Professional Documents
Culture Documents
COLLEGE OF NURSING
Submitted To:-
Mrs.chhotu kumawat
Lecturer Govt.college of nursing
Bikaner.
Submitted by:-
Mrs. Anju didel
M.sc(N)Previous
INTRODUCTION
As a part of my clinical experience in janana hospital PBM bikaner, . When I was
posted to labour ward, I got one patient name as Netravati having full term normal vaginal
delivery. I have selected this case for my care plan on 10/4/2014 in order to use this
knowledge in my day to day clinical practice.
1.BIOGRAPHICAL INFORMATION
Name : pooja
Age : 25 years
Sex : Female
Religion :hindu
2.HISTORY COLLECTION:
Chief complaints:-
Patient is pregnant and comes to hospital for delivery.
Personal Habits:-
Diet- he takes a mixed diet, and eats two meals per day.
Sleeping habits- regular, 5-6 hours per day, but the last 2-3 days she is
not able to sleep due to abdominal pain.
Bowel and Bladder habits- urinate 5-6 times per day and the bowel
pattern is regular, except the last 3-4
days she is having constipation.
Socialization- she is a socialise person and a loving person.
Family history:-
50y 48
rs yrs
27 25yr
22 s
yrs yrs
There is no any history of any hereditary disease like HTN, DM, asthma, epilepsy or seizures
in the client’s family.
3. PHYSICAL EXAMINATION:
Vital signs:-
Temperature : 990 F
Pulse : 78 beat per minute
Respiration : 20 per minute
Blood Pressure: 120/70 mmHg
General appearance:-
Constitution : normal
State of nutrition : good
Personal appearance: Normal
Posture : lordosis
Skin and hair : dark complexion
Emotional state : Anxious
Co-cooperativeness: cooperative
Head:
Skull - has no abnormalities noted.
Hair - black hair, hair distribution normal
Movement of head- has full range of movement
Fore head - no scar or lesion noted
Face - anxious looking
Eyes:
Eye brows - equal and even distribution
Eye lids - no lesion or scar noted.
Lacrimation - clear fluid expression
Conjunctiva - appears pale and clear
Sclera - appears white
Cornea - appears moist
Irish pupil - appears round and central in the sclera.
Ears:
Appearance- no mass or lesion noted
Discharge - None
Hearing - normal
Lesion - none
Nose:
Appearance - no septum deviation.
Discharge - none
Patency -both nostrils are patent
Sense of smell - good.
Mouth and throat:
Lips - dry
Tongue - coated tongue
Teeth - yellowish in colour
Gums - brownish
Buccal mucosa- no lesion and ulceration
Tonsil - not palpable
Taste - abnormal
Neck:
General appearance- normal
Lymph nodes - not palpable
Thyroid glands - not palpable
Cysts and tumour - absent
Abdomen:
Inspection - enlargement.
Percussion - tenderness present
Auscultation - FHS present.
Spine and back:
Spine and curvature- lordosis noted.
Movement - all movement are normal
Tenderness - no tenderness noted
Genitalia:
Normal.
Skin:
Colour of skin- dark complexion
Edema- pedal edema present
Moisture- dry
Turgor- moderate
SYSTEMIC ASSESSMENT:-
Nervous system:
Conscious- client is conscious
Orientation- oriented to time, place and person.
Obeys commands- yes, client obeys commands.
Respiratory system:
Inspiration & expiration- present
Respiration rate- 20 per minute
Ronchi/ wheezing-not present
Gastro-intestinal system:
Peristalsis movement- present
Bowel pattern- normal.
Urinary system:
Frequency- 5 to 6 times per day normally
Burning micturition- present.
INTRANATAL HISTORY
NURSING DIAGNOSIS:-
2. Subjective data:- Pain To -Administer analgesic -Analgesic(pethidine)/IM -Analgesic is given to the -Pain is
Patient is saying related to reduce to the patient. is given when pains are patient. reduced.
that i have acute uterine pain well established in active
pain in abdomen. contractio level. phase of labour to reduce
Objective data:- n. pain.
Facial expression,
seems to be -Allow patient to -Patient chooses a -Patient chosen her comfort
uncomfortable. choose her position. comfortable position to position.
get relief of pain.
4. Objective data:- -Infection -To -Administer -Antibiotics help in -Antibiotics are -The chance of
Un gloved hands related to prevent antibiotics to the decrease infection. administered. infection
of nurse and unsterilize from patient. becomes
unclean bed d infection. minimized.
sheets and using instrumen -Maintain scrupulous -Surgical instrument -Surgical cleanliness is
unsterilized ts using surgical cleanliness. cleanliness helps in maintained.
instruments. during decrease chance of
labour. infection.
-Delivery is avoided by
-Avoid delivery by -It will decrease the risk early extention.
early extension. of perineal injury.
HEALTH EDUCATION:-
Name of client - Mrs. pooja
Topic -intranatal care
General Objectives -At the end of health education Patients knowledge will be improved
related to patient’s condition.
Specific objectives:-
1. To increase awareness that disease are significant health problem.
2. To increase awareness of symptoms and signs of disease.
3. To improve the knowledge and attitudes of patients about detection, treatment and
control of disease and infection.
4. To promote the family educational material essential for positive lifestyle habits.
5. To create awareness about the ill-effects drugs, and other substance abused.