1.

INDENTIFICATION DATA

MOTHERS DATA BABYS DATA STUDENTS DATA

Name of the mother- Farmana Name of the baby- Baby of Farmana Name of student- Nadiya Rashid
Husband’s name- Mr. Sultan Sex- male Class- M.Sc. Nursing II year
Age- 2 years Bed no- 1 Date of care started-27 November 2019
Religion- Muslim Name of the ward- Obstetric ward Date of care ended- 29 November 2019
Ward/unit- Obstetric ward, unit 3 Date of the birth- 29 November 2019 Duration of care provided- 3 days
Bed no- 1 Time of birth- 10.00am
Date of admission- 26 November 2019 at 1.30pm Weight of the baby- 2.600 kg
Occupation of husband- private job
Address- H.no. 143, Ugala, Barara, Ambala
Provisional diagnosis- G2 P1A1 with period of
gestation 40 weeks with decreased fetal
movements.
Diagnosis- Full term normal vaginal delivery with
right medio-lateral episiotomy
L.M.P- 16 -2- 2019
E.D.D- 23- 11- 2019
Educational status- 10th standard

HISTORY COLLECTION

ADMISSION HISTORY– Mrs. Farmana came to MMIMS&R hospital’s OPD on 26 November 2019 with chief complaints of:
 Amenorrhea since 9 months
 Lower abdominal pain since 1 day
 Decreased fetal movements since 1 day
 Disturbed sleep since 7 days
 PRESENT CHIEF COMPLAINTS– Mrs Farmana complaints of:
 Mild Pain in sutures since 3 days
 Breast tenderness since 2 days
 Disturbed sleep since 3 days
 Weakness since 1 day

MEDICAL HISTORY
Past medical history- There is no significant past medical history of hypertension, asthma, tuberculosis, pneumonia, jaundice etc.

Present medical history- Client came to MMIMS&R hospital’s OPD on 26 November 2019 with chief complaints of Amenorrhea since 9
months, Lower abdominal pain since 1 day, Decreased fetal movements since 1 day and Disturbed sleep since 7 days. After the physical and
obstetric examination and investigations like ultrasonography, hematological tests and urine examination, the client is diagnosed as G2 P1A1
with period of gestation 40 weeks with decreased fetal movements and shifted to antenatal ward.

SURGICAL HISTORY

Past surgical history- There is no significant past surgical history of accidents, falls etc.

Present surgical history- Mrs Farmana is not having any significant present surgical history.

MENSTRUAL HISTORY
Menarche- at 16 years of age
Menstrual cycle- 28- 30 days
Regularity- Regular
Duration- 3-4 days
Dysmenorrhea- Mild dysmenorrhea
L.M.P- 16 -2- 2019
E.D.D- 23- 11- 2019
OBSTRETICAL HISTORY-
S.NO YEAR PREGNANCY LABOUR METHOD OF PUERPERI BABY REMARKS
AND DATE EVENT EVENT DELIVERY UM
G1 2017 Spontaneous abortion ( May 2017)

G2 2019 Multi gravida Uneventful Full term normal Normal and Healthy Baby is healthy and
vaginal delivery with healthy cried immediately
right medio-lateral after birth and fully
episiotomy under local immunized till date.
anesthesia.

PERSONAL HISTORY
 Hygiene- well-groomed and hygiene is maintained
 Dietary pattern- Mrs. Farmana is vegetarian
 Sleep- disturbed sleep at night i.e. 4-5 hours of sleep due to pain in episiotomy sutures and frequent breast- feeding of baby.
 Elimination- normal bowel and bladder habits and there is no complaint of burning micturition and constipation.
 Social relation- client is having good inter-personal relationship with all of the family members.
 Alcoholic/ smoker- client is non alcoholic and non-smoker.

DIET PATTERN-

DAY BREAKFAST LUNCH EVENING SNACKS DINNER

1 Tea with biscuits Khichadi Tea with biscuits Dal with roti

2 Bread with tea Dal with roti Tea with biscuits Porridge with milk

3 Bread with tea Dal with roti Tea with biscuits Dal with roti
FAMILY HISTORY

FAMILY TREE KEYS:

Mohd. Iqbal, 55 years Shaista begum, 50 years Male

Mr. Sultan, 25 years farmana 24 years Female

Baby of Farmana, 1 day old Female

Patient
FAMILY COMPOSITION-
S.NO NAME OF RELATION TO AGE SEX MARITAL EDUCATION OCCUPATION HEALTH
FAMILY THE PATIENT STATUS STATUS
MEMBER
1 Mohd iqbal Father in law 55 years Male Married 5th pass Farmer Healthy

2 Shaista begum Mother in law 50 years Female Married 8th pass Home maker Backache

3 Mr. sultan Husband 25 years Male Married 12th pass Private job healthy

4 Mrs Farmana Self 24 years Female Married 10th pass Home maker G2 P1A1 with
period of
gestation 40
weeks with
decreased fetal
movements
6 Baby of Farmana Son 1 day old Male Single - - Healthy

SOCIO ECONOMICAL HISTORY

 Monthly income- Rs 20,000/ month
 Working person- Mr. sultan (husband)
 Family members- 5
 Per-capita income- Rs 4000/ member

HISTORY OF PRENATAL PERIOD

History of first trimester- Pregnancy confirmed by urine pregnancy kit at home. There is history of mild nausea and vomiting, and no
history leakage per vaginum, or bleeding per vaginum and folic acid intake. Ultrasonography was done in third month.

History of second trimester- quickening felt at the end of 6th month. Injection tetanus toxoid covered at third month and fourth month.
History of hyperthyroidism. No history of leakage per vaginum, or bleeding per vaginum, blurring of vision, fever, rash or pedal edema.
Ultrasonography done and was normal .History of iron and calcium intake.
 History of third trimester- No history of leakage per vaginum, or bleeding per vaginum, blurring of vision, headache, fever, rash or pedal
edema. Ultrasonography done at 7th month and was normal .History of iron and calcium intake.

HISTORY OF NATAL PERIOD- newborn was born by normal vaginal delivery with right medio-lateral episiotomy under local anesthesia
with birth weight of 2.600 kg and cried immediately after birth.

INVESTIGATIONS
DATE INVESTIGATIONS DONE PATIENTS VALUE NORMAL VALUE REMARKS

HEMATOLOGICAL INVESTIGATIONS

26-11-2019 Hemoglobin 10.02 gm% 12-15 gm% Mild anemic

26-11-2019 TSH 2.14 milli IU/L 0.35- 5.50 milli IU/L Normal

26-11-2019 RBS 72 mg/dl Upto 140 mg/dl Normal

26-11-2019 Clotting time 2.0 min Upto 10 min Normal

26-11-2019 Bleeding time 6.0 min Upto 6 min Normal

URINE EXAMINATION
27-11-2019 Volume 20 ml -
Color Pale yellow -
Albumin Nil -
Sugar Nil -
RBC Nil - Normal
Pus cells 4-6 -
Epithelial cells 2-4 -
Casts Nil -
Crystals Nil -
 RADIOLOGICAL INVESTIGATIONS

27-11-2019 Ultrasonography Single live intra-uterine pregnancy with period of gestation 40 weeks.

MEDICATION
S. TRADE NAME CHEMICAL DOSE ROUTE FREQUENCY ACTION NURSING RESPONSIBILITY
NO. NAME
1 Tab Gramoceff Cefixime 200mg Oral BD Antibiotic  Assess for infection at the beginning of
Generation- 10 am and 10 and throughout the therapy.
cephalosporin pm  Obtain specimen for culture and
sensitivity before initiating therapy.
 Observe client for sign and symptoms of
anaphylaxis. Discontinue the drug and
notify the physician if symptom occurs.
 Monitor bowel function. Diarrhea,
abdominal pain and bloody stool should
be reported to health care professionals.
2 Tab Rantac Ranitidine 150mg Oral BD Antacid  Assess client for epigastric or abdominal
Pharmacological 10 am and 10 pain and frank blood in the stool, emesis
class- H2 pm or gastric aspirate.
receptor  Inform client that smoking interferes
antagonist with the action of histamine antagonist.
Encourage client to quit smoking or at
least not to smoke after the last dose of
the day.
 May cause drowsiness and dizziness
caution client to avoid activities require
alertness until response to the drug is
known.
 Advice client taking OTC preparations,
not to take the maximum dose
 continuously for more than two weeks
without consulting health care
professionals.

3 Tab Lyser D Diclofenac 10 mg oral OD Analgesic  Caution client to avoid concurrent use of
Sodium, and 10 am alcohol, aspirin, acetaminophen, other
Serratiopeptidase NSAIDs, or OTC medications without
consulting physician.
 Instruct client to notify health care
professionals promptly if unexplained
weight gains, swelling of extremities,
nausea, vomiting, fever or flu like
symptoms occurs.
 Caution client to wear sunscreen and
protective clothing to prevent
photosensitivity reactions.
 May cause drowsiness and dizziness
caution client to avoid activities require
alertness until response to the drug is
known.

PHYSICAL EXAMINATION OF MOTHER

Date: 27/11/2019
Time: 10:00 am

GENERAL APPEARANCE AND BEHAVIOUR

Body built- mesomorphic
Gait-normal
Nourishment- client is well nourished
 Vital signs

 Temperature- 99o f
 Pulse- 78 beats/min
 Respiration- 22 breaths/min
 Blood pressure- 110/60 mmhg

MENTAL STATUS: Mrs. Farmana is oriented to time, place and person.

POSTURE:
Body curve- normal
Movements-normal body movements, no tics and tremors present.
Height- 5’3”
Weight-55 kg

INTEGUMENTARY SYSTEM
SKIN
 Color- wheatish colour
 Moisture- present
 Temperature- normothermic
 Turgor- elastic turgor present
 Edema- absent
 Lesions- absent

HAIR AND SCALP

 Hair and Scalp- client was having black hair with smooth texture with normal distribution of hair and there was no pediculosis or dandruff
present.
EYES
 Alignments- proper alignment present
 Eyes lids- eyelids were symmetrical, and meet completely when eyes are closed. No ptosis or lash loss present
 Conjunctiva- Both palpebral and bulbar conjunctivae are pale in color with many minute capillaries. Conjunctiva is moist with no ulceration
or foreign object
 Pupils- pupil is round, equal and reactive to light and accommodation.
 Vision- Mrs. Farmana is having normal vision, and there is no history of double vision or blurring of vision.
 Sclera- sclera is white in color and there is no yellowish discoloration of the sclera
 Eyebrows and eyelashes- the eyebrows and eyelashes are symmetrical with normal hair distribution and there is no eyebrow or lash loss
present.

EARS
 External ear- normal, no discharge, redness or crust formation present.
 Hearing- normal hearing in both the ears.

NOSE
Nose in normal in shape and size, nasal mucosa is moist and no discharge or deviated nasal septum present.

MOUTH AND PHARYNX

 Lips- pink in color
 Odor- absent
 Teeth- white, no dental caries present
 Tonsils-normal, no enlargement and tenderness.
 Gums-healthy, no bleeding present
 Mucus membrane-moist and reddish pink in color

NAIL

 Shape-normal, no clubbing present

 Color- light pink

NECK
 Thyroid gland- normal, no enlargement and tenderness.
 Lymph node- normal, no enlargement and tenderness.

CHEST

 Inspection- chest is normal in shape as anterior posterior diameter is less than that of lateral diameter.
 Palpation- on palpating the chest there was no abnormal mass nodules were present.
 Percussion- on percussion the findings were normal, no fluid or air filled cavities present.
 Auscultation- on auscultation normal breath and heart sounds were present.

BREAST
 Shape- normal
 Symmetry- both breasts are symmetrical
 Discharge- absent
 Milk Secretion- present
 Engorgement- present

ABDOMINAL EXAMINATION
 Inspection- abdomen is normal in shape and linea nigra and striae albicans present
 Palpation- Normal, uterus is well contracted
 Fundal height- 15cm.
 Auscultation- normal bowel sounds that is 5 times/minute

EXTREMITIES
Extremities are normal in shape and size and symmetrical and range of motion is present.
 BLADDER AND BOWEL
Bladder and bowel movements are present .Mother pass urine after 1 hour of delivery .she has no complaint of urine retention and constipation.

GENITALIA AND RECTUM

 Vaginal discharge- Lochia rubra is present and the discharge is normal in amount and mother is using two pads/ day

NEUROLOGICAL TEST
1. REFLEXES:
 Biceps reflex- normal, flexion of arm
 Triceps reflex- normal, extension of arm at elbow
 Patellar reflex-normal, extension of lower leg
 Achilles reflex-normal, plantar flexion of foot
 Jaw reflex-normal, wide opening of mouth
 Plantar reflex-normal, slight wrist extension
 Supinator reflex-normal, downward bending of toe

2. TEST FOR SENSATION: normal, mother is able to feel the touch and differentiate between hot and cold temperature.

CONCLUSION

Mrs Farmana was calm and conscious and oriented to time, place and person. All of the vital signs were stable except for the blood pressure as
mother was having decreased blood pressure due to deficient fluid volume. Client was having breast engorgement and pain in episiotomy sutures.
Lochia rubra was present with average bleeding. No fresh complaints found.

PHYSICAL ASSESSMENT OF NEWBORN

Date: 29/11/2019
Time: 11:00 am
IDENTIFICATION DATA
 Name- Baby of farmana
 Age- 1 day old
 Sex-Male
 Time of birth-

GESTATIONAL AGE: 40weeks

PHYSICAL MEASUREMENT
 Length-48 cm
 Weight- 2.55 kg
 Head circumference- 32cm
 Chest circumference- 30 cm

SKIN
 Vernix caseosa- present
 Lanugo- present
 Color of skin- pink

HEAD
 Head circumference- 32 cm
 Size and shape- normocephalic
 Fontanel- normal, no bulging or depression present.

EARS
 Position- normal, no low set ears present.
 Pinna- normal elastic recoiling present
 Discharge- absent
FACE AND MOUTH
 Lips and palate- pink lips and no cleft lip or palate present
 Epstein pearl-absent
 Oral thrush-absent

EYES: Normal in symmetry and alignment, pupil is reactive to light and no ocular abnormality present

NOSE

 Shape- normal
 Placement- normal
 Patency- patent
 Septum- no deviated nasal septum present
 Discharge- absent

CHEST
 Chest circumference- 30 cm
 Size and shape-normal in shape and size
 Respiratory rate- 40 breaths/min
 Heart rate- 130 beats/min

ABDOMEN
 Abdomen circumference- 28 cm
 Umbilical cord- clean and healthy, no discharge, redness or inflammation present.
 Liver- no hepatomegaly present
 Spleen-no splenomegaly present
EXTREMITIES
 Shape and symmetry- normal in shape and symmetrical.
 Polydactyl/ syndactyl- absent
 Range of motion- normal
 Hip Joint- no dislocation present

GENITALIA: normal, no congenital abnormality present.

BACK: normal in shape and size

NEUROLOGICAL EXAMINATION

REFLEXES:
 Glabellar reflex: Normal, baby closed his eyes when tapped on node root.
 Corneal reflex: Normal, baby immediately closed his eyes when object is brought near to his eyes.
 Sucking reflex: Diminished, sucking reflex was poor on first day as baby was unable to suck the breast.
 Rooting reflex: Normal, when stroked with tip of the finger baby turned to the similar side and opened his mouth.
 Grasp reflex: Normal, baby grasped the finger when placed on his open palm.
 Moro reflex: Normal, baby was startled when he heard a loud clap simultaneously extended out his legs and arms.
 Extrusion reflex: Normal extrusion reflex.
 Doll’s eye reflex: Normal, when head was turned to one side, baby slowly adjusted his eyes to the similar side.
 Tonic neck reflex: Normal tonic neck reflex
 Dancing reflex: Normal, when baby was held upright he appears to take steps.
 Babinski reflex: Normal, when sole was stroked, baby made fan like structure of toes.

NURSING ASSESSMENT: Baby is healthy and active and all the findings are normal and there is no significant abnormality present
while doing the assessment.
DELIVERY NOTES: baby was delivered on 29 November 2019 at - 10.00am and cried immediately after the birth. APGAR score for first
minute was 8 and at 5 min it was 9.

CONDITION OF MOTHER AND BABY AFTER DELIVERY

MOTHER’S VITAL SIGNS

 Temperature- 99o f
 Pulse- 78 beats/min
 Respiration- 22 breaths/min
 Blood pressure- 110/60 mmhg

BABY’S VITAL SIGNS

 Temperature- 98.2o f
 Heart rate- 130 beats/min
 Respiration- 40 breaths/min

NURSING DIAGNOSIS
FOR MOTHER

1. Acute pain related to episiotomy as evidenced by facial expression of the client.

2. Breast engorgement related excessive milk production as evidenced by breast examination.
3. Deficient fluid and volume related to blood loss as evidenced by intake output chart.
4. Risk of decreased tissue perfusion related to inadequate blood supply secondary to anemia as evidenced by neurological examination.
5. Impaired tissue integrity related to episiotomy as evidenced by postnatal examination.
6. Disturbed sleeping pattern related to acute episiotomy pain and secondary to breastfeeding and care of newborn.
7. Risk of genital infection related to episiotomy as evidenced by observation.
8. Activity intolerance related to physical weakness as evidenced by verbal report of the client.
S.No ASSESSMENT NURSING GOAL PLANNING RATIONAL IMPLEMENTATION EVALUATION
DIAGNOSIS
1. Subjective Acute pain To  Assess the level  To know the  Level of pain is Day 1: Level of pain
data: related to minimi of pain by pain baseline assessed by pain was decreased up to
Client said that “ episiotomy as ze the rating scale. data. rating scale. some extent as
my perineal area evidenced by pain. Pain score 6 evidenced by
hurts when I sit facial communication and
or walk” expression of  Assess for the  To rule out  Assessed for the facial expression
the client. sign and early signs sign and symptoms Pain score: 4
symptoms of of infection. of infections like
infections like redness, discharge, Day 2: level of pain
redness, increased was decreased as
discharge, temperature. expressed by the
increased client and pain level
temperature. was assessed by pain
Objective data:  Provide  To provide  Comfortable rating scale.
It was observed comfortable comfort to position i.e. semi- Pain score was: 3
that the client position to the the client. recumbent position
was having client. is given to the Day 3: level of pain
acute pain in client. was assessed by pain
episiotomy  Provide  To promote  Extra pillows were rating scale and pain
sutures as comfort devices comfort of provided to the score was 2.
evidenced by to the client. the client. client for supporting
Communication back.
and  Provide  To divert the  Diversional therapy
Facial diversional mind of the was provided by
expression therapy to the client. communicating
client e.g. by with the client.
communicating
, reading etc.

 Advice the  To minimize  Advised the client

client to the chances to maintain perineal
maintain of infection hygiene.
perineal and to
 hygiene. maintain
hygiene of
the client.

 Educate the  To boost up  Educated the client

client to take the immune to take vitamin C
vitamin C rich system and rich diet as it will
diet as it will minimizes help in faster
help in faster risk of recovery of wound.
recovery of infection.
wound.

 Advice the  To improve  Advised the client

client to take the perineal to take sitz bath.
sitz bath. circulation
and to
promote
healing.

 Administer  To relieve  Administered tab

medication as the pain. lyser D 10 mg
prescribed by (analgesic) to the
the physician. client as prescribed
by the physician.
S. ASSESSMENT NURSING GOAL PLANNING RATIONAL IMPLEMENTATION EVALUATION
No DIAGNOSIS
2. Subjective Breast To  Assess the level  To know the  Level of pain is Day 1: Breast
data: engorgement minimize of pain by pain pain level. assessed by pain engorgement
Client said that “ related the scale. rating scale. relieved up to
I feel heaviness excessive milk breast Pain score 8 some extent as
and tenderness production as engorge  Assess for the  To know the  Assessed for the evidenced by
in both breast” evidenced by ment sign and early signs of sign and symptoms decreased
breast symptoms of infections of infections and tenderness,
examination. infections like hardness and heaviness and
redness, tenderness was increased softness
increased present. of the breast
temperature and tissue.
hardness.  To empty the Pain score-6
Objective data:  Advice mother breast and to  Advised the mother
It was observed to frequently reduce to breastfeed the Day 2: breast
that the client breastfeed the heaviness. every 2 hourly. engorgement was
was having mild baby every 2 relieved as
breast hourly. expressed by the
tenderness  To reduce the client and as
related to breast  Advice mother heaviness of  Advised mother to evidenced by
engorgement as to empty the the breast. empty the breasts decreased
evidenced by breasts after each after each feed by heaviness and
breast feed by manual manual expression tenderness.
examination, expression or or breast pump. Pain score-5
verbalization breast pump
and facial  To improve Day 3: breast
expression.  Provide breast the circulation  Provide breast care engorgement was
care with hot and decrease with hot relieved and
compressions to breast compressions to the mother was able
the mother. tenderness mothe to breastfeed the
baby without
 To promote feeling any
 Advice the comfort and  Advice the mother tenderness and
mother to avoid for proper to avoid tight fitted pain in the breast.
Pain score- 2
 tight fitted bras circulation bras and wear
and wear nursing nursing bras.
bras.  To soften the
breast and
 Advice the relieve  Advised the mother
mother to take tenderness. to take hot shower
hot shower before feeding the
before feeding baby.
the baby.  To relieve
 Provide chilled engorgement  Chilled cabbage leaf
cabbage leaf and therapy was
therapy to the tenderness. provided to the
mother to relieve mother to relieve
tenderness of the tenderness of the
breast. breast.

 Advice the
mother to gently  To soften the  Advised the mother
message the breast tissue. to gently message
breast and clean the breast and clean
the nipple before the nipple before
feeding the baby. feeding the baby.

 Teach mother  To improve  Taught the mother

about breast the knowledge about feeding
feeding of the mother techniques that is
techniques. cradle and lying
down.
 Teach the mother  To empty the  Taught the mother
about the method breast and to about the method of
of expressing decrease the expressing milk.
milk. breast
heaviness.
S. ASSESSMENT NURSING GOAL PLANNING RATIONAL IMPLEMENTATION EVALUATION
No DIAGNOSIS
3. Subjective Deficient fluid To  Assess the  To know the  Client was assessed Day 1: Normal
data: volume related maintain client for baseline data and baseline data was fluid and
Client said that “ to blood loss normal baseline data. collected. volume balance
I frequently feel as evidenced fluid  Monitor vital  To check for was maintained
thirsty” by intake volume signs and nail signs of  Monitored vital signs up to some
output chart. level. capillary refill hemorrhage and nail capillary refill extent as
time. and shock time and which was evidenced by
 Assess the  To know the normal. normal intake
level of level of and output and
hemoglobin. hemoglobin well hydrated
 Hemoglobin level was skin.
 Frequently  To know any assessed and was
monitor vital deviation 10.02gm%. Day 2: Normal
Objective data: signs of client from the fluid and
It was observed (every 2 hours) normal volume balance
that client is  Monitor daily  To evaluate was maintained
having deficient weight of the the  Frequently monitored as evidenced by
fluid and client on the effectiveness client’s vital signs. normal intake,
volume as same time of the output and well
evidenced by every day. treatment hydrated skin,
intake output provided. and normal
chart and  Note down the  To know the  Monitor daily weight capillary refill
decreased blood amount of quantity of of the client on the time that is <3
pressure. bleeding and blood loss same time every day seconds.
number of pads
changed in a Day 3: Normal
day. fluid and
 volume balance
 Advice client  To maintain Noted down the
amount of bleeding was maintained
to increase the the normal
which was normal and as evidenced by
oral intake of intake output.
number of pads well hydrated
fluid.
skin and normal
 To increase changed in a day i.e. 2
capillary refill
 Advice client the oral intake pads.
time that is <3
 to drink fresh of the fluids seconds.
fruit juices.
 Maintain strict  To keep a  Client was advised to
intake output check on increase the oral intake
charting. input and of food.
output of the
client

 Educate client  To impart  Client is advised to

of oral knowledge drink fresh fruit juices.
rehydration about oral
solution. rehydration
solution and
to maintain  Intake output charting
normal intake is maintained.
and output

 Educated the client

about oral rehydration
solution.
S. No ASSESSMENT NURSING GOAL PLANNING RATIONAL IMPLEMENTATION EVALUATION
DIAGNOSIS
4. Subjective Risk of To  Assess the  To know the  General condition of Day 1: Normal
data: decreased maintai general condition baseline data the client was tissue perfusion is
Client said that “ tissue n the of the client to assessed and baseline maintained up to
she feels weak” perfusion normal get baseline data data was collected. some extent as
related tissue of the client. evidenced by
inadequate perfusi  Monitor vital  To assess for  Monitored vital normal
blood supply on. signs; assess the signs of signs; assessed neurological status
secondary to capillary refill shock and capillary refill time, and normal urine
anemia as time, skin color, hemorrhage skin color, mucous output.
evidenced by mucous and to know membranes, and nails
neurological membranes, and any deviation and which was Day 2: Normal
examination. nails. from the normal. tissue perfusion is
Objective data: normal maintained as
It was observed  Elevate the foot  To improve  Elevate the foot of evidenced by
that the client of bed as the venous bed as tolerated to normal
was having tolerated to return improve the venous neurological status
altered tissue improve the return. and normal urine
perfusion related venous return. output.
to inadequate  Frequently  To know any  Frequently assessed
blood supply as assess the blood deviation the bloods pressure of
evidenced by pressure of the from the the client every 2 Day 3: Normal
monitoring vital client every 2 normal hourly and that was tissue perfusion is
signs. hourly. normal. maintained as
 Assess the level  To know the  Hemoglobin level evidenced by
of hemoglobin. level of was assessed and was normal
hemoglobin 10.02gm%. neurological status,
normal behavior
 Evaluate the  To observe  Evaluated the and normal urine
neurological for any neurological status output.
status and behavior and observed for any
observe for any changes. behavior changes.
behavior
changes.
 Provide  To improve  No oxygen was
supplemental the oxygen administered as it
oxygen as saturation. wasn’t required.
indicated
 Advice client to  To maintain  Client was advised to
increase the oral the normal increase the oral
intake of fluid. intake output. intake of food.

 Advice client to  To increase  Client is advised to

drink fresh fruit the oral intake drink fresh fruit
juices. of the fluids juices.

 Maintain strict  To keep a  Intake output

intake output check on charting is
charting. input and maintained.
output of the
client
 SUMMARY OF THE CARE PROVIDED TO THE MOTHER
DAY GENERAL ANY SPECIFIC MEDICATION VITAL SIGNS CARE PROVIDED/ ADVICES
CONDITION OF COMPLAINTS
CLIENT
1 General condition of the  Pain in  Tab Gramoceff 200 Temperature: 99o f  Advised to maintain personal hygiene
client was fair and client episiotomy mg  Advised to pay more attention to
was oriented to time  fatigue Pulse: 78 beats/ min perineal and breast care
place and person Vitals  Tab rantac 150 mg  Advised to take adequate rest and sleep.
were stable. Respiration: 22
 Advised to take plenty of oral fluids
 Tab lyser D 10 mg breaths/ min
 Advised to start with light diet and shift
BP: 110/60 mm hg to balance diet later on
2 General condition of the  Breast  Tab Gramoceff 200 Temperature: 98.4o f  Advised to take fiber rich diet to avoid
client was fair and client tenderness mg constipation
was oriented to time and Pulse: 74 beats/ min  Advised to take vitamin c rich diet.
place and person Vitals heaviness.  Tab rantac 150 mg  Advised to daily change clothes and
were stable. Respiration: 22
wash and dry them in direct sunlight.
 Tab lyser D 10 mg breaths/ min
 Provided breast care to the mother.
BP: 110/60 mm hg  Did hot compression to treat breast
3 General condition of the  Breast  Tab Gramoceff 200 Temperature: 98.2o f engorgement.
client was fair and client tenderness mg  Advised mother to exclusively
was oriented to time and heaviness Pulse: 74 beats/ min breastfeed baby up to six months.
place and person Vitals  Weakness and  Tab rantac 150 mg  Advised mother to manually express out
were stable. fatigue Respiration: 22
the breast milk or with the help of breast
 Tab lyser D 10 mg breaths/ min
pump.
BP: 110/60 mm hg
NURSING DIAGNOSIS
FOR BABY

1. Risk of hypothermia related immature compensation for changes in environmental temperature as evidenced by monitoring vital signs.
2. Imbalance nutrition less than body requirement related to poor infant feeding behavior as evidenced by newborn examination.
3. Risk of aspiration related to poor swallowing and sucking reflex as evidenced by observation.
4. Risk of infection related to immunological immaturity as evidenced by observation
S.No ASSESSMEN NURSING GOAL PLANNING RATIONAL IMPLEMENTATION EVALUATION
T DIAGNOSIS
1. Objective data: Risk of To maintain  Assess the  To know the  Assessed the Day 1: Normal
It was observed hypothermia stable and general baseline general condition body temperature
that the baby is related normal condition of the data. of the baby to get was maintained as
at risk of immature temperature. baby to know the baseline data. evidenced by
hypothermia compensation the baseline monitoring vital
related to for changes in data. signs.
 Monitor vital  
o
change in environmental To know Monitored vital Temperature- 97 f
temperature. temperature signs of the any signs of the client
as evidenced baby every four deviation every four hourly. Day 2: Normal
by monitoring hourly. from the body temperature
vital signs. normal was maintained as
 Educate the  To educate  Educate the mother evidenced by
mother about the mother about the early monitoring vital
the early signs so she can signs of signs.
of hypothermia: identify the hypothermia: skin Temperature-
o
skin cold, poor early signs cold, poor feeding 96.8 f
feeding habits, of habits, decrease
decrease hypothermia activity.
activity. Day 3: Normal
 Advice mother  To maintain  Advised the body temperature
to properly the normal mother to properly was maintained as
cover the baby body cover the baby and evidenced by
and do the temperature do the clothing monitoring vital
clothing of the baby. according to the signs.
according to the season. Temperature- 98of
season.
 Advice the  To maintain  Advised the
mothers to the ambient mother to switch
switch off extra room off extra fans and
fans and close temperature. close the windows.
the windows.
 Educate  To minimize  Educate mother to
mother to the risk of perform hand
 perform hand infection washing every time
washing every before touching the
time before baby to prevent
touching the infection.
baby to prevent
infection.

 Educate mother  To minimize  Educated the

to limit the the risk of mother to limit the
number of infection number of visitors.
visitors visiting
the baby.
S.No ASSESSMENT NURSING GOAL PLANNING RATIONAL IMPLEMENTATION EVALUATION
DIAGNOS
IS
2. Objective data: Imbalance To  Assess the  To get baseline  Assessed the general Day 1: Normal
It was observed that nutrition maintain general data. condition of the baby nutritional status
the baby is having that is less the condition of the to get baseline data. maintained as
imbalance than body normal baby to get evidenced by the
nutritional status requirement nutrition baseline data.  To know note body weight of
related to poor related to al status.  Daily monitor down the  Monitored the weight the baby.
sucking reflex as poor infant the weight of changes in the of the baby at the Body weight:
evidenced by feeding baby at the weight. same time every day. 2.55 kg
newborn behavior same time every  To improve the
examination. secondary day. nutritional Day 2: normal
to poor  Advice the status.  Advised the mother to nutritional status
sucking mother to frequently breastfeed was maintained
reflex as frequently  To minimize the baby. as evidenced by
evidenced breastfeed the the chances of the normal
by baby. infection and feeding pattern
observation.  Educate the diarrhea  Educated the mother of the baby
mother to not to to only provide breast Body weight:
give anything milk to the baby up to 2.50 kg
else except for 6 months.
the breast milk Day 3: normal
to the baby.  To educate the  Taught the mother nutritional status
 Teach the mother about about the breast was maintained
mother about proper feeding techniques. as evidenced by
breast feeding breastfeeding the normal
techniques. feeding pattern
 Teach the  To teach  Taught the mother and newborn
mother, how to mother, how to that how to give examination of
give expressed express the expressed breast milk. the baby
Body weight:
breast milk. breast milk.  Avoided the use of
2.50 kg
 Avoid any use  To minimize pacifiers.
of pacifiers. the risk of
infection  Advised the mother to
  Advice the  To maintain not to skip night
mother to not to normal feeding feeds.
skip night feeds. pattern
 Encouraged the
 Encourage the  To maintain mother for exclusive
mother for the normal breastfeeding
exclusive nutritional
breastfeeding. status of the
baby

S.No ASSESSMEN NURSING GOAL PLANNING RATIONAL IMPLEMENTATION EVALUATION

T DIAGNOSI
S
3. Objective Risk of To  Assess the level  To know the  Assessed the level of Day 1: risk of
data: aspiration minimize of risk for level of risk risk for aspiration by aspiration was
It was related to the risk of aspiration. for checking the reflexes minimized as evidenced
observed that poor aspiration. aspiration of baby. by newborn
the baby is swallowing examination.
having a risk and sucking  Educate  To educate  Educated the mother
of aspiration reflex as mother about the mother about the care of Day 2: risk of
related to poor evidenced by the care of about the newborn. aspiration was
swallowing observation. newborn. newborn minimized as evidenced
and sucking care by newborn
reflex as  Teach the  To minimize  Taught the mother examination and
evidenced by mother about the risk of about the techniques of observing the normal
observation. the techniques aspiration breastfeeding. feeding pattern.
of breast
feeding.  To impart Day 3: risk of
 Teach the knowledge  Taught the mother aspiration was
mother about to the about the signs of good minimized as evidenced
the signs of mother. attachment. by newborn
good examination and
 attachment.  To improve  Encouraged the mother observing the normal
 Encourage the the sucking to breastfeed the baby. feeding pattern.
mother to and .
breastfeed the swallowing
baby. reflex of the
baby.
 Educate the  To minimize  Educated the mother
mother about the risk of about expressed breast
expressed milk aspiration milk and the technique
and teach how of expressing the milk,
to give
expressed milk.
 Advice the  To improve  Encouraged the mother
mother to the sucking to frequently
frequently and breastfeed the baby.
breastfeed the swallowing
baby. reflex.
 Avoid the use  To minimize
of pacifiers for the risk of  Avoided the use of
baby. infection and pacifiers for the baby.
aspiration
BABY EVALUATION
DAY GENERAL CONDITION VITALS WEIGHT ANTHROPROMETRY
MEASUREMENT
1 General condition of baby Temperature: 97o f 2.600 kg Head circumference: 32 cm
was fair because poor sucking
and swallowing reflex. Respiratory rate: 40 Chest circumference: 30 cm
breaths/min
Length of the baby: 48 cm
Heart rate: 130 beats/ min
2 General condition of the baby Temperature: 96.8o f 2.500 kg Head circumference: 32 cm
was good. Mother was
feeding baby frequently and Respiratory rate: 48 Chest circumference: 30 cm
also giving expressed milk. breaths/min
Length of the baby: 48 cm
Heart rate:136 beats/min
3 General condition of the baby Temperature: 98o f 2.400 kg Head circumference: 32 cm
was good. Baby was latched
frequently to both breasts and Respiratory rate: 46 Chest circumference: 30 cm
also given expressed milk and breaths/min
there was no fresh complaint. Length of the baby: 48 cm
Heart rate: 146 beats/min
HEALTH EDUCATION
FOR MOTHER

Regarding diet

 Advised the mother to take plenty of oral fluids

 Advised the mother to start with light diet and shift to balance diet later on
 Advised the mother to take fiber rich diet to avoid constipation
 Advised mother to take green leafy vegetables
 Advised mother to take gram and jiggery
 Advised mother to take vitamin- c rich diet.

Regarding hygiene
 Advised the mother to maintain personal hygiene
 Advised the mother to pay more attention to perineal and breast care
 Advised the mother to daily change clothes and wash and dry them in direct sunlight
 Advised the mother to keep baby clean, dry and warm
 Advised the mother to perform hand washing each and every time before handling the baby.
 Advised the mother to daily perform post-natal exercises like deep breathing exercises, pelvic floor exercise, foot movement etc.

Miscellaneous
 Advised the mother to take adequate rest and sleep.
 Advised the mother to lie with closed legs
 Advised the mother to frequent urination
 Advised the mother to frequently breastfeed the baby
 Advised the mother to avoid tight fitted bras and instead wear nursing bras
 Advised the mother to avoid lifting heavy weight
 Advised the mother to avoid sexual intercourse for 6-8 weeks
 Mother is advised to use contraceptive method for birth spacing
For Baby
 Advised the mother to observe for cord bleeding, color, general condition, cry, feeding pattern and passage of urine and bowel
 Advised the mother to clothing should be according to the season
 Advised the mother to breastfeed as early as possible after delivery
 Advised the mother to pay special attention towards the care for cord
 Advised the mother to maintain a daily weight record of the baby
 Advised the mother to observe for sign and symptoms of jaundice
 Advised the mother to maintain an immunization card for baby
 Advised the mother to exclusive breast feeding for 6 months
 Advised the mother to expose baby to the sunlight for 10-15 min
 Advised the mother to avoid top feeding and pacifiers
 Advised the mother to strictly avoid any customs like giving honey to baby.
 DIET PLAN

Time Meal
Morning snacks 1 cup of tea/ 1 glass of milk and 4-5 soaked almonds
Breakfast 2 Paranthas with fillings of spinach or dal or potatoes or carrots or beans or cottage cheese, with curd
Or
I bowl of Poha with lots of vegetables with 1 glass of fresh fruit juice.
Or
2 slices of whole grain bread with 2 egg omlette with 1 glass of milk

Mid-morning snacks 1 seasonal fruit

Lunch 2 Roti with one 1 cup of choice of dal with 1 cup of vegetables+ 1 cup rice and a bowl of curd with salad
Or
1 small bowl Palak Paneer + 2 roti + salad + 1 cup curd
Evening snacks 1 glass Milk with 1 mix ladoo (coconut, almond )
Or
1 bowl mix vegetable soup (bottle gourd, beetroot, carrot, toru, ½ tomato)
Dinner 2 roti + 1 bowl mung/ masoor dal with methi leaves + Toru / parwal / bottle gour sabji / paneer + 1 cup
rice with 1 bowl of dry fruits kheer
Bedtime 1 glass of milk

CONCLUSION
I Nadiya Rashid, student of M.Sc. nursing first year was posted in postnatal ward under the supervision of Mrs. Simarjeet mam (Assistant Professor). Mrs farmana,
a 24 years old female was assigned as patient to me. She came to the hospital with 40 weeks with decreased fetal movements on 26 november 2019 at 1.30pm and
delivered a male baby on 29november 2019 Time of birth- 10.00am with right medio lateral episiotomy. After the delivery the vital signs of the client were stable.
Both baby and mother are healthy. During this posting I have learned a lot about postnatal mother and care during postpartum for both mother and baby.
BIBLIOGRAPHY
 Dutta’s D.C. “Textbook of obstetrics”. Seventh edition. Published by New central book agency (P) ltd. Chintamoni das lane, Kolkata
India.2013. Page no. 148-153
 Rama AV. “Textbook of Maternity nursing”. 19th edition. Published by wolters kluwer. New Delhi. 2014. Page no. 233-240
 Lippincott and Wilkins.” Drug handbook’’. 32nd edition. Published by wolter and kluwer. New York. 2012. Page no. 283-285, 1169-1170,
414-418.
 Banka, P. (2017). Indian Diet Plan for Mothers after Cesarean Delivery (confinement care after c section). [online] Dietburrp. Available at:
https://www.dietburrp.com/indian-diet-plan-for-mothers-after-cesarean-delivery/ [Accessed 25 Sep. 2017].
 Anon, (2017). [online] Available at: • http://allnurses.com/general-nursing-discussion/care-plans-for-315228.html [Accessed 25 Sep. 2017].
 Nandanursingdiagnosislist.org. (2017). Postpartum nursing diagnosis | Nanda Nursing Diagnosis List. [online] Available at:
http://www.nandanursingdiagnosislist.org/postpartum-nursing-diagnosis/ [Accessed 25 Sep. 2017].