BIO DATA OF THE MOTHER

NAME – Pushpaben Ajitbhai Ravat

AGE – 25 years
SEX – Female
OPD NO. - 3055549
IPD NO. – 966805
ADRESS – civil hospital Gondal
EDUCATION – Illiterate
OCCUPATION – Housewife
INCOME – 10000/- Rs per month
RELIGION – Hindu
DATE OF ADMOSSION -13/10/2022 at 12:46 pm
DR’S UNIT - Dr. TLP
DIAGNOSIS – G2P0A1L0 + 5 months + Twins

HISTORY OF THE PATIENT:-

1. PRESENT HISTORY (ADMISSION HISTORY AND CHIEF
COMPLAINS ) :-
ON ADMISSION:
 Pushpaben has complained of abdominal pain since 2-3 days.
 She has no any complaints of bleeding per vagina or discharge per
vagina.
PRESENT COMPLAINTS:
 At present also, she has complain of abdominal pain.
 Also her hemoglobin level is low i.e. 8.4 gm/dl. Because of it, she looks
pallor & also complains of fatigue.
 She is anxious about her pregnancy.

2. PAST MEDICAL HISTORY :-

 Pushpaben has no any past medical history like jaundice, typhoid,
tuberculosis, diabetes mellitus, malaria, hypertension, etc.

3. PAST SURGICAL HISTORY :-

 Pushpaben has no any surgical history in her past.
4. OBSTETRICAL HISTORY :-
a) PAST OBSTETRICAL :-
 She has history of 1 spontaneous abortion before 8 years & it was not
followed by D & E.
 She has no history of MTP, contracted pelvis, PPH, ectopic pregnancy,
etc.
  She has history of taking treatment for infertility for around 1 year from
private nursing home.

b) PRESENT OBSTETRICAL :-
 MENSTRUAL HISTORY
- Before pregnancy, Pushpaben is having 28 days of menstrual
cycle which is regular and it comes for 3-4 days. And the
quantity is also moderate.
 MARITAL HISTORY
- Pushpaben got married at her age of 16 years. So she has
history of 9 years of active marriage life.
 OBSTETRICAL HISTORY
- Pushpaben is G2P0A1L0. ..
- She has taken 2 doses of tetanus injection.
- She has 5 months (34 weeks) of pregnancy
- Fundal height – 34 cm
- External ballottement can be done and the uterus is relaxed.

5. FAMILY HISTORY :-
o In her family, there are total 4 members, her father and mother in
law, she and her husband. Only her husband is one earning person
in her family so there is economical burden on them.
o In her family, there is no other medical or surgical history.

6. PERSONAL HISTORY :-
a) Diet – Vegetarian
b) Hobbies & Habits – Pushpaben likes cooking, decorating and house
hold work. She has no any bad habits.
c) Nutritional History – Her nutritional status is average. She is average
nourished.
d) Bladder Bowel Habit – Before pregnancy, bladder and bowel pattern
is normal but during pregnancy, she has complained of polyuria and
constipation sometimes.
e) Social Economical History – Her social relation with her family
members, relatives and neighboures are good. Their economical
condition is not that much good because her husband is only one
earning person in their family.
f) Personal Hygiene - Her personal hygiene is well maintained. She is
in clean clothes, and her hair is nicely combed.
PHYSICAL EXAMINATION:-
General Appearance:-
 Nourishment – Average nourished
 Body built- Thin
 Health- Unhealthy
 Activity – Tired
Mental Status:-
 Consciousness – Conscious
 Look – Anxious, worried and depressed
Posture –
 Body curves – Normal
 Movements – Present
Height and weight – Height- 154 cm Weight – 55 kg
Skin Condition:-
 Colour - Pallor
 Texture - Normal
 Temperature - Warm
 Lesion – Normal
Head and Face:-
 Shape – Normal
 Scalp – Clean, absence of pediculi and dandruff
 Face – Pale, Pain, fear and anxiety, fatigue
Eyes –
 Normal eye brows, eye lashes, eye balls, eye lids.
 White sclera
 Mild paleness in lower conjunctiva.
 No any irregularities and abrasions found in cornea and iris.
 Reaction to light present
 Vision is normal
Ears:-
 No any discharge or cerumen obstructing the ear passage or in external
ear.
 No any perforations, lesions, and buldging in tympanic membrane.
 Hearing acuity is normal.
Nose –
 Absence of crusts or discharges in external nares.
 Absence of inflammation of the mucus membrane in nostrils.
 No septal deviations.
Mouth and Pharynx;-
 Absence of redness, swelling, and cyanosis, angular stomatitis on lips.
 Absence of foul smelling
 No teeth discoloration and dental carries.
  Absence of ulceration and bleeding, swelling, pus formation in mucus
membrane and gums.
 Pale and dry tongue.
 No enlargement of tonsils.
Neck:-
 No enlarged or palpable lymph nodes.
 No enlargement of thyroid gland.
 Normal range of motion like flexion, extension and rotation.
Chest:-
 Normal shape, symmetry of expansion, posture of thorax.
 Absence of wheezing, rales, crepitations and sigh in breath sounds.
 Normal size and location of heart.
 Absence of cardiac murmurs.

Breast:-
 Presence of enlargement of breasts.
 Presence of Montgomery’s tubercles and secondary areola.
 No cracked or flat nipples.
 No enlargement of lymph nodes.
Abdomen: -
1. Observation :-
 Absence of hernia, ascites, distension.
 Absence of any previous scar and skin rashes.
2. Auscultation :-
 Presence of bowel sounds and fetal heart sound.
3. Palpation :-
 No palpable liver margin, spleen.
 No tenderness at the area of appendix, and inguinal hernias.
4. Percussion :-
 Absence of gas, fluid or masses.
Extremities:-
 Absence of tremors, clumbing of fingers, ankle edema, varicose
veins, etc.
 Normal movements of joints.
 All reflexes are present.
Back:-
 Normal back curves
Genitals and Rectum:-
 No enlarged or palpable inguinal lymph nodes.
 Absence of bleeding or discharge per vagina.
 In per vaginal examination, Os is closed.

OBSTETRICAL ASSESSMENT:-
 1. Observation :-
 Presence of linea nigra and striae gravidarum.
 Uterine ovoid is spherical.
2. Palpation :-
Fundal height – 34 cm
On palpation, multiple fetal parts felt.
External ballottement is present.
Uterus is relaxed.
3. Auscultation :-
 FHS of fetus A – 140 beats/min
 FHS of fetus B – 130 beats/min
Location of FHS is not fixed because of variable presentation.
INVESTIGATIONS (BLOOD):-

SR INVESTIGATIONS FINDINGS NORMAL REMARK

NO VALUE S
1 Haemoglobin 8.41 gm/dl 12-15 gm/dl Decreased
2 WBC 8,930/cmm 4000-11000 Normal
3 RBC 2.91*10^6/cmm 3.8-4.8 Decreased
4 Hematocrit 25.9% 36-46% Decreased
5 Polymorphs 74% 60-80% Normal
6 Lymphocytes 21% 20-40% Normal
7 Eosinophills 2% 1-6% Normal
8 Monocytes 3% 2-10% Normal
9 Blood Urea 19.2 mg/dl 20-40 Normal
10 Serum Creatinine 0.76 mg/dl 0.7-1.40 Normal
11 Serum Sodium 132 mEq/L 136-145 Decreased
12 Serum Potassium 3.6 mEq/L 3.5-5.1 Normal
14 Total Billirubin 0.37 mg/dl 0.2-1.0 Normal
15 Direct Billirubin 0.04 mg/dl 0.0-0.2 Normal
16 Indirect Billirubin 0.33 mg/dl 0.2-0.8 Normal
17 MCV 89 fl 80-99 Normal
18 MCH 28.3 pg 27-31 Normal
19 MCHC 32.4 mg/dl 33-37 Normal
20 Platelets 341000/cmm 1.5-4.5 lacs Normal
21 Serum Uric Acid 4.55 mg% 2.6-6.0 Normal
22 Prothrombin time 13.5 sec 12-16 Normal
23 Blood sugar 106.5 mg/dl 70-140 Normal

1. OTHER INVESTIGATIOS :-
  URINE ROUTINE AND MICRO INVESTIGATIONS:
Pus – Nil
RBC – Nil
Cast – Nil
Crystals – Nil

 ULTRA SONOGRAPHY:
- Two live intra uterine fetuses with variable presentation with
following parameters noted.
Fetus A Fetus B
BPD 43 mm 19 weeks 1 day 48 mm 20 weeks 6 days
AC 164 mm 21 weeks 4 days 152 mm 20 weeks 4 days
FL 33 mm 20 weeks 3 days 32 mm 20 weeks 1 day
Placenta Anterior Anterior
Presentation Variable Variable
Liquor Adequate Adequate
Fetal cardiac Present Present
Activity

- No any gross congenital anomaly noted.

- Intervening membranes seen.
- Cervical length measures 3 cm.
MEDICAL MANAGEMENT:-
Tab. Rantac (150 mg) bd
Tab. Folic Acid (0.8 mg) od
Tab. Iron (200 mg) od
Tab. Vitamin C (500 mg) od
Tab. Calcium (500 mg) od

Sr no Name Dosage Action Indication Side effect Nurses

of the /Route/Freq and responsibility
medicat uency contraindica
ion tion
 1. Tab. Dosage neutralise Acidity, constipation,  Assess ECG
Calcium :500 s gastric hypocalcaemi anorexia, for QT and
mg acidity a, nausea, T wave
osteoporosis, vomiting,
Frequency: hyperphospha diarrhoea, Calcium level
OD teamia, RIH rebound during treatment.
hyperacidity.
Route :oral -Assess cardiac
status
Evaluate –
therapeutic response

Assess – fatigue, Hb
Side effects: %, reticulocyte
2. anaemia flushing, count and
Tab. Action :
Dosage needed bronchospas nutritional status
Folic
: for m,
acid Teach family and
200mg erythropo hypersensitiv
it patient – to take
isis,
Frequency: drug as prescribed
increases
RBC, - To alter nutrition
OD
WBC, to include high folic
Route : oral platelet acid food
formation

APPLICATION OF NURSING THEORY

THEORY OF INTERPERSONAL RELATIONS
Introduction
 Born in Reading, Pennsylvania [1909]
 Graduated from a diploma program in Pottstown, Pennsylvania in 1931.
  Published Interpersonal Relations in Nursing in 1952
 1968 :interpersonal techniques-the crux of psychiatric nursing
Roles of nurse
 Stranger: receives the client in the same way one meets a stranger in other life situations
provides an accepting climate that builds trust.
 Teacher: who imparts knowledge in reference to a need or interest
 Resource Person : one who provides a specific needed information that aids in the
understanding of a problem or new situation
 Counselors : helps to understand and integrate the meaning of current life
circumstances ,provides guidance and encouragement to make changes
Theory of interpersonal relations
 Middle range descriptive classification theory
 Influenced by Harry Stack Sullivan's theory of inter personal relations (1953)
 Also influenced by Percival Symonds , Abraham Maslow's and Neal Elger Miller

Identified four sequential phases in the interpersonal relationship:

1. Orientation
2. Identification
3. Exploitation
4. Resolution
Orientation phase
 Problem defining phase
 Starts when client meets nurse as stranger
 Client seeks assistance ,conveys needs ,asks questions, shares preconceptions and
expectations of past experiences
 Nurse responds, explains roles to client, helps to identify problems and to use available
resources and services

Factors influencing orientation phase

Identification phase
 Selection of appropriate professional assistance
 Patient begins to have a feeling of belonging and a capability of dealing with the problem
which decreases the feeling of helplessness and hopelessness
Exploitation phase
 Use of professional assistance for problem solving alternatives
 Advantages of services are used is based on the needs and interests of the patients
 Individual feels as an integral part of the helping environment
 They may make minor requests or attention getting techniques
 Patient may fluctuates on independence
 Nurse must be aware about the various phases of communication
 Nurse aids the patient in exploiting all avenues of help and progress is made towards the
final step
Resolution phase
 Termination of professional relationship
 The patients needs have already been met by the collaborative effect of patient and nurse
 Now they need to terminate their therapeutic relationship and dissolve the links
 between them.
 Sometimes may be difficult for both as psychological dependence persists
 LIST OF NURSING DIAGNOSIS:-

1) Acute pain in abdomen related to normal physiological changes in

pregnancy.
2) Altered bowel pattern related to normal physiological changes as well as
changes in her routine and in diet.
3) Risk for post -partum haemorrhage related to low Hb level.
4) Anxiety related to her present condition and about her previous death
child.
Assessment Nursing Expected Planning Nursing intervention Evaluation
diagnosis outcome
Acute pain To relieve pain Assess the patient for severity of Patient has dull back
Subjective related to uterine To give the and make patient pain. Patient has dull back pain. pain.
data: cramping and medication and comfort.
possible to give support Give comfortable position to the
She is told procedures. cope the pain. patient.
After given back
havind pain in
To provide Monitor the vital sign of the massage patient feel
abdomen and
adequate sleep patient. comfortable.
not to cope
pattern.
with pain. Instruct the patient to maintain
good posture when sitting.
To promote Instruct patient to not remain in
health of the standing position for long time
patient. duration.
Do back massage of the patient.
Administer pain medication as
needed and as prescribed.
Instruct patient to take more liquid.
Instruct patient on the cause of
pain to decrease anxiety.
 ASSESSMENT NURSING GOAL PLANNING IMPLEMENTATION EVALUATI
DIAGNOSIS ON

Risk factors: Risk for The patient • To assess the patient for the • The patient is assessed for the Now there is
infection will remain presence of signs of infection. signs like chills, fever, increased reducer risk
free from WBCs etc. for infection
infection and and till now
Inadequate secondary
will show no • To maintain the sterile • The sterile technique is there are no
defences
signs of technique in every procedure maintained in the procedures any signs of
presence of done on the patient. done on the patient like surgical infection seen
any infection. To use the sterile material for the wound dressing, IV cannulation, in the
Invasive procedures procedures done on the patient. Injections etc. patients.
To provide the nutritious diet to
the patient. • Sterile material and equipments
Malnutrition
are used in the procedures done
on the patient.
• Proper nutritious diet is
Insufficient knowledge provided to the patient so
that it can protect the patient
against infectious
Surgical incision organisms.
• The prophylactic anti-biotic
drugs are provided to the
patient according to the
doctor’s order.

ASSESSMENT NURSING GOAL PLANNING IMPLEMENTATION EVALUATI

DIAGNOSIS
 ON

Subjective data: Activity To make • To assess the activity level of The activity level of the patient is The patient
intolerance patient to do patient. assessed, her activity level is has improved
related to the activities of • To provide assistance in doing reduced.. The patient is provided the activity
lethargy, as daily living activity to patient. assistance with the activities of daily level to some
Report of fatigue and
evidenced by and improve • To provide active and passive living. extent and
weakness
fatigue and the activity exercises to the patient. she is able to
disability to do tolerance. • To provide rest between the The patient is encouraged to do the do activity of
Objective data:
ADL. activities. active and passive exercises as per daily living
Abnormal heart rate To monitor vital signs during the tolerance. to some
and after activity. level.
Paleness The rest is provided between the
activities and the balance is
Low blood pressure maintained between the activities and
rest.
The vital signs are monitored of the
patient, they are within normal
limits.The healthy and balanced
nutritious diet is provided to the
patient.
HEALTH EDUCATION:-
 I have advised her to take complete bed rest and adequate sleep during this period and at home, to keep enough
rest time in between two activities.
 I have given her health education about maintenance of her personal hygiene and keep her private area also clean
and dry.
 I have advised her to think good and not to take anxiety and tension because it is harmful for her and for her baby
also.
 I have also given her health education on dietary management like including green leafy vegetables and fruits,
iron-rich diet in her daily routine for the prevention of severe anaemia because her Hb level is 8.4 gm/dl so there is
risk for post-partum haemorrhage.
 I have advised her to drink more fluids and water and also to take more roughage diet to prevent more
constipation.
 I have given her psychological and spiritual support and advised her for religious activities.
 I have advised her family members and relatives to see her during visiting hours and also to participate in
providing care to Pushpaben.
 I have also given health education to her about family planning methods including various methods and its
advantages and disadvantages of those methods.