CASE STUDY
ON
POSTNATAL CARE
PATIENT ASSESSMENT
PROFILE OF PATIENT:-
Name : supriya samal
Age : 24yrs
Qualification : +2
Occupation : housewife
Husband’s name Niranjan samal
Monthly family income : 30000/-
Marital Status : married
Religion : hindu
Registration Number : 14234
Name of the Hospital : MKCG,MCH
Ward : Maternity-I
Bed Number : 237
Date of admission : 7/08/2022
Date of discharge : 11/08/2022
Date of data collection : 9/08/2022
HISTORY OF ILLNESS
• Chief complaint:-breastfeeding problem,
• Past medical and surgical history;- no significant problem
• Present medical and surgical history:-anemic condition
FAMILY HISTORY:-
• Type:-nuclear
• No of members- 4
• Support person- husband
• Any illness in family-no significant history
HEALTH FACILITY NEAR HOME:-
CHC near house around 3km away
HOUSING:-
• Type of house-concrete
• No of room- 4
• No of windows and doors-6
• Electricity-yes
• Drinking water source-PHD water supply
• Sanitation- Open drainage system
PERSONAL HISTORY
• Oral hygiene:-frequency-twice in a day
• Bath:-frequency-once
• Smoking / alcohol habit- no
• Activity-exercise pattern- moderate
Nutritional history
• Diet:-Veg/ Non-veg- both
• No of meal per day-3
• Fluid:-glasses/day - 6-8 glasses
• Tea/coffee:- no addiction, casual
Sleep and rest:-hours/day- 6 hours, drugs used for sleeping-no
Menstrual history -
• Age of menarche- 14yrs
• Duration of bleeding/amount- 4days, 35ml
• Pain during periods- no
• LMP- 11/11/2022
MARITAL HISTORY:-
Consanguineous marriage – no
Use of contraceptive-condom during coitus
OBSTETRIC HISTORY:
Previous pregnancy; primi mother
Present obstetrics history;
General Health during Present Pregnancy; apparently healthy
Complaints during Pregnancy; vomiting
Morning Sickness Yes
Minor Ailments (Specify); constipation
Immunization (T/T) Yes, complete 2 doses
Calcium, Iron & Folic Acid supplements (specify)- 180 tablet of IFA and calcium
Any other Medications During pregnancy: no
Antenatal Events during Present Pregnancy
First trimester :
no significant problem
Second trimester
Any T/t /medications; no
Hospitalization; No
Any other significant problems; no significant problem
Third trimester
Any T/t /medications; no
Hospitalization: No
Any other significant problems: no significcant problem
Delivery Records
Date & Time of delivery-8/08/2022
Treatment received- inecction oxytocin 10unit IM
Total duration of labour-: 10hrs
Received in Postnatal Ward- 9/08/2022 at 3am
New born condition at birth- baby cried immediately after birth
Any significant Treatment (Blood/ blood components/ Drugs Received); blood transfusion 1 pint
Examination of the Mother (postnatal assessment)
General Appearance Personal Hygiene; maintained
Body built-average
Gait; upright
Weight; 59kg
Nourishment;well nourished, statred oral diet
VITAL SIGNS:-
Temperature; 38.5 degree celcius Pulse- 88bpm
Respiration- 22bpm BP- 122/80mmhg
PHYSICAl EXAMINATION
Head- hair finely distributed, shiny
Scalp-clean , no pediculosis
Eye- pallorness present
Face -no facial puffiness
Mouth-28 number of teeth, no gum bleeding or dental caries
Tongue- moist
Lips- moist
Neck- no thyroid enlargement
Chest- lungs sound is clear , heart sound- H1, H2
Breast- No lump or tenderness, cosotrum secreted , no palpable lymph node
ABDOMEN
Abdomen – flat
Uterus – Contracted
Bladder – empties
Symphysio fundal height – 18cm
Perineal area & anus - episiotomy , no laceration
Vagina- lochia rubra is present, 3 pad changes per day , no foul smelling abnormal discharge
Episiotomy-REEDA not present , aproximation of skin
Extremities
Varicose vein- no Ankle edema – not present
Capillary refill – 3sec Homan’s sign – not present
Emotional response- emotionally attached to her baby
Breastfeeding- adequate process not established
Postpartum discomfort; BF/episiotomy pain
DRUGS-
name of drugs generic name dosage action
Tab. Cefixime cefixime 200mg Prevent infection
Tab. Pantoprazole pantoprazole 40mg Antigastric
Tab. Diclofenac Diclofenac 50mg Reduce pain
NEWBORN ASSESSMENT
PHYSICAL EXAMINATION
General appearance-
Posture of baby- flexion
Condition- active
Vital signs- temp. 36.5 degree celcius , apical heart rate 140bpm, respiration- 50bpm, weight-2.8kg, HC-
35CM, CC-33CM
Integuments- there is no birth marks, injury mark, Mongolian spot
Head- hair is fine and shiny, no caput succedaneum, cephalo hematoma
Frontannel- no bulging
Eyes- symmetrical, and coordinated movement
Ears- both are set at level of eye and rolled helix structure
Nose- no abnormal discharge
Neck and mouth- no abnormal oral discharge
Chest- symmetrical , nipple are at equal distance
Lungs- sound clear
Anogenital area- clitoris is not swollen , no pseudomenstruation , voided 6 times per day , anal opening
patent , meconium – passed
Skeletal structure – back straight , no cyst , symmetrical gluteal fold , extremities flexed
Neuromuscular- head lag +ve , response to sound
Reflexes –blinking, doll’s eye, palmer grasp, tonic neck and babinski present
General condition- active , poor sucking reflex , no sign of jaundice , sleep adequately
POSTNATAL CARE
care of mother and newborn from 1hour after delivery up to 6 weeks post delivery
AIMS AND OBJECTIVES
• to assess the health status of the mother and institute effective therapy to rectify the detect if
any. medical disorder like DM, HTN should be reassessed.
• to detect and treat at the earliest any gynaecological condition arising out of obstetric legacy
• to note the progress of the baby including the immu nization schedule for the infant
• to import family planning guidance
POSTNATAL ADVICE
In book In client
diet : high calorie and high protein diet along given
with minerals and vitamins
breastfeeding : 2hrly with good attachement , not properly maintained
exclusive breast feeding for 6month
personal hygiene: perineal care and skin care given
immunization- immunization of baby as early as possible given
birth spacing- for at least 2yrs given
coitus- abstinence in 1st 1.5 month and with given
caution next 1.5 month
postnatal exercise-abdominal and circulatory exercise given
POSTNATAL VISIT:
First- within 24hrs
Second- within 2-3days
Third-within 4-7days
Fourth - within 42-45 days
ASSESSMENT BY APPLYING OREM’S SELF CARE DEFICIT THEORY:
• Dorothea Elizabeth Orem (July 15, 1914 – June 22, 2007) was one of America’s foremost
nursing theorists who developed the Self-CareNursing Theory, also known as the Orem
Model of Nursing.
• Orem was born in July 15, 1914 in Baltimore, Maryland. Her father was a construction
worker and her mother is a homemaker. She was the youngest among two daughters.
• In the early 1930s, she earned her nursing diploma from the Providence Hospital School
of Nursing in Washington, D.C. She went on to complete her Bachelor of Science in
Nursing in 1939 and her Master of Science in Nursing in 1945, both from the Catholic
University of America in Washington, D.C.
• Dorothea Orem‘s Self-Care Theory defined Nursing as “The act of assisting others in the
provision and management of self-care to maintain or improve human functioning at
home level of effectiveness.” It focuses on each individual’s ability to perform self-care,
defined as “the practice of activities that individuals initiate and perform on their own
behalf in maintaining life, health, and well-being.
Assumptions
The assumptions of Dorothea Orem’s Self-Care Theory are:
(1) In order to stay alive and remain functional, humans engage in constant communication
and connect among themselves and their environment.
(2) The power to act deliberately is exercised to identify needs and to make needed judgments.
(3) Mature human beings experience privations in the form of action in care of self and others
involving making life-sustaining and function-regulating actions.
(4) Human agency is exercised in discovering, developing, and transmitting to others ways and
means to identify needs for, and make inputs into, self and others.
(5) Groups of human beings with structured relationships cluster tasks and allocate
responsibilities for providing care to group members.
The Self-Care or Self-Care Deficit Theory of Nursing is composed of three interrelated theories:
(1) theory of self-care
(2) self-care deficit theory, and
(3) theory of nursing systems
Universal self-care requisites are associated with life processes, as well as the maintenance of
the integrity of human structure and functioning. Orem identifies these requisites, also called
activities of daily living, or ADLs, as:
1. the maintenance of sufficient intake of air, food, and water
2. provision of care associated with the elimination process
3. a balance between activities and rest, as well as between solitude and social interaction
4. the prevention of hazards to human life and well-being
5. the promotion of human functioning
Health deviation self-care is required in conditions of illness, injury, or disease. These include:
1. Seeking and securing appropriate medical assistance
2. Being aware of and attending to the effects and results of pathologic conditions
3. Effectively carrying out medically prescribed measures
4. Modifying self-concepts to accept onseself as being in a particular state of health and in
specific forms of health care
5. Learning to live with the effects of pathologic conditions.
Orem identifies three classifications of nursing system to meet the self-care requisites of the
patient: wholly compensatory system, partly compensatory system, and supportive-educative
system.
Here the mother is able to fulfill her selfcare need , only require support system and
management of normal puerperium. so mother is comes under supportive educative system
day 1(9/08/2022)
GENERAL CONDITION OF ADVICE NURSING INTERVANTION
MOTHER AND BABY--
• Patient conscious take iron rich Bed making done
• Pallor (+ ve) diet Vital sign checked
• Pulse= 78 bpm iron tablet BD I/O chart maintained
• BP= 110/80mmhg per day mother has learned regarding
keep the baby
• Chest/CVS== NAD breastfeeding tehnique and sign of
abreast to
• fundal height- 18cm good attachemnt
mother and
• breast soft and provide preapre a diet chart rich with iron
colostrum present . but breastfeeding icepack and care of episiotomy
baby is not feed episiotomy care site with antibiotic ointment
adequately
• episiotomy pain-
present
• sucking reflex absent
and baby is not fed
properly
• mother's weight- 58kg,
baby weight-2.8kg
• Hb- 9.8g/dl
DAY 2 (10/08/2022)
GENERAL CONDITION OF ADVICE NURSING INTERVANTION
MOTHER AND BABY--
• Patient conscious iron rich diet with Bed making done
• Pallor (+ ve) daily personal Vital sign checked
• Pulse= 80bpm hygiene I/O chart maintain
• BP= 128/90mmhg maintenance promotion of breastfeeding
• Chest/CVS== NAD Medication is given in time
• uterine involution-17cm
• breastfeeding initiated
• lochia- 3pads/day
• baby is healthy and no
jaundice
• body weight-58kg
DAY 3 — (11/08/22)
GENERAL CONDITION ADVICE NURSING INTERVANTION
OF
MOTHER AND BABY--
• Patient nutrious diet • Psychological support is given
conscious intake • Vital sign checked
• Afebrile birth spacing • I/O chart maintained
• Pallor (-- ve) minimum 2yrs • no sign of jaundice
iron tablet intake
• Pulse= 80bpm • measurement of uterine involution
upto 6month and
• BP=
postnatal visit
130/82mmhg care of baby with
• Chest/CVS== aseptic method
NAD
• successful
breastfeeding
• uterine
involution-15cm
• Baby active
• body weight-
57kg
NURSING DIAGNOSIS:
• Pain related to episiotomy incision as evidenced by visualization of facial expression and
verbal statement
• Risk of infection related to lack of hygiene practice as evidenced by observation.
• Imbalance nutrition less than body requirement related to hospitalization as evidenced
by loss of body weight
• risk for hypothermia related to low core body temperature of baby as eidenced by bare
body of baby