NOSE
Nasal septum : midline
Nasal pathway : patent
Nasal polyp : absent
Rhinorrhea : absent
Nasal flaring : absent
Discharge : absent
Pinna : normal
Cartilage : not well developed
 CHEST
Expansion : symmetrical
Heart sound : s1s2 heard
Heart rate : 140 beats per minute
 Respiratory rate : 30 breaths per minute
Respiratory distress : absent
 GENITAL
Rougae : present
 EXTRIMITIES
Edema : Absent
Cyanosis : absent
ROM : Possible

REFLEXES

REFLEX BOOK PICTURE PATIENT PICTURE

Rooting Touch or strocking the Head turns towards the

cheek near the corner of the stimulations
mouth

Sucking Touching the nipple with the Suckling movements

nipples

Swallowing Accompanying the sucking Food reaching the posterior

reflex of the mouth

Blinking Exposure of eyes to bright Blinking the eyes by rapid

light eyelid response

Dolls eye When turning head in to the Normally the eyes are turns
left of the eye deviate in the to left
opposite direction
NURSING DIAGNOSIS

 Acute pain related to breast engorgement as evidenced by facial expression

 Ineffective breastfeeding related to the pain and limited maternal experience as
evidenced by inability to latch on
 Knowledge deficit related to disease condition and its management as evidenced by
frequently asking questions
 Anxiety related to disease condition and inability to feed the baby as evidenced by
anxious face.
 Insomnia related to pain on the breast as evidenced by sunken eyes.
HEALTH EDUCATION

FOR MOTHER

 Adequate rest and sleep

 Should take plenty of oral fluids
 High protein and iron rich diet
 Light diet should be taken immediately and later well-balanced diet
 Do not lie on cross lie with cross legs
 Observe the vital signs and excessive bleeding reports sos
 Encourage the patient for frequent urination
 Advice for breast care (clean the breast before and after feeding)
 Advice for perineal care very often clean from unclean to clean area
 Ambulation can be started from 2nd day of postpartum
 Post natal exercise
 Care of bowel

FOR BABY
 Examine the newborn head to toe
 Keep the baby clean dry and warm
 Observe the vomiting, cord bleeding, cry, activity, passing of urine and meconium
 Use the clothes according to climate
 Breast feed the baby as soon as possible
 Record the weight of the baby

ADVICES ON DISCHARGE

FOR MOTHER

Do’s

 Adopt small family norm

 Attend postnatal clinic after 4 weeks
 Follow regular intake of medicines

Dont’s

 Lifting heavy weights

  Long journey
 Sexual intercourse for 6-8nweeks
 Constipation and strain on sutures while sitting

FOR BABY

Do’s

 Immunization as per schedule

 Attend well baby clinic after 6-8n weeks
 Expose the baby to sunlight for 10-15 minutes every day protecting the eyes
 Introduce solid food after 6 months

Dont’s

 Home hazards after infections

 Top feeds or solid foods for 6 months
 PROGRESS NOTE
Day 1 (3/07/23)

Mrs Anjana 26 years female got admitted in TMM Hospital for the safe confinement on
2/08/23. She delivered a male baby weighing 2.820kg at 2.00pm. postnatal period was un
eventful. Postnatal assessment was done. Fundal height is 14 cm. Vitals are checked and
recorded. Adviced the mother about early ambulation.

Day 2 (4/07/23)

Assessed the general condition of the mother and the baby. The mother had pain on the
episiotomy wound and the breast. Doctor Anu sees the patient and advised to feed the baby
every 2 hours and use the breast pump and express the breast milk and palada feed can be
started. Baby condition was good. umbilical cord care given to the baby.

DAY-3 (5/05/23)

Assess the general condition of the mother and the baby. Newborn care given. Vitals are
checked and recorded. Bowel and bladder pattern are regular. Mother has pain during the
breast feeding. Health education given regarding exclusive breast feeding and breast feeding
techniques.

CONCLUSION

Mrs Anjana 26 years multigravida mother 38 weeks was admitted in TMM hospital
Thiruvalla on 28/06/2023 for safe confinement. She delivered a male baby on 02/07/2023 at
2.00pm. Proper nursing and medical care given to the baby and mother. Health education
given to the mother and family regarding the care of the baby and mother.

Bibliography

 Hiralal konar “Dc Dutta textbook of obstetrics”9 th edition, Jaypee brothers and
medical publishers, New Delhi.
 Annamma Jacob “maternal and neonatal care plan” Jaypee publishers.
 Shwetha naik and Hannah Roslin “procedure manual for obstetrics and
gynaecological nursing” first edition (2019) CBS publishers New Delhi