COLLEGE OF NURSING ,CH(EC) ,KOLKATA

PNC NURSING CASE STUDY

SUBMITTED TO-

MAJ LINCHU P GEORGE

TUTOR

CON,CHEC, KOLKATA

SUBMITTED BY-

MAJ JYOTHI GIRI

2ND YR MSC NURSING

CON,CHEC, KOLKATA
 INTRODUCTION

The post partum period is a time of major physical and psychological transition. A High-risk

pregnancy is one in which the health of the mother, baby or both are in danger before, during or

after birth. Risks can affect how a pregnancy progresses. When a mother and her unborn baby need

specialized care, it’s because of one or more of the following reasons:

• Problems that the woman had prior to pregnancy (fertility issues or a history of miscarriages).

• Problems the woman developed during pregnancy (preeclampsia)

•Health problems that the baby developed during gestation (fetal growth restriction or intrauterine

growth restriction).

Identifying the factors that place a pregnancy at high risk is the first step in developing a care

treatment plan. There are both internal and external factors that put a woman at risk during

pregnancy, including existing health conditions, genetic background, age, lifestyle choices, history

of pregnancy complications, and conditions that may develop with pregnancy.

Common Health Conditions

Common Health Conditions that Affect Pregnancy While some of these factors can be risky

for both mother and baby, with proper assessment, screening, monitoring and/or treatment, many

women have uncomplicated pregnancies, successful deliveries and healthy babies.

Pre-pregnancy Conditions

Some of the more common conditions that can put a pregnancy at risk include:

• Anemia
• Cancer

• Diabetes

• Epilepsy

• Heart Or Kidney Disease

• High Blood Pressure

• Infertility (Use Of Infertility Medicine)

• Polycystic Ovary Syndrome (Pcos)

• Rheumatoid Arthritis

• Thyroid Or Autoimmune Disease

• Weight (Underweight Or Overweight) Pregnancy Conditions During Pregnancy, Some Women

Develop Or Are Found To Have The Following Disorders, Which Put Their Heath And Their

Baby’s Health At Risk:

• Anemia: Low red blood cell count in the mother.

• Gestational diabetes: High blood sugar levels, especially in women who’ve never had diabetes

before pregnancy.

• Preeclampsia: A condition marked by high blood pressure, and often high levels of protein in the

urine during pregnancy.

• Cervical insufficiency: Dilation and widening of the cervix before the pregnancy has reached full

term.

Other Conditions
 Other factors that may influence a doctor’s decisions to identify pregnancies as high-risk,

include number of births, previous pregnancy complications, and timing between births.

. • Pregnancy with multiples: Women who are pregnant with two or more babies typically need to

see their physicians more often than single pregnancies because they are at risk for complications,

including preterm labor.

• Pregnancy spacing: Women who get pregnant very quickly after giving birth, as well as those

with several years between pregnancies, can be at risk for premature births and having babies with

lower birth weights.

• Previous pregnancy loss: Women who’ve been unable to carry previous pregnancies to full term

may be identified as high-risk. Examples of External Lifestyle Choices That Affect Pregnancy In

addition to health conditions, certain lifestyle choices can also negatively impact a woman and her

baby, including: preterm labor.

Screening tests are used to estimate whether the baby is at higher risk or lower risk of

having a certain condition. A diagnostic test can give a definite answer about whether the baby has

a certain condition. Stress from variety of sources like high risk pregnancy can have a negative

effect on mother and the new born.

Nursing care makes unremarkable contributions to the care of mother and baby by providing

priority and evidenced based care.

 DEMOGRAPHIC DETAILS

Name : Mrs Punam Choudhary

Age : 22yrs

Sex : female

Relation :wife of Nk Dhannu Choudhary

Service no : 15504308A

Unit : 58 ARMD REGT

Religion : Hindu

Address : Vill-Titagarh, PO+PS-Titagarh

North 24 PGNS

West Bengal

Occupation : Home maker

Obstetric score : Primigravida

LMP : 16.04.21

EDD : 23.01.22

POG : 37wks 3 days

DOA : 03.01.22
Diagnosis :Rh negative pregnancy

Presenting complaints s

Smt Punam Choudhary, 22 yrs primigravida admitted on 03.01.22 with H/O 37 wks 3days

amenorrhea and intermediate lower abdomen pain radiating towards thigh since last night .

History of present illness

Smt Punam Choudhary was apparently alright till 02.01.22 , suddenly she started realizing

mild lower abdomen pain which was progressive in nature overnight. On admission NST was

reactive and PV Findings were- 4-5cm dilated, min effaced , HS -1,membranes intact. she was in

active labour and she was prepared for the same.

Past medical/surgical history

No History of any pulmonary, cardiac, Renal Illness. No significant surgical history.

Allergies : Nil

Immunization : Immunized

Family history

Type of family :Nuclear family

No of family members :03

SN NAME AGE SEX RELATI OCCUPATION HEALTH STATUS

O ON

1 Dhannu Choudhary 28yrs Male Husband Serving personnel Healthy

2 Punam choudhary 22yrs Femal Wife Home maker Patient

e
3 NBB 1day Male Son - Breast feeding and
immunized upto date

Family tree

Key-

- Mr Suresh Choudhary

- Mrs Neetu Choudhary

- Mrs Rinki Choudhary

- Mr Dhannu Choudhary

- Mrs Punam Choudhary

 - NBB

Socio economic history

Total income : 55,000/-

Total family members : 03

Percapita income : Total income

Total number of family members

: 55,000 =18,330/- per head

03
Depending ratio : Total number of earning persons
Total number of family members

: 01 =1:3

03

Bar diagram showing percentage of expenditure

50%
45%
40%
35%
30%
25%
20%
15%
10%
5%
0%

Food: 20000 (40%)

Clothing: 2000 (4% )
Transport: 2000 (4% )
Health: 1000 (2% )
Miscellaneous: 2000 (2% )
Savings: 22000 (44%)

PERSONAL HISTORY

BRUSHING BATHING NAIL CUTTING HYGIENE/CLOTHING

HOME Twice/Day Twice/Day Once/week -Maintains

-Wears saree at home

HOSPITAL Once/week Once/week Once/week -Maintains

-Wears Gown in hospital

BOWEL BLADDER ABNORMALITIES

HOME Twice/Day 5-6 Times/Day NIL

HOSPITAL Once/week 6-8 Times/Day NIL

HOURS OF SLEEP PROMOTING DISTURBING

FACTORS FACTORS

HOME 7-8 hours/Day Daily routine Work stress

HOSPITAL 10-12 hours/Day No workload -Noise

-light

Menstrual history

Age at menarche : 13yrs

Menstrual cycles : Regular

Duration : 4-6days

Flow : Average

Cycles : 28+ 3 days

Marital history

Age at marriage : 20yrs

Dyspareunia : absent

Complications : absent

Contraceptives : male condoms

Obstetric history

Ist Trimester

▪ Unplanned pregnancy, Spontaneously conceived, confirmed by UPT.

▪ Booked at CHEC, Kolkata at 9 wks POG

▪ Regular ANC visits

▪ No history of hyperemesis gravidarum, threatened abortion

▪ Taken Tab folic acid 5mg BD ,Taken first dose of DT

▪ ANC profile done at 10wks POG ( Dtd 21.07.2021 )

Hb :10.6 g/dl

Tlc : 6,200/mm3

N58, L32, M10, E04

Plt : 1.6 L/mm3

BSL : F-84 mg/dl PP-91mg/dl

TSH : 0.51 mU/L, ICT-Negative

HIV : Negative

HbsAG : Negative

VDRL : Non reactive

ABORH : ‘B’ Negative, (Husband : ‘O’ Positive)

Urine RE/ME : NAD

USG(29.7.21) : SLIUF at 11wks+1day POG

NT-1.2 mm,

CRL-45 mm

FCA-158 b/min
 2nd Trimester

▪ Supplements :Tab ferrous fumarate 200mg BD

Tab calcium carbonate 500mg BD

▪ Immunization : Took DT x 2 dose

▪ Regular ANC visits

▪ Quickening : Felt at 18 wks

▪ Fetal movements : Perceiving adequately

▪ Investigations : Dual marker test : Negative

OGTT: F- 70 mg/dl (Dtd 20.10.2021)

1 hr-80 mg/dl

2 hr-74 mg/dl

▪ ICT : Negative

▪ Anomaly scan : (Dtd 20.10.2021)

SLIUF at 19wk+5days POG

Placenta-fundo Anterior

EFW- 335 gms

AFI-Adequate

No congenital anomaly seen

3rd Trimester

▪ Continued supplements
 ▪ Attended regular ANC visits

▪ ICT done at 28wks+3 days (negative )

▪ Anti D given at 35wk+1 (Patient reported late with reports)

USG : SLIUF at 34wks +6 day POG

Cephalic presentation at the time of

placenta –fundo Anterior

AFI-12cm

EFW-2.277kg

Delivery notes

Maintaining respectful maternity care Mrs Punam is shifted to labour room at 0630hrs .she

is asked to lie on her back with knee flexed and thigh apart. She is encouraged to bear down during

contractions. Bladder is emptied. FHR checked at 15min interval. At 0700hrs a full term baby boy

was delivered with the help of episiotomy and good maternal bearing down efforts.

Baby details-

APGAR sco :7/10-9/10 at 5 and 10 min respectively

Sex ;Male

Birth weight :2.47kg

DOB : 03.01.22

TOB : 0700hrs
 PHYSICAL EXAMINATION

DATE – 04.01.22 TIME-0930hrs WARD –Maternity WD

Anthropometric measurements

Height : 153 cm

Weight : 62kg

BMI 23kg/m2

General condition

Body built : moderate

Nourishment : well nourished

Appearance : neat and clean

Pallor : absent

Edema : absent

Lymphadenopathy : not palpable

Gait : normal

Vital signs

Temperature : 98.6℉

Pulse : 92b/min

Respiration : 20b/min

Blood pressure :118/78mmhg

HEAD TO TOE ASSESSMENT

Skin

Colour : whitish complex, no pallor or jaundice

Turgor : moist, well hydrated

Lesions : no vesicular, papules present

Pigmentation : no palmar erythema

Head

Hair distribution : uniform

Scalp : clean and clear

Face
Puffiness : absent

Fatigue : absent

Eyes and vision

Eye lids conjunctiva : normal

Sclera : no redness

Pupil : reactive to light

Vision : normal

Ears and hearing

External ears : no discharge/pain

Wax : present

Hearing : normal

Nose

External nares : no discharge

Septal deviation : absent

Epistaxis : absent

Neck

Lymph nodes : not enlarged on palpation

Thyroid gland : not enlarged

ROM : normal

Chest and thorax

Shape : normal

Symmetry : bilateral equal

Lungs : normal

Heart sounds : s1 s2 heard, no murmur present

Breath sounds : no wheeze, B/L equal entry

Breast

Inspection : On inspection no nipple retraction, erect, cracked, crust formation,

engorged veins, redness present

Palpation : On palpation no lumps, mass felt, colostrum present

Abdomen

▪ Linea nigra and gravidarum present

▪ Bowel sounds

▪ Fundal height is 34cms

▪ Mild tenderness present on palpation

Genitalia

▪ No signs of infection, leaking PV present

▪ No history of any vaginal bleeding present

▪ Leucorrhea present, no foul smell

▪ Smells of increased urinary frequency

▪ No constipation

Extremities

▪ ROM-normal

▪ No pedal/facial edema present

▪ No vascular veins, no tenderness noticed

▪ Active in doing all works

 POSTNATAL ASSESSMENT

INTRODUCTION

Examination of a postnatal mother and early identification of complication is one of the

important responsibility of a nurse in the postnatal area. Adequate postnatal examination is

necessary for planning the care of postnatal mother.

DEFINITION/MEANING

Postnatal care includes systematic examination of mother and the baby and the appropriate

advice given to the mother during postpartum period. Postnatal assessment is an important

component of postnatal care.

PURPOSE

• To assess the health status of the mother and institute therapy to rectify the defect if any.

• To detect and treat at the earliest any gynecological condition arising out of obstetric legacy.

• To impart family planning guidance.

AIMS

▪ Demonstrate understanding of the normal and expected postpartum changes.

▪ Conduct thorough assessments to identify signs and symptoms of problems before they

become serious complications.

▪ Initiate appropriate interventions when problems do occur.

▪ Prevent problems by teaching the woman appropriate ways to care for herself and her

newborn

PERLIMINARY ASSESSMENT

PREPARATION OF PATIENT

▪ Explained the procedure to the mother.

▪ Instructed the mother to empty the bladder and to wash the perineum with warm water.

▪ Placed the mother in supine position with hands at the sides and legs straight

▪ Brought the mother towards the examiner.

▪ Made the mother to be relaxed.

PREPARATION OF ARTICLES

▪ A large enamel tray containing:-

▪ Large sheet to drape the client.

▪ Stethoscope to auscultate chest and bowel sounds.

▪ Torch to visualize eyes, ears and mouth.

▪ Bowl with gauze piece to clean the breast.

▪ Paper bag to discard the solid waste.

▪ Inch tape to measure fundal height.

 ▪ Pen and paper to record the findings.

PREPARATION OF ENVIRONMENT

▪ Selected a clam and quite environment.

▪ Provided privacy.
 PROCEDURE

▪ Explained the procedure to the woman completely and clearly.

▪ Asked her to empty the bladder.

▪ Provided privacy and assembled articles at bedside.

▪ Checked anthropometric measurements.

▪ General appearance assessed – Looks dull/good√/fair.

▪ vital signs assessed

▪ Head to foot examination performed.

▪ Postpartum assessments: BUBBLE HE should be checked carefully to know the deviation from

normal and prevent complications.

 Assessment Procedure Patient picture

B – Breast Inspection

• Expose only the needed area that On inspection no nipple retraction, erect,

is one breast at a time. cracked, crust formation, engorged veins,

• Inspect for the engorged veins, redness present.

redness.

• Inspect nipple for retracted, erect,

cracked, crust formation.

Palpation

• Feel for warmth

• Palpate from the periphery to the

centre with finger pads in a

circulatory motion On palpation no lumps, mass felt. Colostrum

• Palpate for any masses/ lumps, present

hardness

• While palpating for axillary tails,

instruct the to raise the hands

above the shoulder level

• Express the colostrum/ milk and

wipe with gauze piece

• Repeat this for the other side.

U – Uterus Inspection

Cover the chest with draw sheet and

expose only the abdomen. Similarly use

the other sheet to cover up the pelvic

region. Inspect the abdomen for

consistency, presence of any wound

( LSCS, PPS) and if present assess the

condition of the wound.

Palpation

Start from the xiphisternum down, Uterus is Centrally placed, it is well

feel for the uterine fundus. Place the contracted,

ulnar border of the hand. Feel for the Fundal height- 13cm

upper border of the symphysis pubis,

place inchtape inch part up and measure

the symphysis fundul height. Feel the

consistency of the uterus-hard/well

contracted and flabby.

Examine the fundus by placing one

hand above the symphysis pubis to

support the lower uterine segment and

using the side of the other hand to locate

the fundus. And measure the fundal

height with inch tape. Here, the fundal

height decreases 1.25cm daily to get

beyond the symphysis pubis and become

a pelvic organ at 6weeks of puerperial

 period.

Immediately after delivey the fundus

should be firm and in the midline at

approximately the level of the umbilicus.

Following delivery the uterine muscle

must remain in a state of contraction to

prevent hemorrhage. If the uterus is not

contracting adequately, support the lower

uterine segment and use gentle massage to

increase contraction of the uterine muscle

fibres.

B – Bowels Most women do not have the urge to

defecate for a few days following Flatus passed

delivery, although some may do so. Loss

of abdominal tone contributes to

Problems with constipation following

child birth. Fear of pain or tissue damage

during the first defecation after delivery

is also common.

B – Bladder The urinary bladder should be Passed urine after 2 hrs of delivery

assessed for the presence of distention.

When the bladder becomes distended , No bladder distention, normal urine output.
 inspection and palpation will reveal a

bulge directly above the symphysis pubis.

A distended bladder is dangerous

following delivery because it will

interfere with normal contraction of the

uterus. The woman should void within 4-

6 hours following delivery. This time is

monitored closely.

L – Lochia The amount and characteristics of the

lochia are assessed each time the fundus is Bright red ,average amount.

checked. Immediately after delivery this

drainage is red and contains blood, small

clots and tissue fragments.

In case of uterine atony increases

blood loss. So, general condition should

be checked by monitoring vital signs.

The amount of lochia described as

scant, light, moderate or heavy. This is

determined by assessing how rapidly

perineal pads are saturated. The nurse

must be careful to look underneath the

woman’s buttocks and back to make sure

that the drainage is not missing the pad

 and pooling in the bed linens.

For the first 1-2 hours following

delivery the flow is expected to be

moderate, with one or two pads being

saturated in an hour. A heavier rate of

flow than this is considered excessive.

The pads can be weighed to determine

blood loss more precisely. One gram of

weight is approximately equivalent to

1ml of blood.

Less than expected flow should also

be viewed with caution to determine that

the uterus is contracting and clots are not

forming within the uterus or vaginal

canal.

The amount of lochia diminishes

gradually over time. Lochia changes

colour and consistency as healing of the

endometrium takes place.

E– The woman should be positioned in Episiotomy wound is healthy, no sign of any

Episiotomy lithotomy position and good room light infection seen.

or flash light is needed to visualize the

 stitches/suture line adequately.

REEDA should be observed,

R – Redness

E – Edema

E – Ecchymosis

D – Discharges

A – Approximation of suture line

H – Homan’s Ask the mother to flex the leg at the

Sign knee level and relax. Support at the calf No complaints of calf muscle pain.

muscle with other hand dorsiflex the foot.

If the mother experiences pain at the calf

region then Homan’s sign is positive.

-not performed routinely

E – Emotional Relationship with the newborn and Positive emotional bonding is present with the

status family dynamics: new born.

The early postpartum period is the ideal

time for bonding between mother and

newborn. The immediate family should

have the opportunity to spend time with

each other and the newborn while their

emotions and level of excitement are

high.
 GORDONS TYPOLOGY

Gordon’s typology health pattern is a method described by Margery Gordon to be used by

nurses in the nursing process to provide a comprehensive assessment of the patient.It was proposed

in the year 1987.These 11 categories are assessed through questions and asked by the nurses to

provide an overview of individuals health status and the health practices.

Health perception and management

Smt Punam has a positive attitude towards health and life style.she is anxious about labour

process. she shows concern about weight gain and asks how to reduce it after delivery. she is

willing to listen to the health education provided to her.

Nutrition and metabolic change

She is well nourished .she consumes non vegetarian diet and takes all type of food.

Elimination pattern

She has normal elimination pattern, she passes stool every day as a routine practice.no pain

sensation or bleeding is reported by her. Her urine output is adequate .

Exercise, activity pattern

She use to go for brisk walking throughout her pregnancy. she is well aware about the need

for exercise and activity every day. she does all household activities till hospitalization. she was

well receptive while educating about newborn.

Sleep rest pattern

She sleeps for 6-8 hrs at night but somehow she is disturbed now after hospitalization. she is

taking nap for 2 hours in the afternoon also.

Cognitive perception

She is aware about the changes during pregnancy but is anxious about her disease condition

and outcome during delivery. She has positive attitude during pregnancy. she asks doubt about the

management process and care after delivery.

Self perception

She understands herself as a unique human being she has ideas of self and her

responsibilities. She has goos self esteem and understands her role as a family member. she knows

very well the needs and requirements of her family members.

Role relationship pattern

She is living with her husband and her parents. she belongs to a family where relations has

good effect. she has good family support.

Coping and stress tolerance pattern

She has a positive attitude towards self and family.Copes up well with household stressors,

does not breaks up at given situations as she has good support system from parents and husband.
Values, belief pattern

She belongs to a Hindu family. follows all rituals of Hindu conservative family. she believes

in god she has good positive values and beliefs. she respects her husband, in –laws and all other

family members.

Sexuality pattern

She is married since 02 years she has good sexual relationship with her husband and has no

complaint’s about sexual life.

Inference

Mrs Punam is physically mentally and sexually healthy lady with strong family support

system and good coping mechanism and value beliefs.

 ROYS ADAPTATION THEORY

• Sister Callista Roy was born in 1939 in Los Angeles.

• In 1963, she earned a Bachelor of Arts Degree in Nursing from Mount St. Mary’s College in

Los Angeles.

• In 1966, she earned a Master’s Degree in Pediatric Nursing from the University of

California-Los Angeles.

• She also earned a Master’s Degree in Sociology in 1973, and went on to complete a

Doctoratal degree in Sociology in 1977. She is a sister of St. Joseph of Carondelet.

• While working at the University of Portland, Roy helped create a Master’s program in

Nursing. And at the Connell School of Nursing, she was involved in developing a Ph.D.

program in Nursing. She also served as a visiting professor to colleges around the world,

including La Sabana University in Colombia, the University of Lund in Sweden, and the

University of Conception in Chile.

Since developing her Adaptation Model of Nursing, Roy has had over 100 publications, which

includes 11 books with translations in 12 languages. She has been awarded four Honorary Doctoral

degrees, has several teaching awards, and won national awards from STTI, NANDA, and NLN. In

1995, Mount St. Mary’s College awarded Roy the Carondelet Medal for her contributions to the

nursing field. In 1978, she was elected to the American Academy of Nursing, and is still an active

Fellow.

Theory assumptions

Philosophical Assumptions

▪ Persons have mutual relationships with the world and a God-figure

Philosophical Assumptions

▪ 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 entering the process of deriving, sustaining, and transforming the

universe

Scientific Assumptions

▪ 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

▪ Human decisions are accountable for the integration of creative processes

▪ Thinking and feeling mediate human action

▪ System relationships include acceptance, protection, and fostering interdependence

▪ Persons and the earth have common patterns and integral relations

▪ Person and environment transformations are created in human consciousness

▪ Integration of human and environment meanings results in adaptation

Cultural Assumptions
Philosophical Assumptions

▪ Experiences within a specific culture will influence how each element of the RAM model is

expressed

▪ Within a culture there may be a concept that is central to the culture and will influence some or all

of the elements of the RAM to a greater or less extent

▪ Cultural expressions of the elements of the RAM may lead to changes in practice activities such as

nursing assessment

▪ As RAM elements evolve within a cultural perspective, implications for education and research

may differ from experience in the original culture

The philosophical assumptions are characterized by the general principles of humanism,

and cosmic unity. Humanism assumes that individuals behave purposefully, possess intrinsic

holism, realize the need for relationships, share in creative power, and strive to maintain integrity.

Veritivity complements humanism and affirms a common purposefulness of human existence.

Veritivity assumes the activity and creativity for the common good, the purposefulness of human

existence, the unity of purpose of humankind, and the value and meaning of life. Cosmic unity

assumes that reality is based on people and the earth having common patterns and integral

relationships. The scientific assumptions are based on the phenomena of living systems having

complex processes of interaction and acting to maintain the purposefulness of existence in a

universe.1 The cultural assumptions are an integration of cross-cultural experiences, cultural needs

and the necessity to eliminate culture-bound analysis of key concepts.

The major concepts of the RAM include: an individual as adaptive system, the environment,

health, and the goal of nursing.

- As an adaptive system, an individual is defined as a whole with parts that function as a unity for a

purpose.

-The environment is defined as all conditions, circumstances, and influences that surround and

affect the development and behaviour of humans as adaptive systems with particular consideration

of human and earth resources.

-Health is a state and process of being and becoming integrated and whole.

-The goal of nursing is to enhance life processes to promote adaptation, with adaptation being the

process and outcome of thinking and feeling individuals who use conscious awareness and choice to

create human and environmental integration.1

Similar to any complex adaptive system, an individual has coping processes or defence

mechanisms which serve to maintain adaptation in four critical modes: interdependence,

physiological, role-function, and self-concept.

 Representation of Human Adaptive Systems

Stimuli-

Stimuli are a way to describe the environment, and the environment consists of complex

patterns of interaction, feedback, growth, and decline. Three classes of stimuli (i.e., contextual,

focal, residual) make up the adaptation level, and are constantly shifting in response to interactions

between humans and earth.

Focal stimulus is internal or external, involves the immediate awareness of the individual and

requires the use of energy and resources. with body weight gain. During acute treatment,

individuals with AN tend to focus on thoughts, feelings, and behaviors related to body weight,

resulting

Contextual stimuli are internal or external factors that influence the ability to respond to the focal

stimulus and contribute directly to adaptation but are not the focus of attention and energy.

Residual stimuli are internal or external environmental factors that may affect the current

situation, but the influence of such variables are unknown or unclear. 1 Residual stimuli constantly

shift in response to the individual's interactions with the changing environment.

Adaptation Level

The ability of an individual to effectively adapt to stimuli is contingent upon the person's

adaptation level, the situational demands, and pre-existing life processes. Life processes are

conceptualized as integrated, compensatory, and compromised. Integrated is an adaptation level at

which the structures and functions of a life process are working as a whole to meet human

needs. Compensatory is an adaptation level at which defence mechanisms have been activated by a

challenge to the integrated life processes. Compromised results from inadequate integrated and

compensatory life processes, and is an adaptation problem. If an integrated life process changes to a

compensatory level of functioning, then the person will attempt to re-establish an integrated

adaptation level. A compromised level of functioning is the result of the inability to re-establish an

integrated adaptation level. Healthy body weight is an anthropometric measurement that indicates

adequate nutrition and caloric intake to maintain energy homeostasis. Healthy persons eat normal

amounts of food to maintain a healthy body weight.

Behavioural Responses

Behavioural responses, or behaviours, are internal or external actions and reactions under

specific circumstances and demonstrate how well an individual is adapting to stimuli. Behavioural

responses reflect defence mechanisms ability to adapt to the constantly changing environments, and

also act as feedback and additional input to the adaptive system. Behaviours can be observed,

measured and subjectively reported. Unlike ineffective behavioural responses, effective behaviours

promote the integrity of the person and the goals of adaptation including survival, growth,

reproduction, mastery, and human and environment transformations.

Defence Mechanism

Defence mechanisms are internal ways of interacting with the environment, and are divided

into two subsystems, regulator and cognator. The cognator subsystem refers to learned defence

mechanisms through repetition, and involves perceptual and informational processing, learning,

judgment, and emotion. the learned response. The regulator subsystem refers to genetically pre–

determined defense mechanisms that occur without human intervention, and is concerned with the

individual's innate and automatic signals from neural, chemical, and endocrine system channels.

Adaptive Modes

Since it is not possible to directly observe the processes of the regulator and cognator

subsystems, behavioral responses are manifested in four critical modes of adaptation:

interdependence, physiological, role function, and self-concept.

 The interdependence mode involves interaction with others, and a central notion is the

giving to and receiving from others, such as love, respect, value, nurturing, knowledge, skills,

commitment, time, talents, and material possessions. Interdependence consists of affectional

adequacy and developmental adequacy, and difficulties in one or both components can lead to a

compromised level of functioning. Thus, for the interdependence mode, the nurse should focus on

social support. In general, persons often seek assistance, or social support, when affection and

developmental challenges occur.

For the physiologic mode, nurses should be “knowledgeable about normal body processes

to recognize compensatory and compromised processes of physiologic adaptation” (Roy, 2009, p.

89). Within the physiologic mode, nutrition and fluid, electrolyte, and acid-base balance are

essential for physiologic integrity. Compromised processes related to these vital aspects of the

physiologic mode include malnourishment, dehydration/over-hydration, electrolyte imbalance, and

metabolic acidosis or alkalosis.1 Thus, nurses should focus on monitoring vital signs, body weight,

and caloric intake to provide information about the physiologic mode of individuals

For the role function mode, nurses should focus on autonomy and sense of control.

Autonomy is defined as a “core psychological need that transpires as individuals' ability to act in a

self-determinant manner and with an internal perceived locus of control regularly monitor sense of

autonomy and sense of control to help guide nursing interventions to promote social adaptation

related to role function, inclusive of the facilitation of individuals' ability to act in a self-determinant

masnner and regain control of self and personhood.

 INTRODUCTION

 Landsteiner and Weiner (1940) discovered a specific unknown antigen .

 This antigen present is present in Rhesus monkey and is named as Rh antigen.

 Individuals having the antigen is called Rh positive , without this antigen is Rh negative.

DEFINITION

BOOK PICTURE PATIENT PICTURE

-Rh disease is the hemolytic disease caused by the Mrs Punam’s blood group is B negative, hence

incompatibility of Rh factor in maternal and fetal diagnosed as Rh negative pregnancy.

blood.

-It occurs when the women is Rh negative and the

fetus is Rh positive
 GENOTYPES

BOOK PICTURE PATIENT PICTURE

Complete genetic makeup of Rh complex is its Rh neg (patient) + Rh positive(husband)

genotype (C,D,E,)

D antigen is the most potent and accounts for Rh +/-

almost all damage (95%)

INCIDENCE

BOOK PICTURE PATIENT PICTURE

5-10% in India

15-17% European/American whites Prevalence is 2.96% in

1% in china West Bengal from where mrs punam belongs .

Nil in Japan
 ISO/ALLOIMMUNIZATION

BOOK PICTURE PATIENT PICTURE

It is defined as a production of immune antibodies

in an individual in response to foreign red cell

antigen derived from another individual of the

same species.

RISK FACTORS- My patient is not exposed to any of the risk

Abortion factors that causes isoimmunisation.

MTP
CVS
Amniocentesis
APH
ECV
Manual removal of placenta
LSCS

TYPES OF ANTIBODIES

IgM(sensitization) IgG (Immunization)

▪ First to appear ▪ Appears in subsequent pregnancy

▪ They are Larger molecules hence cannot ▪ Small molecules and can easily cross the

cross placental barrier placental barrier.

▪ These are not harmful to the foetus ▪ Harmful to the foetus

Patient picture-if fetomaternal blood escape occurs during labour ,she will be at risk of developing

IgG Antibodies.

PATHOPHYSIOLOGY

The mother's blood can come into contact with the fetus’s blood, most commonly during

childbirth, and this leads to the formation of antibodies against the Rh factor. This means that the

mother is now sensitized against the Rh factor.

During the first pregnancy, the sensitization does not become a big issue because the number of

antibodies that have developed in the body is not big enough to cause any significant damage. The

second pregnancy, however, is much more dangerous because the next time the fetus and the mother’s

blood come into contact, the severity of the immune response will be much more pronounced.
 To put it simply, the antibodies in the mother’s blood will try and store the red blood cells of the

fetus and this can lead to a condition called hemolytic anemia. If this response is left unchecked then it

can cause a severe lack of oxygen transporting cells in the fetus. leading to symptoms similar to those

seen in asphyxiation.

In extremely severe cases, this reaction can even be fatal to the fetus.
 CAUSES

BOOK PICTURE PATIENT PICTURE

•Ectopic pregnancy X

•Partial molar pregnancy X

•Blighted ovum •Antepartum bleeding X

•External version X

•Platelet transfusion X

•Placenta previa X

•Placental abruption X

•Abdominal/pelvic trauma X

•In utero fetal death X

•Any invasive obstetric procedure (eg, amniocentesis) X

•Lack of prenatal care X

•Postpartum (Rh+baby) X

•Spontaneous abortion √ (B+ NBB )

DIAGNOSIS

BOOK PICTURE PATIENT PICTURE

▪ Maternal Rh negative blood group B-

▪ Coombs test on maternal blood shows presence of Rh Negative

antibodies

▪ Antibody titer more than 1:6 Not done

▪ H/O complications in past pregnancy Nil

▪ Fetal cord blood sampling at birth shows-

Presence of Rh factor B+

Positive direct Coombs test Negative

Hemoglobin value < 10gm% at birth 16.2%

High bilirubin level 1.0mg/dl

EFFECT OF RH ISOIMMUNIZATION ON PREGNANCY

▪ Preeclampsia

▪ Polyhydramnios

▪ Large baby in uterus

▪ Hyperfibrinogenemia

▪ Postpartum hemorrhage

▪ Big placenta

▪ Blood coagulopathy

EFFECT OF RH ISOIMMUNIZATION ON FETUS

▪ Destruction of fetal RBC causes hemolytic anaemia and it continues during the intrauterine life

▪ Hemolytic jaundice is because of breakdown of hemoglobin and high bilirubin content in blood

▪ In severe anaemia,heart failure, generalized edema,ascitis,pericardial effusion.

▪ IUFD can occur because of tissue hypoxia and acidosis.

 EFFECT OF RH ISOIMMUNIZATION ON NEONATE

▪ Hemolytic anaemia

▪ Hemolytic jaundice

▪ Congestive heart failure

▪ Perinatal mortality

MANAGEMENT

▪ During the first ANC visit all pregnant mothers should be screened for Rh type.

▪ All Rh negative mothers should be screened for Rh antibodies by ICT

▪ On screening if the husband is found Rh positive,at 28wks the mothers blood should be given

300mg of Rh immunoglobulin IM injection as antenatal prophylaxis.

▪ At the 35th week of pregnancy,the mothers blood should be again screened for Rh antibodies

and if it is negative close observation should be made till delivery.

▪ When the mother is found Rh antibody positive,she is treated like any other Rh sensitized

patient

▪ . Fetal assessment should be done by electronic fetal monitoring .sonography is done for assess

of fetal maturity,placental and cord thickness and decision should be made for intrauterine

blood transfusion and induction of labor after steroid administration.

▪ Soon after delivery a cord blood sample should be taken and tested for-DCT ,HB,Blood

bilirubin and ABORH of the baby.

 SHEMATIC REPRESENTATION OF MANAGEMENT

Mother( –ve) and father (+)

Serial antibody/ICT testing

No antibody antibody present

Primi multipara

No H/o FM hemorrhage H/o previous affection Supervision

Repeat ICT at 36 wks ICT monthly till 24wks/2wk serial USG 2/3WK

Negative Negative USG abnormality

Amnio/cordocentesis

Delivery at term Delivery

(No prophylactic ergometrin, rapid cord clamping,cord blood examination)

INFERENCE

▪ During the first ANC visit mrs punam was screened for Rh type.

▪ Anti D was administered to her at 29wks and 34 wks POG

▪ Fetal assessment was done through USG that shows no signs of any anomalies

▪ Soon after delivery a cord blood sample was sent and tested for-

DCT-negative

HB-16.2gm%

Blood bilirubin-1.0 mg/dl

ABORH –B positive
 NURSING MANAGEMENT DURING LABOR

1st stage

▪ Continuous labour monitoring was done.

▪ Side lying position was provided

2nd stage

▪ Immediate cord clamping was done.

▪ Large length of cord for exchange transfusion if needed was left.

▪ Cord blood collection for Hb , Sr Bil, DCT, Bld grouping done.

3rd stage

▪ Massaging of uterus is avoided

 NURSING DIAGNOSIS

RELATED TO MOTHER

1. Acute pain related to episiotomy wound as evidenced by pain assessment scale

2. Risk for infection related to tissue trauma.

3. Disturbed sleep pattern related afterpains as evidenced by dark circles under the eyes.

4. Deficient knowledge related to incomplete information about Rh negative pregnancy as

evidenced by verbalization of concerns and misinterpretation.

RELATED TO NBB

1. Risk for Injury related to hemolytic disease.

2. Ineffective thermoregulation related to heat loss from exposure to extra uterine life as evidenced

by cold extremities.

3. Risk for hypoglycaemia related to pre pregnancy disease condition.

 FOLLOW UP CARE

Mrs Punam was provided with all the aspects of postnatal care given by WHO .

TIMING OF POSTNATAL VISITS

Following childbirth Mrs Punam and her newborn were examined within 24 hours of

delivery. At this time it was discussed with the woman and family the timing of subsequent visits and

the immunization schedule for the baby. WHO recommends that the mother and baby will be visited at

home by a trained health worker, preferably within the first week after birth but my patient being

availing the services from CHEC it was advised her to visit after 1 week of discharge . These visits

early in the postnatal period are important for the mother and baby. It is also an important opportunity

to ensure the establishment of breastfeeding and address any difficulties with attachment and

positioning.

SEXUALITY ISSUES

These visits are a good time to discuss sexuality issues. Often the woman will come to see you

or be on her own at home with the baby. This can give you more privacy to discuss topics about which

she may feel ‘shy’. The timing of when a couple resume sexual relations after childbirth is often guided

by local sexual practices . A woman is often embarrassed to ask when she can resume intercourse and

may already be pressured by her husband or partner. In some cases, the partner may have had sexual

intercourse outside the relationship during the period of abstinence following childbirth and hence the

woman may be at risk of contracting STIs and HIV

Information to resume Sex after 6 weeks was adviced to Mrs Punam as It is important to tell

women about the changes to her body after childbirth that may affect resuming sexual relations. The
tiredness that many women feel after childbirth means that they often have little desire for intercourse.

The first time they have sex may be painful especially if they had stitches to their perineum. Damage

and strain to their internal pelvic muscles which happens during childbirth will mean that sex may ‘feel

different’. Many women will need information about these normal changes and some reassurance that

these things usually improve with time.

PROVIDING ADEQUATE CARE IN THE HOME

Mrs Punam has been provided with information that the immediate weeks following childbirth

women need extra care, including partner and family support. Labour and childbirth are physically

demanding, as is breastfeeding and looking after a newborn baby. It is therefore very important that

women regain their strength and maintain their health as they adjust to life with their new baby.

Women in the postnatal period need to maintain a balanced diet, just as they did during pregnancy.

Iron and folic acid supplementation should also continue for 3 months after birth. Women who are

breastfeeding require additional food and should drink sufficient clean water.

Family members were encouraged to take care of her at home as the first few weeks with a new

baby are very demanding, physically and emotionally. Women need to rest and take care of themselves

as they recover from labour and birth. This often requires that other family members and friends help

out.

DANGER SIGNS

It is important to discuss danger signs with every woman as the majority of maternal deaths

occur in the first week after birth. My patient was informed to report immediately when any of the

following signs is noticed –

• vaginal bleeding has increased

 • fits

• fast or difficult breathing

• fever and too weak to get out of bed

• severe headaches with blurred vision

• calf pain, redness or swelling; shortness of breath or chest pain.

• swollen, red or tender breasts or nipples

• problems urinating, or leaking

• increased pain or infection in the perineum

• infection in the area of the wound (redness, swelling, pain, or pus in wound site)

• smelly vaginal discharge

• severe depression or suicidal behavior

NEW BORN CARE

It is important to provide mothers, fathers and families with practical advice on how to care for

the baby during the first few days

. • Keep the baby warm - a baby should wear 1-2 layers more than an adult. If cold, put a hat on

the baby’s head.

• Care for the umbilical cord. Do not put anything on the stump

. • Keep the baby clean. It is not necessary to wash the baby every day, but wash baby’s face
 and bottom when needed. Make sure the room is warm when undressing baby.

• Provide nothing but breast milk day and night

. • You should see a health worker on day 3 and between 7 and 14 days and 4-6 weeks after

birth. At the 6 week visit the baby will be immunized.

• Let the baby sleep on his/her back or side.

• Keep the baby away from smoke.

• It is not recommended to expose the baby to direct sun

DANGER SIGNS FOR THE NEWBORN

In addition to advising parents and the family on general care of the newborn, Mrs punam was

also adviced about new born danger signs as it is important to alert them to danger signs. As for the

mother, there are also danger signs for the newborn that mothers and families need to identify and

respond to immediately

Advised the mother and family to seek care immediately, day or night. They should not wait if

the baby has any of these signs:

• difficulty in breathing or indrawing

• fits

• fever

• feels cold
• bleeding

• not feeding

• yellow palms and soles of feet

• diarrhea

• difficulty feeding (poor attachment, not suckling well)

• is taking less than 8 feeds in 24 hours

• pus coming from the eyes or skin pustules

• irritated cord with pus or blood

• yellow eyes or skin.

• ulcers or thrush (white patches) in the mouth

 HEALTH EDUCATION

The role of family planning counseling is to support a woman and her partner in choosing the

method of family planning that best suits them and to support them in solving any problems that may

arise with the selected method. During late pregnancy, after giving birth and after an abortion, it is

important that the woman or the couple receives and discusses correct and appropriate information so

that they can choose a method which best meets their needs. If a woman, preferably with her partner, is

able to make an informed choice, she is more likely to be satisfied with the method chosen and

continue its use.

Mrs Punam was provided with health education regarding Family planning as she was

primiparous mother at 22 yrs of age.

THE HEALTH BENEFITS OF BIRTH SPACING AND FAMILY PLANNING:

• Delaying having children can give people the opportunity to complete education or further

studies

• Waiting to become pregnant at least 24 months after birth can lead to health benefits for the

mother and baby.

• Spacing births allows the mother to recover physically and emotionally before she gets

pregnant again, and faces the demands of pregnancy, birth and breastfeeding.

• Limiting the number of children in a family means more resources for each child and more

time for the parents to dedicate to each child.

 • Family planning can also help couples in a sexual relationship not to be worried about the

woman getting pregnant.

• STIs including HIV/AIDS can also be prevented with correct and consistent use of condoms.

• Younger women (adolescents) can delay pregnancy until their bodies are mature and they are ready in

terms of their life course.

• Older women (over 35) can prevent unwanted pregnancies that are often risky for their health

and can lead to complications for both mothers and infants.

OPTIONS PROVIDED TO MY PATIENT

IUD Insert within 2 days of childbirth, or from 4 weeks after childbirth Insert within 2 days of

childbirth, or from 4 weeks after childbirth .Always very effective, long term method but may have

side-effects.

Combined pill (estrogenprogestogen) From 6 months after childbirth From 3 weeks after

childbirth Very effective with careful use, may have side-effects.

 DMPA and NET-EN (3 or 2 month injection) From 6 weeks after childbirth From

immediately after childbirth Very effective with careful use, may have side-effects

Condoms From immediately after childbirth. From immediately after childbirth .Effective with

careful use.
 SUMMARY AND EVALUATION OF CARE

▪ Punam Choudhary, 22 yrs primigravida reported to CHEC Kolkata on 03.01.22 with

H/O 37 wks 3days amenorrhea and intermediate lower abdomen pain.

▪ Maintaining respectful maternity care Mrs Punam delivered a full term baby boy with

the help of episiotomy and good maternal bearing down efforts.

▪ Baby details-

APGAR sco :7/10-9/10 at 5 and 10 min respectively

Sex ;Male
Birth weight :2.47kg
DOB : 03.01.22
TOB : 0700hrs

▪ Postnatal stay was uneventful

FIGO/ICM GUIDELINES AND PATIENT MANAGEMENT

ABORH -A pre-requisite for the prevention of Rh(D) sensitization is a priori knowledge of

maternal Rh status was done to identify blood grouping.The Rh(D) type should preferably be de

termined in the first trimester, because indications for anti-Rh(D) immunoprophylaxis may arise early

in pregnancy.

OBSTETRIC HISTORY- my patient was primigravisa with no history of blood transfusion,it

is unlikely that the baby will be affected. In a multiparous woman,a detail obstetric history has to be
taken.History of prophylactic administration of anti D Immunoglobulin following abortion or delivery

should be enquired.

ANTIBODY DETECTION-IgG antibody is detected by ICT and in my patient it was negative

at 28wks and 34 wks which is recommended by FIGO. In positive cases it should be supervised to

tackle with Rh problems.

POSTPARTUM ANTI-RH (D) IMMUNOGLOBULIN ADMINISTRATION-Rh D

Immunoglobulin 300mg is administered following delivery to my patient according to the FIGO

guidelines.

Inference –Mrs Punam has been managed well during her hospital stay according to the existing

guidelines .
 BIBLIOGRAPHY AND REFERENCES

1. Hiralal Konar ; Dc Dutta text book of obstetrics. 9 th edition. Jaypee publishers pvt ltd. New Delhi.

Page 308-311.

2. Jacob Annamma ;A comprehensive textbook of midwifery and gynecology nursing.6 th edition. Jaypee

publications, New Delhi.page 267-272.

3. Jaypee marshal; marvel rays textbook of obstetric and gynaecology. Oxford publishers.4th edition.page

233-234.

4. Linda. Skidmore Roth. Mosbys drug reference.29th edition. Elseiver publishers Pvt ltd. New Delhi.page

355-357.

5. Arup kumar Majhi, Text book of obstetrics .7th edition. Jaypee publishers pvt ltd. New Delhi.

Page.529-531.

6. Family medicine and community health; prevalence of Rh negative pregnancy in india, National

journal of India.

7. World health organization; integrated management of pregnancy and childbirth .Managing

complications in pregnancy and childbirth. A guide for midwives 2019.

8. National institute of health and excellence ;Rh negative pregnancy diagnosis and treatment ;NICE

guidelines 2010.

9. FIGO/ICM guidelines for preventing Rhesus disease: Safe Motherhood & Newborn Health.

10. Net references (accessed on 12.02.22)

www.pubmed.com

www.Research gate.com

www.BMC pregnancy childbirth.com

COLLEGE OF NURSING CHEC ,KOLKATA

EVALUATION CRITERIA

SNO CRITERIA MARKS MARKS OBTAINED

ALLOTED
1 Introduction 02
2 History and assessment 06
3 Theoretical knowledge of disease 10
condition
4 Nursing process 10
5 Application of nursing theory 05
6 Follow up care 05
7 Health teaching 03
8 Research evidence 05
9 Summary and evaluation of care 02
10 Bibliography & References 02
Total

Remarks:
Mrs Punam,22yrs FTND WITH EPISIOTOMY date- 03/2/22

ASSESSMENT OF STIMULI DIAGNOSIS GOAL INTERVENTION EVALUATION

BEHAVIOUR
Disrupted physical/ Focal stimuli Acute pain related to To reduce the • Monitored Vital signs • Patient verbalizes

physiological mode Acute pain episiotomy wound as pain pain relief and

evidenced by pain • Inspected perineum to note for comfort.

Subjective data Contextual stimuli assessment scale. any redness, swelling,

Patient says Episiotomy incision ecchymosis, laceration, • Scores in numeric

“mujhe neeche stitches approximation of wound by pain rating scale has

me bahut dard ho raha Residual stimuli using REEDA scores. also reduced .

hai” pregnancy and

delivery process • Encouraged Mrs Punam to

Objective data ambulate and empty her

Evidenced by pain bladder frequently to relieve

assessment by numeric pain.

rating scale.

• Analgesics-Tab combiflam

500mg stat was provided .

Mrs Punam,22yrs FTND WITH EPISIOTOMY date- 03/2/22

ASSESSMENT OF STIMULI DIAGNOSIS GOAL INTERVENTION EVALUATION

BEHAVIOUR
Distrupted Self concept Focal stimuli Deficient knowledge understanding of • Assessed for the level of Patient verbalizes

mode Lack of knowledge related to incomplete the condition. knowledge of Rh negative understanding of the

information about Rh pregnancy. Rh negative pregnancy

Subjective data Contextual stimuli negative pregnancy as and follow up

Patient says- Rh negative blood evidenced by • Counselled for future requirement.

“pata nahi aage dusre group verbalization of pregnancy and importance of

bacche ke saath kya concerns and screening in early pregnancy

hoga” Residual stimuli misinterpretation. for early detection of

pregnancy complications associated with

Objective data Rh negative pregnancy.

Patient asks doubt about

follow up and future • Inform about the need to

pregnancy. follow up was provided.

Educate about Breast feeding,

Warning signs, Immunization

Mrs Punam,22yrs FTND WITH EPISIOTOMY date- 03/2/22

ASSESSMENT OF STIMULI DIAGNOSIS GOAL INTERVENTION EVALUATION

BEHAVIOUR
Distrupted Focal stimuli Risk for Injury related to To reduce the • Assessed infant/maternal All parameters were

physical/physiological Risk for injury hemolytic disease. risk of blood group and blood type. normal ,not indicative

mode complications. of any risk to the

Contextual stimuli • Assessed the infant in daylight. newborn.

Subjective data Rh negative blood

Patient says- group • Kept newborn warm and dry;

“bacche ko kuch monitored skin and

problem ho sakta hai Residual stimuli core temperature frequently.

kya” pregnancy

• Evaluated infant for pallor,

Objective data edema and

Patient asks doubt about hepatosplenomegaly.

newborn risks.

• Checked for newborn weight

changes.
ASSESSMENT OF STIMULI DIAGNOSIS GOAL INTERVENTION EVALUATION
BEHAVIOUR

Distrupted physical/ Focal stimuli Risk for maternal injury To reduce the • Reviewed obstetric and • primigravida with

physiological mode maternal injury related to Rh negative risk of maternal medical history no significant

pregnancy injury . med/sur history.

Subjective data Contextual stimuli • Monitored Vital signs • WNL

Patient says Alloimmuni-zation

“Mujhe koi problem • Provided information • Verbalized

hogi kya” Residual stimuli regarding the risk understanding of

Present pregnancy associated with her her pregnancy.

Objective data pregnancy .

Rh negative pregnancy
• Verbalized
is high risk pregnancy • Educated to take inj
understanding of
Anti D and its
anti D
importance during next

pregnancy .
ASSESSMENT OF STIMULI DIAGNOSIS GOAL INTERVENTION EVALUA-
BEHAVIOUR TION

Distrupted Self concept Focal stimuli Knowledge deficit understanding of • Assess the level of Patient verbalizes

mode Lack of knowledge regarding prognosis of disease knowledge of disease understanding of the

Subjective data Contextual stimuli disease condition as prognosis condition prognosis and follow up

Patient says Presence of disease evidenced by • Inform about the need requirement.

“pata nahi aage kya condition during verbalization of concerns to follow up

hoga” pregnancy • Educate about

Objective data Breast feeding

Patient asks doubt about Residual stimuli Exercise

management of her pregnancy Warning signs

condition Immunization

Family planning
ASSESSMENT OF STIMULI DIAGNOSIS GOAL INTERVENTION EVALUA-
BEHAVIOUR TION

Distrupted physiological Focal stimuli Ineffective To maintain • Recorded vital signs. Thermoregulation

mode Distrupted thermoregulation related normal body • Maintained ambient established

thermoregulation to heat loss from exposure temperature temperature in the room

Subjective data to extra uterine life as and covered the newborn

Patient says Contextual stimuli evidenced by cold with full sleeves cloths

“bacche ka hath thanda Exposure to external extremities. ,cap and wrapped in a

hai ” environment warm blanket.

• Demonstrated the mother

Objective data Residual stimuli how to provide kangaroo

On assessment baby’s Pregnancy and labour mother care and

extremities were cold process encouraged her to do it.

• Blood sugar levels of

the newborn were

monitored.
SNO MECHANISM OF INDICATION CONTRAINDICATION DOSE SIDE NURSES RESPONSIBILITY
ACTION EFFECTS
SNO MECHANISM OF INDICATION CONTRAINDICATION DOSE SIDE NURSES RESPONSIBILITY
ACTION EFFECTS
SNO MECHANISM OF INDICATION CONTRAINDICATION DOSE SIDE NURSES RESPONSIBILITY
ACTION EFFECTS
TIME TPR BP TIME INTAKE ORAL IV TIME U/S/O OBSERVATION IMPLEMENTATION EVALUATION

0800hrs 98.6℉ 124/78 0830hrs Milk 200ml - 0930 300ml Patient bed was untidy Bed making was done Unit was neat and
mmhg
tidy
Vital signs were due Vital signs ,checked Vital signs were
1000hrs 98.6℉ 120/70 1030hrs Biscuits 200ml - 1200 150ml
for recording and recorded. within normal
mmhg with water ______
450 ml limits.
Patient seems to be Educated her about Patient took bath.
1230hrs 98.2℉ 122/70 1230hrs Lunch with 250ml -
mmhg water ______ not taken bath in the importance of personal
650 ml
morning hygiene and outcome
in postnatal period in
terms of controlling
infection and
promotion of health for
both newborn and self.

Patient had complaints Encouraged to take Passed

of not passing stool adequate oral fluids
after delivery. and syp lactulose 15ml
stat and tab combiflam
500 mg stat.
TIME TPR BP TIME INTAKE ORAL IV TIME U/S/O OBSERVATION IMPLEMENTATION EVALUATION

0800hrs 98.6℉ 120/80 0800hrs Milk 200ml - 0930 300ml Patient bed was untidy Bed making was done Unit was neat and
mmhg
tidy
Vital signs were due Vital signs ,checked Vital signs were
1000hrs 98.6℉ 116/70 1030hrs Juice 200ml - 1230 250ml
for recording and recorded. within normal
mmhg ______
water 200ml 550 ml limits.
DFMC chart was not Educated her about Patient
1200hrs 98.6℉ 120/70 1240hrs Lunch with 300ml -
mmhg water ______ maintained importance of DFMC understood it and
900 ml
chart and how to started marking
maintain it. DFMC .

Patient had complaints Encouraged to feed the Mother verbalizes

baby sleeping in NBB every 2 hrly, satisfaction of
between feeds. explained her about the baby feeding.
normal pattern of baby
feeding and stimulation
she needs to do while
baby is sleeping during
breast feeding.
TIME TPR BP TIME INTAKE ORAL IV TIME U/S/O OBSERVATION IMPLEMENTATION EVALUATION

0800hrs 98.6℉ 124/80 0830hrs Milk 200ml - 0930 300ml Patient bed was untidy Bed making was done Unit was neat and
mmhg
tidy

1000hrs 98.4℉ 120/74 1000hrs Apple with 200ml - 1200 150ml

Vital signs were due Vital signs ,checked Vital signs were
mmhg water ______
450 ml for recording and recorded. within normal
limits.
1230hrs 98.6℉ 118/78 1230hrs Lunch with 250ml -
mmhg water ______ Patient seems to be Counseled her about Patient verbalizes
650 ml
anxious during ward importance of follow satisfaction from
rounds. up for NBB for early the information
detection of neonatal that is provided to
jaundice or any other her.
complications related
to Rh negative
pregnancy. Educated
her about the
importance of Anti D
which was given to her
after childbirth.
SNO CRITERIA MARKS MARKS OBTAINED
ALLOTED
1 Introduction 02
2 History and assessment 06
3 Theoritical knowledge of disease 10
condition
4 Nursing process 10
5 Application of nursing theory 05
6 Follow up care 05
7 Health teaching 03
8 Research evidence 05
9 Summary and evaluation of care 02
10 Bibliography & References 02
Total