POSTNATAL CASE STUDY

[Link] OF MOTHER : PROFILE OF THE HUSBAND

[Link] of the mother : Name of the husband :
2. Age : Age :
3. Education : Education :
4. Occupation : Occupation :
5. Nationality :
6. Religion :
7. Address :

8. Marital status :
9. Name of the hospital :
10. [Link] :
11. Gestational age :
12. Obstetrical score :
LMP :
EDD :
13. Date & Time of delivery :
14. Type of delivery :
15. Mode of delivery :
16. Total hours of labour :
17. New born sex :
18. New born weight :
19. Postnatal day :
20. Days of hospital stay :
21. Diagnosis :
22. Care started on :
23. Care completed on :
24. Chief complaints ;
 HISTORY COLLECTION
[Link]-Economic Status:

1. Type of Family : Nuclear / Joint /Extended

2. Bread Winner :

3. Total Income of the Family :

4. Type of House : Thatched / Tiled / Terraced

5. Ownership of House : Own / Rented

6. Electricity & Water Supply :

7. Drainage & Kitchen Garden :

8. Latrine &Refuse Disposal :

9. Ventilation :

2. Family History:

[Link]. Name of the Age Sex Educational Occupationa Relationship Health

Family Status l Status With the Status
members Mother

[Link] Tree :
4. Family Medical History:

1. Multiple pregnancy :
2. Systemic disorders : Asthma, Hypertension, DM etc….
3. Genetic Abnormalities :
4. Communicable Disease :
5. Psychiatric Illness :
6. Others

5. Personal History:

(a) Personal Habits: Tobacco Chewing, Cigarette smoking, Alcohol, Coffee, Cola, Tea

(b) Diet
Vegetarian / Non Vegetarian :
Allergies to any food item :
Number of meals and snacks/day :
Likes & Dislikes of food :
Nutritional assessment 24 hours recalls and recommended diet plan (for mothers
on therapeutic diet)

(c) Sleep / Rest

Number of hours per day & night :
Wake times :
Difficulties in sleeping :
Remedies used for difficulties :

(d) Activities of daily living

Any difficulties experienced in the basic activates
Eating / Brushing / Bathing :
Grooming / Dressing :
Elimination / Locomotion :
(e) Hygiene

(f) Elimination
Bowel habits : Number of times per day
Bladder habits : Number of times during day and night

(g) Hobbies / Interests

Reading books :
Watching TV :
Playing
Listening to music :
Others (Specify) :

(h) Immunization History :

(i) Menstrual History

 1. Age at menarche :
2. Duration of cycle :
3. Amount of flow :
4. Regular / Irregular:
5. Any abnormalities:
6. Remedial measures for complaints:

(j) Marital History : Consanguineous / Non consanguineous

Duration of Marriage :

(k) Sexual History :

(l) Contraceptive :

(m)Drug History :

6. Past Medical History / Surgical History:

[Link] Medical History /Surgical History :

8. Past Obstetrical History:

S.N Year Mother Baby

Complication Abortion/ Type of Compli Sex Birth Conditi Health

During Preterm/ Deliver cation Weig on At Status
Pregnancy Full term y During ht Birth
Puerpe
rium
 8.1 ANTENATAL PERIOD :

1st trimester: H/o Nausea, Vomiting, Pica, Anorexia, Constipation,

Exposure to drugs / Radiation / Infection / Any other

2nd Trimester: H/o Heart Burn, Back ache, Muscle cramps, Anemia, GDM, PIH,
Anyother

Quickening felt at :

Weight Gain : Normal / Abnormal

3rd Trimester: H/o Heart burn, Constipation, Frequencyof micturition, Any other

Lightening : Yes / No

Fetal Movement : Normal/ Excessive / Less / Not Felt

Antenatal Attendance:

Urine Ht of
Fundus
Date [Link] in
Kg. weeks/
Cms
Alb Sugar B.P. Weeks of Presentation F.H.R. Treatment
mm Gestation Per & Remarks
of Hg Minute

8.2 INTRANATAL PERIOD ;

 Duration of first stage :
Second stage :
Third stage :
Total :
Episiotomy : done/not done
Type of anesthesia :
Drug administered :
Amount of blood loss :
Characterestic of liquor :
Baby cry at birth : yes/ no

8.3 POSTNATAL PERIOD :

Mother’s condition :
Postpartum haemorrhage/pyrexia/sepsis/other complication
Lactation :
Involution :
REEDA scale score : (if episiotomy done)

PHYSICAL EXAMINATION

General Condition:
Height : cms

Weight : Kgs.
Gait : Posture:
Vital signs:

Temperature :

Pulse :

Respiration :

BP :

General Appearance:

Body Built :

Health Status :

Activity :

Mental Status:

Orientation :
Facial expression: Normal / Anxious / Depressed

Any other :
Head :
Hair : Colour: Texture:

Scalp : Clean / Dandruff

Any other problems:

Face:
Pallor :

Oedema :

Chloasma :

Any other :

Eyes
Eye brows :
Eye lashes :
Eye lids :

Papillary reaction:

Conjunctiva :

Sclera :
Papillary reaction:
Vision

Ears:

Hearing acuity :

External ear :
Tympanic membrane :

Nose :

External nares :

Septal Deviation:

Mouth :

Lips :
Tongue :

Teeth :

Gums :

Mucosa :

Thorat and pharynx : :

Neck :

Lymph Nodes :

Thyroid :

Jugular Vein:

Carotid Pulsation:
Any other:

Chest:
Shape :

Movement :

Respiration :

Breath Sound:

Heart beats :

Murmur :

Any other :

Extremities: (Upper & Lower)

Pulsation:

Symmetry:

Oedema:

Tremors:

Varicose Veins:

Reflexes:
Anyother:

OBSTETRICAL EXAMINATION:

Breast:

Size :

Consistency :

Symmetry :

Veins :

Areola Primary:

Secondary:

Montgomery’s Tubercles:

Nipple Protractility :

Nodules / Lumps :

Axillary Nodes :

Discolouration :

Any other :

OBSTETRICAL EXAMINATION

Abdominal palpation :
Fundal height :
Involution :
Abdominal girth :

BUBBLE :
S.N COMPONENT CURRENT CONDITION
O
1. Breast
2. Uterus
3. Bladder
4. Bowel
5. Lochia
6. Extremities
 PUERPERIUM CHART :

MOTHER NEW BORN

DAY 1 2 3 4 5 6 1 2 3 4 5 6
Time M E M E M E M E M E M E M E M E M E M E M E M E
Temperature

Pulse
Respiration
Blood
pressure
Bladder
Bowel
Lochia
Urine
albumin/suga
r
Wt of
newborn

ASSESSMENT OF NEW BORN :

1. Name of the baby :

2. Age of the baby :
3. Weight at birth :
4. Apgar score : 1 minutes.................. 5 minutes
a) Anthropometric Measurement :
Length :
Weight :
Head circumference :
Chest circumference :
Abdominal girth :
b) Vital signs :
Temperature :
Heart Rate :
Respiration :
c) General Assessment :
Activity :
Head :
Mouth :
Eyes :
Ears :
Nose :
Neck :
Chest :
Abdomen :
Umbilicus :
 Genitalia :
Anus :
Spine :
Extremities :

d) Reflexes :

Moro :
Tonic neck reflexes :
Stepping or dancing reflexes :
Grasping :
Babinski :
e) Feeding Reflexes :
Rooting :
Sucking :
Swallowing :
Gag :
f) Protective Reflexes :
Blinking :
Cough and sneeze :
Yawn :
g) Urine :

h) Meconium :

i) Impression :

INVESTIGATIONS:

Blood :

Blood Group:Rh Factor:

Hb:

Blood Sugar:

VDRL:

HIV:

Hepatitis B:

Any other

Urine Test:
Stool examination

Ultra sound examination:

Non Stress Test:

MEDICATIONS :

Date Name of the Drug Route & Action Side effects Nurses
& Dose Frequency Responsibility

ANATOMY AND PHYSIOLOGY :

DISEASE CONDITION :

1. Introduction
 2. Definition
3. Etiology ( book picture &patient picture)
4. Pathophysiology
5. Clinical manifestations ( book picture &patient picture)
6. Diagnostic evaluation ( book picture &patient picture)
7. Management ( book picture &patient picture)

NURSING DIAGNOSIS

Postnatal Advice / Health Education On:

a) Personal Hygiene
b) Diet
c) Exercise
d) Care of the breast
e) Breast feeding
f) Family planning

CONCLUSION

1. Reflection of the Student Nurse:

2. Reflection of the Mother:

3. Reflection of the Family:

BIBLIOGRAPHY