ASSESSMENT:-

Name of the mother : - Joba Sutradhar

Age of the mother : -22yrs
I.P NO :- MB-I/1998
Education of Mother :- X Passed
Education of Husband :- XII Passed
Occupation of Mother :- House wife
Occupation of Husband :- Business (Jewelry)
Age of Marriage :- 20 yrs.
Duration of Marriage :- 2 yrs.
Obstetrical score : -G1P0A0L0
Last menstrual period : -16/9/23
Expected date of delivery : -23/06/24
Date of admission : - 19/06/24
Gestational age (as on date of admission): -39 weeks 3 da y s
Religion : - Hindu
Antenatal diagnosis : -Primigravida with Pre-labour Rupture of the
Membranes (PROM)
Address : - Vill+Po:- Pratapgarh, PS:-East PS, Agartala

CHIEF COMPLAIN: -
She was having abdominal pain since 6 days
Unable to perceive fetal movement since 1 day

HISTORY OF PRESENT ILLNESS: -

Onset of symptoms: - patient was apparently good 7 days back, she had started pain abdomen
in the last 6 days back and then show that watery discharge comes from vagina she feels less
fetal movement, come to obstetric OPD, IGM Hospital on dated 19/06/2023, after consulting
with doctor, the doctor advise her for admission.
HISTORY OF PRESENT PREGNANCY: -
LMP:16\9\23
EDD:23\6\24
Current gestational age (with date):39 weeks 3 Days (19\6\24)
She is a registered case. She had attended antenatal clinic 4 times,
1st trimester-

She missed her menstrual period & went to nearby clinic & tested her urine for
pregnancy

& become confirm of her pregnancy. On her examination her weight was 50kg,
BP=120/70mmhg, pulse =78bpm.At that time she suffered from minor alignments like
nausea & vomiting and she takes 1st does of T.T injection.
2nd trimester-
In 2nd trimester she feels quickening at the 18 th week of gestation and she take iron
and folic acid and calcium tablet. USG= done showing single live intra-uterine fetus in
cephalic presentation. she takes 2nd does of T.T injection.

3rd trimester-
In 3rd trimester she suffering pain in lower abdomen, weakness, restlessness sleeplessness.
watery discharge comes from vagina she feels less fetal movement,

OBSTETRIC HISTORY: -

Nothing significant as she is Primigravida.

Menstrual history-
Age of Menarche-13 yrs.
Duration-4 to 5 days
Cycle:-
Flow-Normal
LMP-16\09\23

PAST MEDICAL HISTORY-

-No H/o Hypertension prior to pregnancy.

- No H/o Diabetes Mellitus.
 - No H/o Tuberculosis.

SURGICAL HISTORY—

There is no significant of any past surgical history

FAMILY HISTORY—

Type of Family - Nuclear family.

No of family member- 4
History of consanguineous marriage-Absent
History of hereditary illness- There is no history of Epilepsy, DM, HTN, Twins pregnancy,
congenital malformation.
Relationship among the family members: Good.

FAMILY COMPOSITION—

SL AGE RELATIONSHIP EDUCATION OCCUPATION HEALTH

N NAME AND WITH PATIENT STATUS
O SEX
1 Pranesh 52 Father-i n-l a w IX passed Business Healthy
Sutradhar years

2 Basanti Roy 44 Mother-in-law VIII passed House wife Healthy

years

3 Pradip 27 Husband X passed Business Healthy

Sutradhar years

4 Jaya 22 Patient himself XII passed House wife Unhealthy

Sutradha years
r
FAMILY TREE—

Lt. Paresh Sutradhar Lt. Maya rani Paul

Pranesh Sutradhar, 52 yrs. Basanti Roy, 44 yrs.

Pradip Sutradhar, 27 yrs. Jaya Sutradhar, 22 yrs.

(Husband) (Patient)

KEY POINT: -

= Male (Grandfather in law)

= Female (Grandmother in law)

= Male

= Female

= Female (Patient)
PERSONAL HISTORY-
Nutrition-She is non vegetarian; she takes 3 times meals. she also takes extra diet in breakfast
and evening tea and snacks.
Rest and sleep-7-8 hours per
Daily Activity-She do some home activity
Habits: - No history of any drug, tobacco, smoking addiction
Hygiene-She maintain her personal
hygiene
Drug history-No history of continous medication.
Drug Allergy-No allergy from any drugs.
Activity- Dull
Hygiene- Well Maintained
Bowel and bladder pattern: No history of constipation or any other complicatios related to bowel and
bladder pattern.

SOCIO ECONOMIC HISTORY—

Income: Rs. 30,000/month.

House type:Pucca

Water supply: Tap water

Electricity: Available

Ventilation: Available, cross ventilation is present

Sanitation: Sanitary latrine is present.

Drainage system: Open drainage system is present

 Examination:
Vital Signs:
Temparature-97.50 F
Pulse- 76 bpm
Respiration: 20bpm
Blood Pressure: 140/90 mmHg.

GENERAL HEAD TO FOOT EXAMINATION—

General appearance-

Body Built - Thin

Height-

Weight-

Activity – Dul

Posture-Normal

Pallor- Present

Consciousness - Patient is Conscious

Skin:

Colour-Patient skin colour is pallor.

Texture-Skin texture is dry.

Edema- Edema is absent.

Head:

Hair-Hair colour is black, equally distributed

Scalp-Scalp is clear, dandruff absent.

Face: Anxiousness is present

Eyes

Eye brows-symmetrical

Eye lids- Eye lids is normal,

Eye lashes - Eye lashes is equally distributed

Eye balls- Eye balls is movable

Sclera-Sclera is normal whitish colour

Conjunctiva -conjunctiva is slight white

Pupils - Pupils is react with light

Vision-Normal
Nose

Nasal Septum- Not deviated

Nostril- Nostril is normal.

EARS

External Ear - External car is normal absent of any discharge.

Gross hearing- Gross hearing normal

Pinna - Pinna is symmetrical.

Discharge - Discharge absent.

MOUTH

Lips- Lips are dry.

Gums-Gums are normal and gingivitis absent

Teeth-Teeth are whitish and equally distributed

Tongue - Tongue are normal but slight white in colour

Throat - Throat are normal

Neck:

Range of motion-Range of motion normal

Thyroid gland-Thyroid glands are not enlarged

Lymph nodes - Lymph nodes are not enlarged

 S Y S T E M A T I C E X A
M I N A T I O N:-

Chest:

Inspection

Shape-chest shape is normal. Symmetry of expansion

Respiration rate - 20b / m –

Breast - Primary and secondary areola present Montgomery tubercles are also present

, nipples are erected.

Palpation-Absence of any abnormal mass

Auscultation-S1andS2 sound are present

OBSTETRIC EXAMINATION: -

Abdomen:

Inspection: -

Size-Normal

Shape-cylindrical shape

Linea nigra-present

Striae gravidrum – Present

Umbilicus - Protruded.

Scar marks-Absent.

Palpation:

Abdominal girth-80 com

Fundal height-32 cm

Fundal palpation-Broad irregular mass I felt, suggest as buttock of fetus.

Lateral Palpation:

Left Side-Smooth and continuous resistant is felt suggest as back of fetus.

Right Side-Knob like Structure are present Suggest as limbs.

Pawlick grip: In the Pawlick grip smooth hand felt, suggest of fetal head is present in the

lower part of uterus.

Pelvic Grip- The fetal head is not engaged

Auscultation:

Fetal Heart Sound-130 b/min

Finding of the abdominal Examination

Lie-Longitudinal

Presentation-Cephalic presentation.

Attitude-flexion

Position - LOA

Denomination-occiput

VAGINAL EXAMINATION: -

Effacement- 100%

Dilation- Full dilation (10 cm)

Membrane-Ruptured / clear
Extremity

Upper capillary refill - Normal.

Numbness- Absent.

Range of motion-Performed, but dull.

Nails: Nails are clean and short.

Lower Extremity: -

Range of motion-very dull

Edema-Absent.

varicosity-Absent.

Homan's sign-pain absent.

Back:
Curves- Absent, Lordosis on kyphosis are absent

Genito urinary system:

Discharge- Present

Bleeding -Absent

Vulva- Normal
INVESTIGATION: -

DATE INVESTIGATION MOTHERS NORMAL REMARKS

VALUE VALUE
19/06/24 Hemoglobin 11.9 gm 12-13 gm Low
19/06/24 Blood group O (+VE)
19/06/24 RBS 87mg/dl 80-110mg/dl Normal
15/01/24 VDRL/HBsAg NR
15/01/24 HIV NR
19/06/24 Urea 17.23mg/dl 14-40mg/dl Normal
19/06/24 Creatinine 0.74mg/dl 0.6-1.1mg/dl Normal
19/06/24 Urine for Sugar Absent
19/06/24 Albumin Absent

Special Investigation:

LABOUR PROGRESS CHART:

SUMMARY OF LABOUR:

Contractions commenced on -20/06/24 at 2 Am

Membranes ruptured at-19/06/24 at 8 pm

Condition of liquor is normal

Expulsive contractions commenced at -20/06/24 at 10 am

Date and time of delivery on 20/06/24 at 12.30 pm

Delivery of the placenta at -20/06/24 at 12.40 pm

Weight of the placenta: -500 gm

Length of the cord: -48 cm

Episiotomy type: -j type

Bleeding PV: Present (Normal bleeding)

Condition of the uterus: -Involution started of the uterus

Drugs given: Ing oxytocin 10-unit IM

LENGTH OF LABOUR:

I STAGE= Ten hours

II STAGE= One hour

III STAGE = 15 minute

Total = Eleven hour fifteen minutes.

CONDITION AFTER DELIVERY :

Mother:

Pulse-78 b/min

BP-130/80 mmHg

Uterus-The condition of the uterus is normal

Vaginal Bleeding-Normal

BABY:-
Sex-Male

Weight-2.6 kg

Length-48cm

Head circumference-32 cm

Chest circumference-31 cm

Mother and baby transferred to post-natal word

THEORY APPLICATION

Mrs. Joba Sutradhar was admitted in the IGM hospital. She is primi mother. suffering
lower abdominal and episiotomy wound pain,weakness.So she cannot do care himself
due to her condition. She needs support from others to perform daily living activities.
So, I applied Dorothea Orem’s self-care Deficit Theory for my patient while caring
him to improve her health status by setting the goals with both the nurse and the
patient’s mutual understanding.
According to Dorothea Orem the conceptual frame work is

SELF CARE

R R

SELF
THERAPEUTIC
CAPABILITIES R
(SELF CARE
SELF CARE
AGENENCY) DEMAND

R R

NURSING CAPABILITIES
(NURSING AGENCY)
IN MY PATIENTS CONDITION THE FRAMEWORK ARE AS FOLLOWING

SELF CARE

R R

SELF
CAPABILITIES THERAPE
UTIC
(SELF CARE SELF
CARE
AGENENC DEMAND
Y)
Limited  Activity
activity  Infection
Risk of
infection

NURSING CAPABILITIES
(NURSING AGENCY)

 Improve the level of

activity
 Maintain the
balance
between
intake and
output
Maintain proper
personal hygiene
NURSING MANAGEMENT ASSESSMENT

1.Assess the patient pain level

2.Assess the infection level of the patient

3.Assess the activity level of the patient

4.Assess the nutrition of the patient

5. Assess the fluid level of the patient

NURSING DIAGNOSIS

1. Acute abdominal pain related to progress of labour and episiotomy wound as evidenced by

facial expression and patient’s verbalization.

2. Risk for infection related toward defense mechanism as evidence by elevated body temperature.

3.Fluid electrolyte deficit related to bleeding and hemorrhage as evidenced by dehydration, dry mucous
membrane.

4. Actively intolerance related to imbalanced nutrition, decreased energy as evidenced by lethargy

Weakness and fatigue.
5. Impaired nutrition level less than body requirement related to in adequate intake of essential

nutrition as evidence by weakness.

 Nursing care plan
Assess Nursing Goal Planning Rational Implement Evalua
ment diagnosis tion tion
SUBJECT Acute pain To -To assess -To know Assessed the Patients pain
IVE related to reduce the the pain level. level is
DATA episiotomy as the pain type ,duration baseline -Provided slightly
Patient says evidence by level , severity of data. comfortable reduced in
that I am patient pain. -To position. some extent
heaving pain verbalization -Provide minimize -provided
in lower comfortable the pain diversional
abdomen position. level. therapy and
OBJECTIV -Provide -To divert psychological
E DATA diversional the main support.
Patient looks therapy and from pain. -Administered
dull psychological -To reduce medication
support. the pain
-Administer level.
medication as
per as doctors
order.
ASSESS NURSING GOAL PLAN RATI IMPLE EVAL
MENT DIGNOSIS NING ONAL MENT UATION
ATION
SUBJECTIVE Activity To -Assess the It will -Assessed the Patient
DATA intolerance increase activity level help to activity level maintained
Patient related to the of the patient. collect of the patient. normal
complain that pain, activity -Arrange all base line -Arrange all activity
she is as evidence level the article data for the article level.
feel Pain and by facial near the case near the
not interest to expression,an patient side. study. patient side.
do any work xirty -Give -It will -Patient feel
OBJECTIVE psychological help to relax
DATA support. promote
Patient is activity
look weak level of
and anxious. the
patient.

-It will
also help
to
promote
activity
level of
the
patient.
ASSESS NURSING GOAL PLANNING RATIONAL IMPLEME EVALUA
MENT DIAGN NTATION TION
OSIS
SUBJECTIVE Deficit To -Assess the -To assess -Assessed the Patient’s fluid
DATA fluid maintain fluid level of the fluid fluid level of level will be
Patient volume Fluid patient level patient maintained
complain that related to volume -Advice to -To -Advised to
I am thirsty excessive patient to maintain patient to take
OBJECTIVE blood loss take large normal fluid large amount
DATA after amount of volume of fluid
Patient is delivery fluid level -advised the
dehydrated -Advice the -To patient to take
patient to maintain fruit juice
take fruit normal fluid
juice volume -advised the
level patient to take
-Advice the -To fruits juice
patient to maintain -Maintained
take fruits normal fluid intake and out
juice level put chart
-Maintain
intake and
out put chart
HEALTH EDUCATION:-

Nutrition and dietary pattern:-

o Provide nutritious balance diet to the patient.

o Advice and educate mother and family about the importance of good nutritious diet in hemorrhage
condition.
o Explain foods rich in iron e.g. spinach, fenugreek, dates etc.
o Instruct to have milk and milk products and explain its importance in mother health and lactation
and encouraged to have soft diet like dahlia.
o Explain mother and family member to take fiber rich diet e.g. Banana, Papaya,Guava,oranges etc.

o To take plenty of water and fluid.

Rest and Sleep:-

1. Hard and strenuous activities should be avoided in the beginning after and gradually it should be
increased.
2. Instruct to be in bed rest and in comfort position as she feel good.
3. Encourage go-sleep with newborn.

Care of Breast:-

1. Breast should be cleaned before and after the feeding.

2. Inspect the breast and nipples for any presence of redness, edema and discharge.
3. Check the breast and nipples for cracks and engorgement.
4. Palpate the both breast for presence of any mass and gland formation.

Personal hygiene:

 Advised the patient and family members to wash hands before and after
giving breast milk.
 Advised the patient to brush the teeth twice a day bath daily.

 Advised the patient to wash clothes regularly

 Advise for self-perineal care.

Exercise:

1. Explained the importance of postnatal exercise to strengthen the weak abdominal muscle like
pelvic tilt exercise, tailor sit, sleeping position, brisk walk in the morning and evening. etc.
2. Day-to-day domestic and social activities can start gradually.
3. Explain vulnerable injuries if back is not properly held.
4. Teach deep breathing exercise in relaxation and improving circulation like palm method, balloon
method, candle method, etc.
5. Ask to move the foot, ankles and leg to improve circulation.
6. Ask to start pelvic floor exercise to strengthened weakened pelvic floor after delivery.

Bathing and clothing:-

1. Advice to wear dress that will provide easy access to newborn while breastfeeding.
2. Daily clothing should be change.
3. Daily bathing and loose comfortable clothes are advised for the comfort during breastfeeding.

Care of the vulva:-

1. Clean the vulva after each and every urination and defecation.
2. Inspect the vulva for any presence of infection or discharge.
3. Use a sterile pad in vulva for control of bleeding.
4. Pad should be changed frequently if more bleeding is there.
5. Check the pad for foul smelling, excessive clots and pus particles.

Medication:

 Advised the patient to take medicine at proper time without forgetting.

 Encouraged the patient to complete the full dose as ordered by the physician/surgeon.

Breastfeeding:-I advised her:

1. To use the proper techniques of breastfeeding like the head of the baby slightly elevated
during feeding.
2. Explain signs of good breastfeeding e.g. audible/visible to the baby, wide opening of mouth,
covering of areola completely, and baby’s chin to the chin to mother breast etc.

3. Breastfeeding should be done with both breasts.

4. Breastfeeding is given whenever babies on demand.
5. Use proper hand washing while before and after feeding.
6. Clean the breast before and after feeding.

Follow up:-
1. Teach mother and family to report immediately in:
2. For mother à fever, excessive pain in abdomen, dyspnea, breast swelling or pain,
burning micturition, depression, active vaginal bleeding, swelling of face, fingers & toes,
persistent vomiting, blurred vision, painful uterine contractions, sudden gush of watery
fluid per vagina, fever with chills.
3. For newborn à poor suckling of breast milk, hypothermia, hyperthermia, skin changes,
elimination problems etc.

Family planning: -
Education is given regarding family planning.
 Aware mother and family regarding health services about family planning.
 Explain about the importance of breast feeding in spacing and baby’s health and
advice to breastfeed baby till 6 months only breastfeed.

Immunization: -
 Explain the mother regarding immunization schedule.
CONCLUSION
As per my clinical posting I had posted in the intra-natal ward and during my
posting I got a mother in primigravida. She was suffering lower abdomen pain,
weakness, episiotomy wound pain. I have given care as per the need of the
patient and it will help me to deal with the same kind of patient in future.
BIBLIOGRAPHY:-

1. Konar Hiralal .D.C Dutta's “Textbook of Obstetrics”. 10th ed. New Delhi: Wolters Kluwer (India)
Pvt Ltd; 2013. P. 697-703.

2. Bhaskar Nima. “Midwifery and Gynecological Nursing”: A NURSING PROCESS APPROACH.

Volume 1. 1st ed. New Delhi: The Trained Nurses' Association of India; 2013. P. 1145-1149.

3. Chintamani. Mani M, Lewis SL, Heitkemper MM, Dirksen SR, O'Brien PG, Bucher L editors.
“Textbook of Obstetrics and Gynecology”. New Delhi: Elsevier India Pvt Ltd; 2011. P. 613-618

4. Sharma JB, “Textbook of Obstetrics, Avichal publishing Company”, 2nd edition, page no. 504-
514

5. Murray Sharon Et Al. “Foundations of Maternal-Newborn and Womens Health Nursing”.7 th

Edition. Elsevier Publication.2019.Page No.454-461.