NURSING CARE PLAN

SUB: OBSTETRICS AND GYNAECOLOGICAL

NURSING

SUBMITTED TO: SUBMITTED BY:

DR. BARKHA DEVI ROSHMI TAMANG
ASSOCIATE PROFESSOR 1ST YEAR MSC. NURSING
SMCON REG NO: 202263004
SMCON
IDENTIFICATION DATA
 Name of the patient : Mrs. Sarita Subba
 Age :33 years
 Address : Ranipool
 Hospital no. : 732726
 Date of admission : 5/06/2023
 Ward : Postnatal ward
 Husband name : Mr. Avishal Subba
 Education : Graduation and B.Ed.
 Occupation : Teacher
 LMP :13/10/2023
 EDD :20/6/2023
 Diagnosis : Normal Vaginal delivery with Postpartum hemorrhage
 Obstetric score : G1P1L1
 Date of delivery : 6/06/2023
 Under treatment : Dr. Anup Pradhan

CHIEF COMPLAINT
The patient came with the chief complaint of
 Lower abdominal pain and vaginal discharge since one day.

PRESENT HISTORY OF ILLNESS

Mrs Sarita Subba was apparently well till 4/06/2023 evening when she started developing lower abdominal pain which was gradually increasing
in intensity. So, on 5th of June 2023 she was immediately brought to Central Referral Hospital since she was regularly coming CRH for her
antenatal visits. On the way, she started having vaginal discharge as well. She was advised to get admitted after performing per vaginal
examination where the dilatation of the cervix was found to be 1-1.5 cm. On the next day i.e. on 6/06/2023 at 7:35 am she delivered a healthy
baby girl weighing 2.9 kg. Following the child birth she had excess amount of blood loss and she was diagnosed as a case of Post-partum
haemorrhage. Currently, her health status has improved and is planned for discharge.

PAST MEDICAL HISTORY

She does not have any past medical history of illness.

PAST SURGICAL HISTORY

She does not have any past surgical history.

FAMILY HISTORY
Type- nuclear family
Congenital/hereditary diseases- nothing significant
Multiple pregnancies- nothing significant
Any illness-nothing significant
SOCIO- ECONOMIC HISTORY
Type of house/ ventilation- pucca
Monthly income- approximately Rs. 30,000
Toilet facility- yes
Water supply- tap water
Nearest healthcare facility- central Referral Hospital
PERSONAL HISTORY/ HABITS
 Dietary pattern- non-vegetarian.
 No. of meals- 3-4 times daily.
 Allergy- nothing significant
 Substance abuse- nothing significant
 Bowel habit- regular
 Bladder habit- 5-6 times a day, 1-2 times at night
 Sleeping habit- 3-4 hours of sleep, 1 hour of rest
  Personal hygiene- maintained
 Relationship with other family members- good

MENSTRUAL HISTORY
 Age of menarche- 16 years
 Duration of cycle- 28 days
 Flow- normal
 Regularity- regular

MARITAL HISTORY
 Age of marriage-30 years
 Years of married life- 3years
 Use of contraceptives- Yes
 Relationship with partner/spouse- maintains healthy relationship
 Partners health history
 Genetic abnormalities- nothing significant
 Chronic Disease- nothing significant
 Infections/ STD- nothing significant
 Use of drugs/ Alcohol- nothing significant
 Smoking habit- nothing significant

OBSTETRICAL HISTORY:

Past obstetrical history:

Any bad obstetrical history: nothing significant
Number of living child: none
History of abortion/ still birth/ PPH: nothing significant
Present obstetrical history
Obstetrical score- G1P1L1
Number of antenatal-check-up- 6
TT immunization-2 times

PHYSICAL EXAMINATION
GENERAL APPEARANCE
 Body built – Normal
 Nourishment- Well nourished
 Health- Healthy
 Activity- Mild
 Height- 150 cm
 Weight- 56 kg

PHYSIOLOGIG MEASURMENT
 Blood pressure- 120/70 mm of hg.
 Temp- 37° degree C
 Pulse- 78 beats per minute.
 Respiration- 24 breaths per minute.

MENTAL STATUS
Consciousness- patient is conscious and oriented to time, place and person.

SKIN CONDITION
 Colour- fair
 Texture- normal, no skin breakdown
 Lesions-absent
 HEAD AND FACE
 Scalp- Clean, dandruff not present
 Face- Clean, looks worried and anxious

EYES
 Eye brows- normal equally distributed. No infection
 Eye lashes- eyelashes are normal, equally distributed. No infection
 Eye lids-are normal. No oedema, lesion and no signs of infection
 Eye balls- normal
 Conjunctiva- normal
 Sclera- clear and white
 Cornea and iris- normal
 Pupils- pupil equally reactive to light and accommodation
 Lens- transparent

EARS
 External ear- clean, no discharge
 Tympanic membrane- normal, no perforation is present
 Hearing- patient can hear properly without using any hearing aids

NOSE
 External noses are normal, clean. No discharge
 Nostrils- no septal deviation

MOUTH AND PHARYNX

 The lips are dry and no halitosis present
 Teeth- No dental carries, no discolouration
 Tongue- pink, moist and healthy
NECK
 No redness and inflammation and no enlargement of tonsils
 Lymph node-non palpable
 Thyroid glands are non-palpable and not enlarged
 The patient can perform all the range of motion of flexion, extension, external and internal rotation

CHEST
 Shape- normal
 Movement- normal
 Respiratory rate- 24 breaths per minute

EXTREMITIES
 Upper extremities – Normal and can perform all range of motion
 Lower extremities- unable to make upright position due to pain in the episiotomy wound, lordosis present.

OBSTETRICAL EXAMINATION

BREAST
Inspection:
 Breast are normal in shape and size
 Nipples are flat and no cracked nipples
 Hyperpigmentation of primary areolar. Presence of secondary areolar.
 Montgomery tubercles present and prominent visible veins.

Palpation:
 Soft and no tenderness
 No any presence of mass or lymph nodes
ABDOMEN
Inspection:
 Shape: Spherical
 Size: Symmetrically enlarged
 Contour: Concave and enlarged uterus

Palpation:
 Abdominal girth- 86cm
 Involution of the uterus: 18 cm
Lochia: lochia rubra present (severe) saturation of pad every 3 hourly present
Episiotomy: no any redness, edema, ecchymosis and discharge present.
Homan’s sign: positive homan’s signs.

INVESTIGATIONS
BLOOD INVESTIGATIONS

NAME OF THE NORMAL VALUE PATIENT VALUE

INVESTIGATION
WBC (4.00-11.00) 10.33 [10^3/UL]

RBC (3.80-6.50) 2.70 [10^6/UL]

HGB (12.0-18.0) 7.4 g/dl

HCT (36.0-54.0) 35.5 [%]

NEUT% (45.0-70.0) 83.4[%]

 LYMP% (20.0-40.0) 14.0[%]

MONO% (3.0-10.0) 1.8[%]

EO% (1.0-5.0) 0.8[%]

BASO% (0.0-0.5) 0.0[%]

Creatinine 0.6-1.1 mg/dl 11.0 mg/dl

Urea 10-45 mg/dl 11.0 mg/dl

TSH 0.5-5.00 mg/dl 4.4 mg/dl

Blood group A positive

Viral markers
 HBsAg- Non- reactive
 Anti HCV- Non-reactive
 HIV-Non-reactive
URINE EXAMINATION
 Albumin- nil
 Sugar- nil
MEDICATIONS
Sl. Name of Classification Route Frequency
no. the drug Dose

1. Inj. Antibiotic 1gm IV BD

Ceftriaxone

Inj
2. Methergin Ergot 0.2 mg IV OD
alkaloids
3. Inj.
Tranexemic Anticoagulant
Acid 500mg IV BD

4. Tab
Paracetamol Analgesic
650 mg PO TDS
 NURSING CARE PLAN
ROYS ADAPTATION MODEL

INPUT COPING PROCESS EFFECTOR OUTPUT

1. ENVIRONMENTAL Coping Mechanism: Physiologic mode: adequate

STIMULI rest and activity, proper
1. Deep breathing elimination
Focal stimuli: hospitalisation, exercises
Role function: ability to Adaptive
immediate surrounding 2. Support from the
perform activities of daily response: able to
support system
Contextual stimuli: age, living as an individual control and
3. Music therapy
socioeconomic status, support manage
4. Education regarding
system Interdependence mode:
warning haemorrhage
dependence of family members
Residual stimuli: knowledge
deficient regarding the Self-concept: increased self-
management esteem, ease of stress Maladaptive
response: stress
ADAPTATION LEVEL: and anxiety
Physiologic mode: restlessness
Role function: difficulty in
performing routine activities
Interdependence mode:
interpersonal conflicts,
disturbed
Self-concept: fear of not being
able to deal with the situation
NEED OF MY PATIENT:
 Need to maintain fluid volume
 Need to decrease anxiety
 Need to reduce pain
 Need to improve sleeping pattern
 Need to increase knowledge

NURSING DIAGNOSIS
i. Deficient fluid volume related to excessive blood loss after the childbirth as evidenced by decrease in the red blood cells count (haematocrit)
RBC= 2.70 million/mm3 and Hb= 7.4 g/dl
ii. Ineffective tissue perfusion related to hypovolemia (vaginal bleeding) as evidenced by fluctuation in vital signs and decrease milk
production.
iii. Anxiety related to threat of change in the health status and situational crisis as evidenced by expressed concerns due to changes in the life
events and impaired attention.
iv. Acute pain related to episiotomy wound as evidenced by discomfort at the perineal area and patient’s verbalisation i.e.the pain scale rating
was 6/10
v. Disturbed sleeping pattern related to pain in the perineal area as evidenced by verbal report of difficulty in falling asleep and frequent
yawning.
vi. Deficient knowledge related to related to maternal and fetal conditions as evidenced by statement of misconceptions and request for
information.
vii. Risk for infection related to decreased haemoglobin and traumatised tissue.
ASSESSMENT NURSING GOAL PLANNING RATIONALE IMPLEMENTATION EVALUATION
DIAGNOSIS
Subjective data: Deficient fluid Patient will Assess and record the Help to determine the Assessed and found the Client verbalizes of
volume related to demonstrate amount, type, amount appropriate client was having PPH. decrease in the blood
Patient excessive blood improvement and site of bleeding. management of the Recorded the type, loss. There was
verbalizes of loss after in the fluid Count and weigh patient. amount and site of blood subsequent increase
excessive childbirth as balance. perineal pads. loss. in the hemoglobin
bleeding evidenced by count after the blood
through vagina decrease in red Assess the location of The degree of the Assessed the location and transfusion and
blood cells count the uterus and degree of contractility will degree of the uterus. blood pressure was
and hemoglobin the contractility of the measure the status of also in the normal
Objective data: uterus. blood loss range.
Decreased red
blood cell count Monitor the vital signs Increased heard rate, Monitored the vitals
and BP 90/60 and check for the hypotension, cyanosis Temp: 97.6oF
capillary refill. and delayed capillary Pulse: 76b/min
Observe nail beds and refill indicate Resp: 22b/min
mucous membranes. hypovolemia and BP: 90/100 mm/Hg
impending shock.

Check for the complete Helps to determine the Checked and found the
blood count amount of blood loss patient’s hemoglobin was
7g/dl and 2 unit blood
was transfused to the
patient.

Advise the patient to eat Helps to increase the Advised the patient to
foods that are rich in level of hemoglobin take foods rich in iron
iron and folates. through diet and folates. These
modifications includes spinach,
beetroot, fish, eggs,
green vegetables etc.
ASSESSMENT NURSING GOAL PLANNING RATIONALE IMPLEMENTATION EVALUATION
DIAGNOSIS
Subjective data: Acute pain related Patient will Assessment of pain Pain is a subjective Assessed the pain and Patient’s pain
“I am having pain to vaginal delivery verbalize relief which includes experience and must found that patient is was reduced
in the perineal secondary from pain and location, be described by the having pain over the from moderate
area” episiotomy wound discomfort. characteristics, severity client in order to plan episiotomy wound. The to mild i.e. 4/10
as evidenced by and precipitating effective treatment. pain score rating is 6/10
discomfort in the factors of pain
Objective data: perineal area and .
Presence of the patient’s Provide comfort Ice compress Advised the patient to
episiotomy verbalization. measures such as decreases edema and apply ice pack or heat
wound application of ice pack minimizes hematoma application.
into the perineum. and sensation while
Advise the patient to heat promotes
provide heat vasodilatation which
application as well. facilitates reabsorption
of hematoma.

Administer pain Decreases pain and Administered Tab

medication such as anxiety and promotes Paracetamol 650 mg
analgesics as prescribed relaxation. TDS as advised.
by the physician

Elicit behaviors that are Helps to reduce Taught patient deep

conditioned to produce skeletal muscle breathing exercises and
relaxation, such as deep tension which will relaxation techniques to
breathing and reduce the intensity of the patient.
divertional activities. the pain.
ASSESMENT NURSING GOAL PLANNING RATIONALE IMPLEMENTATION EVALUATION
DIAGNOSIS

Subjective data: Anxiety related to Patient will Encourage the client or Verbalization of anxiety Identified the problem Patient anxiety
threat of change report the family to identify provides an opportunity of the patient and her was reduced.
“I am worried in the health decreased feelings of anxiety to clarify information, family
about my health status and anxiety correct misconceptions
status” situational crisis episode and gain perspective
as evidenced by
Objective data: expressed
concerns due to Stay with the client by Helps in maintaining Interacted with patient
Verbalization the changes in the providing a calm, emotional control in and the family
and facial life events. empathic and response to the changing members.
expression supportive attitude. physiological status

Provide information Giving accurate Provided information

about the treatment information can lessen about the treatment and
regimen an the anxiety effectiveness of the
effectiveness of the intervention.
interventions.

Assist in developing To eliminate negative Assisted in developing

skills (e.g. awareness thoughts and to promote skills.
of negative thoughts, wellness.
saying “Stop” and
replacing it with a
positive thought.
HEALTH EDUCATION
i. Educated about the condition and its management to the patient and family member to reduce anxiety and fear.
ii. Advised the patient to take healthy diet that is rich in protein, fiber, carbohydrate, vitamin, etc.
iii. Provided information about the importance of exclusive breast feeding till 6 months and care of the breast.
iv. Taught about the essential newborn care.
v. Health education given on personal hygiene and perineal care.
vi. Advised to come for the follow-up and immunization

CONCLUSION:
As a part of my OBG posting I was posted to postnatal ward where I have given nursing care to Mrs Sarita Subba according to the prioritized
need and care required for her. She was very co-operative while doing assessment, necessary nursing care was provided and health education
given. I wish her quick recovery.