POSTNATAL ASSESSMENT

Case no-1

IDENTIFICATION DATA

Name of the hospital : NRSMC&H Registration :896877

Name of the client : Laila Bibi Age : 19 yrs Religion: Muslim
Address with husband’s name : w/o- Mijanur Sk, 7 No, Kamardanga, Kol-46
GPAL: G1P0A0L0 Period of gestation : 40 weeks
Date and time of admission : 11/11/2019 at 2:00 P.M
Unit : I Unde : Dr. B. Bose
Date and time of delivery : 11/11/2019 at 10.58 A.M
Mode of delivery : ND with episiotomy Sex of baby : Female
Condition of baby at birth : Baby cried immediately after birth
Disc no of mother and baby : F/405
Post natal day :1st postnatal day

MOTHER
Brief History
Type of family : Nuclear Total family members : 4
Support person in the family : Husband
Social: Education: Husband : IX Wife : VII
Occupation : Husband : Labour Wife : House wife
Personal : Any drug allergy : Any drug allergy not identified

Medical and Surgical :

Past : Nothing significant Present : Nothing significant
Family : Nothing significant
Diet (Any harmful cultural practices after child birth) : Non –Veg . She takes adequate diet
during pregnancy . No harmful cultural practice after child birth is present .
Bowel and bladder : Bladder and bowel emptied.

367
 Past Obstetric History : LCB :
No. of Year Abortion Any Mode of Place of Sex Baby Any Remarks
pregna (with problems delivery delivery (alive/ problem with the
ncy period) during stillbirth) during history of
antenatal puerperium breastfeeding
period immunization
.
Primigravida

Present obstetric history:

Booked/unbooked : Booked No of antenatal check up : 4
Immunization : 2 dose of Inj TT is taken Total weight gain : 9 kg
Any problem arise during pregnancy : Yes / No√ .
If yes treatment given : Nil

Laboratory reports:
Blood group : B Rh : Positive VDRL: Negative PPBS : Not done
Fasting : 74 mg/dl Hb% : 11.4 gm/dl Others: TSH :1.74mcg/dl
Urine : Sugar: Nil Albumin: Nil
USG report : Single living fetus , liquor –adequate , Placenta – posterior .

Delivery notes ( from records):Normal delivery with mediolateral episiotomy done .A full
term living baby girl was born on 11/11/2019 at 10.58 am .Inj oxytocin 10 IU given .
Total duration of labour : 13 hours
Removal of placenta : Spontaneous√ /Manual
Treatment : Cap Amoxycillin 500 mg 1 cap TDS, Tab Brufen, Tab Metrogyl, Tab
Famotidine.
Received of mother at post natal ward at 11.30 A.M on 11/11/2019

Post natal assessment:

Build: Obese/average/Thin : Average
Gait/ appearance : Normal
Vital signs :
Blood pressure: 110/80 mm of Hg Temp: 98 0F Pulse : 80 bt/m Resp:20 br/min

368
Head to toe postnatal examination:

Hair and scalp : Clean

Eyes : Normal Face : Normal
Mouth : Normal Tongue : Hydrated Teeth : Normal
Ear : NAD Nose : NAD Throat : NAD
Neck glands : NAD
Extremities : NAD Nails : Clean and no cyanosis
Breast and nipple : Soft and secretory Milk secretion : Colostrum present
Chest and heart: NAD
Liver: NAD Spleen: NAD Abdomen: Pain Bladder: Empty
Legs : No edema Homan’s sign: Nil Back and spine: Normal
Personal hygiene : Good
Emotional response : Normal
Postnatal discomforts / compliants : Mild cramping pain .
(sleep , bowel , bladder , thirst , appetite after pain ,etc)

Obstetrical examination:

Inspection: No undue enlargement

Palpation of uterus: Uterus is hard and globular in shape. Fundal height – 13.5 cm .
(Consistency , shape and descent)
Per vaginal inspection / examination :
Vulval edema : Nil
Vagina : Lochia rubra present (Normal)
(Any vaginal bleeding , clots , warts / mole / infection / discharge )
Perineal area / anus : Intact
(Intact , lacerations or haemorrhoids , any pain )
Inspect REEDA for episiotomy wound: Wound is Healthy , no redness and edema .
(Redness , edema , ecchymosis , discharge and apposition )
Colour and amount of lochia odour: Lochia rubra present , Amount – Normal
Smell -Fishy smell
Any complaints : Pain in episiotomy wound site

369
BABY
Physical Examination Findings
Condition of the newborn : Good , Posture - Flexed, well cried, alert

Vital signs:
Colour of skin : Pink texture - soft smooth. Dryness over hands and feet. Good turgor. Vernix
present.
Heart rate (Apex bit): 138 beats/ min Respiration : 40 breaths/ min

Physical measurement:
Weight:2.8 kg Length : 49 cm Head circumference : 34 cm
Chest circumference : 31 cm

Head to foot examination:

Examination of head:
Frontanelles/sutures/caput: Anterior frontanelle dimond shaped , 2.5X3cm. No overriding of
suture, no moulding.
Face: Normal
Eyes: Clean and healthy;. Sclera –White, Iris – Dark gray
Ears:Top of the pinna of ears is in a horizontal plane to the outer cantus .
Pinna is firm ,cartilage felt along with edge .Instant recoil .
Nose: Nasal passage is patent
Mouth:No precocious teeth , no epstain pearl , uvula in midline .No cleft lip or cleft palate .
Neck: Short .No gland is palpable .
Limbs and digits : 10 fingers of hands and toes each .Palmer creases present over 1/3rd portion.
Chests :Clear .
Breast: Breast tissue is more than 10 mm. Areola raised .
Abdomen: Soft , No palpable mass .
Umbilical cord: Umbilical cord is clean and no bleeding .2 arteries and 1 vein present.
Genitalia : Labia majora well developed and completely cover the labia minora. No discharge
Urethral meatus is located above the vaginal orifice .
Anus: Patent.
Spine/back: Normal
Hips(ortoloni’s test): No hip dislocation.

370
Legs: 10 fingers of toes and sole creases present over a 1/3rd portion .
Reflexes:
Grasp: Present Moro: Present Glabellar: Present Rooting: Present
Sucking: Present Planter and Babinski : Present Muscle activity: Normal
Urine: Passed Meconium: Passed
General impression : Baby is normal
(Specify if any abnormalities found)

Nursing care process for mother

Nursing diagnosis Expected Nursing interventions Evaluation
outcomes (Implementations)
1.Alteration of body Normal body Checked vital signs . BP: 110/80 mm
system due to labour system. Checked dehydration level. of hg.
process. Vital signs within Checked fundal height and P-82 b/m
R- 22 b/m
normal range . consistency .
Fundal height-
Fundus firm . Checked lochia – amount , 13.5 cm.
Lochia scanty to colour. Uterus- Hard ,
moderate rubra . globular .
Lochia rubra
present in normal
amount .
2.Pain related to Mother verbalizes Assess for pain relief in mother Suture area is
episiotomy suturing after relief with and administered pain normal .
. interventions . medication . Wound is clean
Pain at the level of Discussed reasons of pain and and healthy .
toleration . it’s expected duration . No unbearable
Assess perineum Inspected the suture area for pain present .
swelling, redness, edema , bleeding .
bleeding . Perineal care provided.
3.Alteration in Mother Provided comfortable position Expressed better
comfort related to experiences and advised early ambulation. feelings.
uterine cramping minimum For uterine cramps Baby is put to
and heaviness of discomfort. administered pain medication. breast.
breast . Promoted perineal exercise.
Assess breast for engorgement.
Instruct to prevent breast
engorgement.
Encouraged proper emptying
by giving colostrums and
continue exclusive breast
feeding.

371
Nursing diagnosis Expected Nursing interventions Evaluation
outcomes (Implementations)

4. Altered nutrition Receive enough Provided normal diet with She had taken diet
and fatigue due to rest. plenty of water Provided rest. and rest.
labour process and Ensured nutrition Advised to adjust sleep timings
sleep pattern with the baby’s sleep timings.
disturbances . Provided support system for
help .
5. Potential Early identification Postnatal assessment done – Normal findings .
alteration in of any deviation . head to foot examination done
physiological
process due to
labour process .
6.Altered No bladder Encouraged to empty the No bladder
elimination pattern distension. bladder and bowel. distension.
due to physiological No full rectum. Measured the first
process of labour . void .
Mother asked for
frequency and
amount of void .
She did not pass
stool.
7.Risk for infection . No signs of post- Provided antibiotic as ordered . No phlebitis , no
partum Checked for Homan’s sign . Homan’s sign .
complication . Episiotomy
No phlebitis , wound normal .
Homan’s sign .
Episiotomy wound
infection .
8.Knowledge deficit Mother verbalizes Taught postnatal exercises – Verbalizes
on self care as understanding of abdominal and breathing , foot understanding of
mother states to written and verbal and leg , pelvic floor, bending verbal
whom to consult for instructions on self and straightening alternate instructions on
post partum checkup care activities and knee. Provided verbal self care activities
and care . breast feeding . instructions about balanced and breast feeding
nutritious diet in increased .
amount and rich in high
protein, vitamin and roughage .
Plenty of water to drink .
Personal hygiene , daily bath ,
clean , loose cotton garments.
Sexual activity.
Return of menstruation .

372
Nursing diagnosis Expected Nursing interventions Evaluation
outcomes (Implementations)
FP methods for spacing .
Signs of complication.
Baby care especially regarding
hypothermia , cord infection ,
meconium , urine and
immunization .
Provided information about
postpartum check up.

9. Alteration of Patient will Established mutual trust and Demonstrate

family process demonstrate good respect . positive parenting
coping skills . Taught parenting , baby behaviour .
Acceptance of role holding , baby care .
of parent . Provided support system .
Demonstrate
positive parenting
behaviour .
Adequate bonding.

Nursing care process for baby

Nursing Expected Nursing interventions Evaluation

diagnosis outcomes (Implementations)
Ineffective Adequate body Kept infant warm with mother. Baby’s body
thermoregulation temperature . Wrapped the baby in a baby temperature is
related to heat sheet covering the head and normal.
loss from extremities.
exposure in Baby is kept clean and dry after
postnatal ward . urination and passing after
meconium.

Potential risk for Establish Mother is advised regarding the Baby is

ineffective airway breathing risk . crying.
due to pressure of effectively. Support person is informed. Respiration is
mother’s breast Baby is kept under close normal.
and baby’s observation. .
blanket .

373
Nursing Expected Nursing interventions Evaluation
diagnosis outcomes (Implementations)

Potential risk for No sign of Strict aseptic technique is No sign of

infection related infection maintained while handling the infection
to newly clamped baby .
umbilical cord Eyes are cleaned with sterile
and exposure to swabs.
eyes to vaginal Cord is checked for dry
secretions . gangrene.
Altered nutrition Unaltered Breastfeeding :Initiated with Baby is active
less than body nutritional colostrum . and passed
requirement status . Baby is sucking breast milk urine .
related to properly . .
newborn’s Checked passage of urine .
transition to Checked baby’s body weight .
extrauterine life.
Altered Normal Checked passage of urine . Baby has
elimination elimination Checked passage of meconium . passed urine
pattern related to pattern . and
newborn’s meconium.
transition to
extrauterine life.
Potential risk for Early diagnosis A thorough physical Nothing
congenital of any examination done . abnormalities
anomalies or any abnormality or All physical parameters checked found
abnormality anomalies .
All reflexes checked
Potential risk for Parents will Helped to allay anxiety related Demonstrates
ineffective accept the role to sex . positive
parenting related of parent . Taught parenting , parenting
to sex of baby . behaviour.
Health seeking Demonstrate Advice given focusing on Parents asked
behaviour related positive normal newborn's problems more
to needs of a parenting regarding : newborn's normal questions and
normal newborn behaviour. behaviour and abnormal one, clarifies their
during hospital Adequate e.g. sleep pattern, condition and doughts
and after bonding. colour of skin, crying, regarding
discharge form elimination, stabilization. baby care.
the hospital. Exclusive breast feeding for 6
months.
Activity / hygiene / clothing /
saftery / security / bonding.

374
Nursing Expected Nursing interventions Evaluation
diagnosis outcomes (Implementations)
Immunization schedule : Inj.
BCG, Hep B and '0' dose polio
given at hospital.
Advice to continue rest of the
schedule in time.
Attendance at well baby clinic.

Signature of student Signature of supervisor

375
 POSTNATAL ASSESSMENT

Case No-2
IDENTIFICATION DATA
Name of the hospital : NRSMC&H Registration : 896889
Name of the client : Manjila Perveen Age : 20 yrs Religion : Muslim
Address with husband’s name : w/o-Asik Molla , 24A, Sulekha,Jadavpur,Kol-32
GPAL: G1P0A0L0 Period of gestation : 38 weeks
Date and time of admission : 12/11/2019 at 5.20 pm
Unit:II Under : Dr. B. Bose
Date and time of delivery : 12/11/2019 at 09.30 pm
Mode of delivery : ND with episiotomy Sex of baby : Female
Condition of baby at birth : Baby cried immediately after birth
Disc no of mother and baby : F/426 Postnatal day : 1st postnatal day

MOTHER
Brief History
Type of family : Nuclear Total family members : 3
Support person in the family:Husband
Social: Education: Husband: Class X Wife : Class IX
Occupation: Husband : Private company Wife : Housewife
Personal:Any drug allergy: Any drug allergy not identified
Medical and surgical : Past: Nothing significant Present: Nothing significant
Family: Nothing significant
Diet(Any harmful cultural practices after child birth) : Non –veg .She takes adequate diet
during pregnancy . No harmful cultural practice after child birth is present .
Bowel and bladder : Bladder and bowel emptied.

Past Obstetric History : LCB :

No. of Year Abortion Any Mode of Place of Sex Baby Any Remarks with
pregna (with problem delivery delivery (alive/ problem the history of
ncy period) during stillbirth) during breastfeeding
antenatal puerperium immunization .
period
Primigravida

376
Present obstetric history:
Booked/unbooked : Booked No of antenatal check up : 3
Immunization : 2 dose of Inj TT is taken Total weight gain : 9kg
Any problem arise during pregnancy : Yes / No√ .
If yes treatment given : Nil

Laboratory reports:
Blood group : B Rh : Positive VDRL: Negative PPBS : Not done
Fasting : 70 mg/dl Hb% : 12 gm/dl Others: TSH : 1.70mcg/dl
Urine :Sugar : Nil Albumin : Nil
USG report : Single living fetus , Liquor –adequate , Placenta – posterior .
Delivery notes ( from records):Normal delivery with mediolateral episiotomy done. A full
term living baby girl was born on 12/11/2019 at 09.30 pm .Inj oxytocin 10 IU given .
Total duration of labour : 12 hours
Removal of placenta : Spontaneous√ /Manual
Treatment : Cap Amoxycillin 500 mg 1 cap TDS , Tab Brufen ,Tab metrogyl, Tab
famotidine. Received of mother at post natal ward at 10.05pm on 12/11/2019.

Post natal assessment:

Build: Obese/average/Thin : Obese
Gait/ appearance : Normal

Vital signs : Blood pressure, Temp, Pulse, Resp-112/80 mm of Hg , 98.40 F, 80 bt/min ,

20 brs/min
Head to toe postnatal examination:
Hair and scalp : Clean
Eyes : Normal Face : Normal Mouth : Normal
Tongue : Hydrated Teeth : Normal Ear : NAD
Nose : NAD Throat : NAD Neck glands: NAD
Extremities : NAD Nails : Clean and no cyanosis
Breast and nipple : Soft and secretory Milk secretion : Colostrum present
Chest and heart : NAD Liver : NAD Spleen : NAD Abdomen : Pain
Bladder: Empty Legs : No edema Homan’s sign : Nil Back and spine : Normal
Personal hygiene: Good Emotional response: Normal

377
 Postnatal discomforts / compliants : Mild cramping pain
(sleep , bowel , bladder , thirst , appetite after pain ,etc)

Obstetrical examination:
Inspection : No undue enlargement
Palpation of uterus : Uterus is hard and globular in shape .Fundal height – 15 cm
(Consistency , shape and descent)
Per vaginal inspection / examination :
Vulval edema : Nil
Vagina : Lochia rubra present (normal)
(Any vaginal bleeding , clots , warts / mole / infection / discharge )
Perineal area / anus : Intact
(Intact , lacerations or haemorrhoids , any pain )
Inspect REEDA for episiotomy wound: Wound is Healthy , no redness and edema .
(Redness , edema , ecchymosis , discharge and apposition )
Colour and amount of lochia odour: Lochia rubra present , amount – normal, smell -fishy
smell
Any complaints : Pain in episiotomy wound site

BABY
Physical Examination Findings
Condition of the newborn : Good, posture-flexed, well cried, alert

Vital signs :
Colour of skin : Pink texture - soft smooth. Dryness over hands and feet .Good turgor .Vernix
present.
Heart rate (Apex bit) :136 beats/ min
Respiration : 44 breaths/ min

Physical measurement:
Weight : 2.6 kg
Length : 50 cm
Head circumference : 33 cm
Chest circumference : 30cm
Head to foot examination:

378
Examination of head:
Frontanelles/sutures/caput: Anterior frontanelle dimond shaped , 2.5X3cm. No overriding of
suture. No moulding.
Face: Normal
Eyes : Clean and healthy. Sclera –White , Iris – Dark gray
Ears : Top of the pinna of ears is in a horizontal plane to the outer cantus .
Pinna is firm ,cartilage felt along with edge. Instant recoil .
Nose : Nasal passage is patent
Mouth : No precocious teeth, no epstain pearl, uvula in midline. No cleft lip or cleft palate.
Neck : Short. No gland is palpable .
Limbs and digits: 10 fingers of hands and toes each .Palmer creases present over 1/3rd portion.
Chests : Clear .
Breast: Breast tissue is more than 10 mm. Areola raised .
Abdomen : Soft .No palpable mass .
Umbilical cord : Umbilical cord is clean and no bleeding .2 arteries and 1 vein present .
Genitalia : Labia majora well developed and completely cover the labia minora.No discharge.
Urethral meatus is located above the vaginal orifice .
Anus : Patent.
Spine/back : Normal .
Hips(ortoloni’s test) : No hip dislocation .
Legs : 10 fingers of toes and sole creases present over a 1/3rd portion .

Reflexes:
Grasp : Present. Moro : Present. Glabellar : Present.
Rooting : Present Sucking : Present. Planter and Babinski : Present.
Muscle activity : Normal. Urine : Passed.
Meconium : Passed .
General impression : Baby is normal .
(Specify if any abnormalities found)

379
Nursing Care Process for Mother
Nursing diagnosis Expected Nursing interventions Evaluation
outcomes (Implementations)
1.Alteration of body Normal body Checked vital signs . BP: 110/80 mm
system due to labour system. Checked dehydration level. of Hg.
process. Vital signs within Checked fundal height and P-82 bt/m
R- 22 br/m
normal range . consistency .
Fundal height- 15
Fundus firm . Checked lochia – amount , cm.
Lochia scanty to colour. Uterus- Hard ,
moderate rubra . globular .
Lochia rubra
present in normal
amount .
2.Pain related to Mother verbalizes Assess for pain relief in mother Suture area is
episiotomy suturing after relief with and administered pain normal .
. interventions . medication . Wound is clean
Pain at the level of Discussed reasons of pain and and healthy .
toleration . it’s expected duration . No unbearable
Assess perineum Inspected the suture area for pain present .
swelling, redness, edema , bleeding .
bleeding . Perineal care provided.
3.Alteration in Mother Provided comfortable position Expressed better
comfort related to experiences and advised early ambulation. feelings.
uterine cramping minimum For uterine cramps Baby is put to
and heaviness of discomfort. administered pain medication. breast.
breast . Promoted perineal exercise.
Assess breast for engorgement.
Instruct to prevent breast
engorgement.
Encouraged proper emptying
by giving colostrums and
continue exclusive breast
feeding.
4.Altered nutrition Receive enough Provided normal diet with She had taken diet
and fatigue due to rest. plenty of water Provided rest. and rest.
labour process and Ensured nutrition Advised to adjust sleep timings
sleep pattern with the baby’s sleep timings.
disturbances . Provided support system for
help .
5.Potential alteration Early identification Postnatal assessment done – Normal findings .
in physiological of any deviation . head to foot examination done
process due to
labour process .

380
Nursing diagnosis Expected Nursing interventions Evaluation
outcomes (Implementations)
6.Altered No bladder Encouraged to empty the No bladder
elimination pattern distension. bladder and bowel. distension.
due to physiological No full rectum. Measured the first
process of labour . void .
Mother asked for
frequency and
amount of void .
She did not pass
stool.

7.Risk for infection . No signs of post- Provided antibiotic as ordered . No phlebitis , no

partum Checked for Homan’s sign . Homan’s sign .
complication . Episiotomy
No phlebitis , wound normal .
Homan’s sign .
Episiotomy wound
infection .

8.Knowledge deficit Mother verbalizes Taught postnatal exercises – Verbalizes

on self care as understanding of abdominal and breathing , foot understanding of
mother states to written and verbal and leg , pelvic floor, bending verbal
whom to consult for instructions on self and straightening alternate instructions on
post partum checkup care activities and knee. Provided verbal self care activities
and care . breast feeding . instructions about balanced and breast feeding
nutritious diet in increased
amount and rich in high
protein, vitamin and roughage .
Plenty of water to drink .
Personal hygiene , daily bath ,
clean , loose cotton garments.
Sexual activity.
Return of menstruation .
FP methods for spacing .
Signs of complication.
Baby care especially regarding
hypothermia , cord infection ,
meconium , urine and
immunization .
Provided information about
postpartum check up.

381
Nursing diagnosis Expected Nursing interventions Evaluation
outcomes (Implementations)
9. Alteration of Patient will Established mutual trust and Demonstrate
family process demonstrate good respect . positive parenting
coping skills . Taught parenting , baby behaviour .
Acceptance of role holding , baby care .
of parent . Provided support system .
Demonstrate
positive parenting
behaviour .
Adequate bonding.

Nursing care process for baby

Nursing Expected Nursing interventions Evaluation

diagnosis outcomes (Implementations)
Ineffective Adequate body Kept infant warm with mother. Baby’s body
thermoregulation temperature . Wrapped the baby in a baby temperature is
related to heat sheet covering the head and normal.
loss from extremities.
exposure in Baby is kept clean and dry after
postnatal ward . urination and passing after
meconium.
Potential risk for Establish Mother is advised regarding the Baby is
ineffective airway breathing risk . crying.
due to pressure of effectively. Support person is informed. Respiration is
mother’s breast Baby is kept under close normal.
and baby’s observation.
blanket.
Potential risk for No sign of Strict aseptic technique is No sign of
infection related infection maintained while handling the infection
to newly clamped baby .
umbilical cord Eyes are cleaned with sterile
and exposure to swabs.
eyes to vaginal Cord is checked for dry
secretions . gangrene.
Altered nutrition Unaltered Breastfeeding :Initiated with Baby is active
less than body nutritional colostrum . and passed
requirement status . Baby is sucking breast milk urine .
related to properly .
newborn’s Checked passage of urine .
transition to Checked baby’s body weight .
extrauterine life.

382
Nursing Expected Nursing interventions Evaluation
diagnosis outcomes (Implementations)
Altered Normal Checked passage of urine . Baby has
elimination elimination Checked passage of meconium . passed urine
pattern related to pattern . and
newborn’s meconium.
transition to
extrauterine life.
Potential risk for Early diagnosis A thorough physical Nothing
congenital of any examination done . abnormalities
anomalies or any abnormality or All physical parameters checked. found
abnormality anomalies All reflexes checked
Potential risk for Parents will Helped to allay anxiety related Demonstrates
ineffective accept the role to sex . positive
parenting related of parent . Taught parenting , parenting
to sex of baby . behaviour.
Health seeking Demonstrate Advice given focusing on Parents asked
behaviour related positive normal newborn's problems more
to needs of a parenting regarding : newborn's normal questions and
normal newborn behaviour. behaviour and abnormal one, clarifies their
during hospital Adequate e.g. sleep pattern, condition and doughts
and after bonding. colour of skin, crying, regarding
discharge form elimination, stabilization. baby care.
the hospital. Exclusive breast feeding for 6
months.
Activity / hygiene / clothing /
saftery / security / bonding.
Immunization schedule : Inj.
BCG, Hep B and '0' dose polio
given at hospital.
Advice to continue rest of the
schedule in time.
Attendance at well baby clinic.

Signature of student Signature of supervisor

383
 POSTNATAL ASSESSMENT

Case No-3

IDENTIFICATION DATA

Name of the hospital : NRSMC&H Registration : 896877

Name of the client : Bulti Roy Age : 20 yrs Religion : Hinduism
Address with husband’s name : w/o-Rakesh Mahato ,137/B, Ananda Palit Road,Kol-14
GPAL: G1P0A0L0 Period of gestation : 40 weeks
Date and time of admission : 12/11/2019 at 6.42 am
Unit:III Dr: S.S.Roy
Date and time of delivery :12/11/2019 at 09.30 pm
Mode of delivery: ND with episiotomy Sex of baby : Female
Condition of baby at birth : Baby cried immediately after birth
Disc no of mother and baby : 236
Post natal day :1st postnatal day

MOTHER
Brief History
Type of family : Nuclear Total family members : 4
Support person in the family : Husband
Social : Education: Husband : Class VII Wife : Class VI
Occupation: Husband : Labour Wife : House wife
Personal:Any drug allergy : Any drug allergy not identified
Medical and surgical : Past: Nothing significant
Present: Nothing significant
Family: Nothing significant
Diet (Any harmful cultural practices after child birth): Non –veg .She takes adequate diet
during pregnancy . No harmful cultural practice after child birth is present .
Bowel and bladder : Bladder and bowel emptied .

384
Past Obstetric History : LCB :
No. of Year Abortion Any Mode of Place of Sex Baby Any Remarks with
pregna (with problem delivery delivery (alive/ problem the history of
ncy period) during stillbirth) during breastfeeding
antenatal puerperium immunization .
period
Primigravida

Present obstetric history:

Booked/unbooked : Booked No of antenatal check up : 4
Immunization : 2 dose of Inj TT is taken Total weight gain : 9 kg
Any problem arise during pregnancy : Yes / No√ .
If yes treatment given : Nil

Laboratory reports:
Blood group : B Rh : Positive VDRL: Negative PPBS: Not done
Fasting: 71 mg/dl Hb%: 11.8 gm/dl Others: TSH :1.72mcg/dl
Urine :Sugar: Nil Albumin: Nil
USG report : Single living fetus , Liquor –adequate , Placenta – posterior .

Delivery notes( from records):Normal delivery with mediolateral episiotomy done .A full
term living baby girl was born on 12/11/2019 at 9.30 pm.Inj oxytocin 10 IU given .
Total duration of labour : 13 hours
Removal of placenta : Spontaneous√ /Manual
Treatment: Cap Amoxycillin 500 mg 1 cap TDS , Tab Brufen ,Tab metrogyl , Tab famotidine
.
Received of mother at post natal ward at 09.55 pm on 12/11/2019.
Post natal assessment:
Build: Obese/average/Thin : Obese
Gait/ appearance : Normal

Vital signs : Blood pressure, Temp, Pulse, Resp — 110/78 mm of Hg, 98.40F, 82 b/m,
22 brs/min

385
Head to toe postnatal examination:
Hair and scalp : Clean
Eyes: Normal Face : Normal
Mouth : Normal Tongue : Hydrated Teeth : Normal
Ear : NAD Nose : NAD Throat : NAD
Neck glands : NAD
Extremities : NAD Nails : Clean and no cyanosis
Breast and nipple : Soft and secretory Milk secretion : Colostrum present
Chest and heart: NAD
Liver : NAD Spleen : NAD Abdomen: Pain Bladder : Empty
Legs : No edema Homan’s sign : Nil Back and spine : Normal
Personal hygiene : Good
Emotional response : Normal
Postnatal discomforts / compliants : Mild cramping pain .
(sleep , bowel , bladder , thirst , appetite after pain ,etc)
Obstetrical examination:
Inspection: No undue enlargement

Palpation of uterus : Uterus is hard and globular in shape .Fundal height – 14cm .
(Consistency , shape and descent)
Per vaginal inspection / examination :
Vulval edema : Nil
Vagina : Lochia rubra present (normal)
(Any vaginal bleeding , clots , warts / mole / infection / discharge )
Perineal area / anus : Intact
(Intact , lacerations or haemorrhoids , any pain )
Inspect REEDA for episiotomy wound : Wound is Healthy , no redness and edema .
(Redness , edema , ecchymosis , discharge and apposition )
Colour and amount of lochia odour: Lochia rubra present , amount – normal Smell -Fishy
smell
Any complaints : Pain in episiotomy wound site

386
 BABY
Physical Examination Findings
Condition of the newborn :Good, posture-flexed, well cried, alert

Vital signs:
Colour of skin :Pink texture - Soft smooth. Dryness over hands and feet. Good turgor .Vernix
present.
Heart rate (Apex bit) : 138 beats/ min
Respiration : 40 breaths/ min

Physical measurement:
Weight : 2.8 kg
Length : 49 cm
Head circumference : 34 cm
Chest circumference : 31 cm

Head to foot examination:

Examination of head:
Frontanelles/sutures/caput : Anterior frontanelle dimond shaped , 2.5X3cm. No overriding of
suture. No moulding.
Face : Normal
Eyes : Clean and healthy. Sclera –white , Iris – Dark gray
Ears : Top of the pinna of ears is in a horizontal plane to the outer cantus .
Pinna is firm ,cartilage felt along with edge .Instant recoil .
Nose : Nasal passage is patent
Mouth : No precocious teeth , no epstain pearl, uvula in midline. No cleft lip or cleft palate.
Neck : Short. No gland is palpable.
Limbs and digits : 10 fingers of hands and toes each .Palmer creases present over 1/3rd
portion.
Chests : Clear.
Breast: Breast tissue is more than 10 mm. Areola raised.
Abdomen: Soft .No palpable mass .

387
Umbilical cord: Umbilical cord is clean and no bleeding .2 arteries and 1 vein present .
Genitalia : Labia majora well developed and completely cover the labia minora . No discharge
Urethral meatus is located above the vaginal orifice .
Anus: Patent.
Spine/back: Normal .
Hips(ortoloni’s test): No hip dislocation .
Legs: 10 fingers of toes and sole creases present over a 1/3rd portion .

Reflexes:
Grasp : Present .
Moro : Present .
Glabellar : Present .
Rooting : Present .
Sucking : Present .
Planter and Babinski : Present .
Muscle activity : Normal .
Urine : Passed.
Meconium : Passed .
General impression : Baby is normal .
(Specify if any abnormalities found)

Nursing care process for mother

Nursing Expected outcomes Nursing interventions Evaluation
diagnosis (Implementations)
1.Alteration of Normal body system. Checked vital signs . BP: 110/80
body system due Vital signs within Checked dehydration level. mm of Hg.
to labour normal range . Checked fundal height and P-82 bt/m
R- 22 br/m
process. Fundus firm . consistency .
Fundal
Lochia scanty to Checked lochia – amount , colour. height- 14
moderate rubra . cm.
Uterus- Hard
, globular .
Lochia rubra
present in
normal
amount .
2.Pain related to Mother verbalizes Assess for pain relief in mother Suture area is
episiotomy after relief with and administered pain medication normal .

388
Nursing Expected outcomes Nursing interventions Evaluation
diagnosis (Implementations)
suturing . interventions . . Wound is
Pain at the level of Discussed reasons of pain and it’s clean and
toleration . expected duration . healthy .
Assess perineum Inspected the suture area for No
swelling, redness, edema , bleeding . unbearable
bleeding . Perineal care provided. pain present .

3.Alteration in Mother experiences Provided comfortable position Expressed

comfort related minimum discomfort. and advised early ambulation. better
to uterine For uterine cramps administered feelings.
cramping and pain medication. Baby is put to
heaviness of Promoted perineal exercise. breast.
breast . Assess breast for engorgement.
Instruct to prevent breast
engorgement.
Encouraged proper emptying by
giving colostrums and continue
exclusive breast feeding.

4.Altered Receive enough rest. Provided normal diet with plenty She had taken
nutrition and Ensured nutrition of water Provided rest. diet and rest.
fatigue due to Advised to adjust sleep timings
labour process with the baby’s sleep timings.
and sleep pattern Provided support system for help .
disturbances .
5.Potential Early identification of Postnatal assessment done – head Normal
alteration in any deviation . to foot examination done findings .
physiological
process due to
labour process .
6.Altered No bladder distension. Encouraged to empty the bladder No bladder
elimination No full rectum. and bowel. distension.
pattern due to Measured the
physiological first void .
process of labour Mother asked
. for frequency
and amount
of void . She
did not pass
stool.
7.Risk for No signs of post- Provided antibiotic as ordered . No phlebitis ,
infection . partum complication . Checked for Homan’s sign . no Homan’s

389
Nursing Expected outcomes Nursing interventions Evaluation
diagnosis (Implementations)
No phlebitis , sign .
Homan’s sign . Episiotomy
Episiotomy wound wound
infection . normal .

8.Knowledge Mother verbalizes Taught postnatal exercises – Verbalizes

deficit on self understanding of abdominal and breathing , foot understanding
care as mother written and verbal and leg , pelvic floor, bending and of verbal
states to whom instructions on self straightening alternate knee. instructions
to consult for care activities and Provided verbal instructions about on self care
post partum breast feeding . balanced nutritious diet in activities and
checkup and care increased amount and rich in high breast feeding
. protein, vitamin and roughage . .
Plenty of water to drink .
Personal hygiene , daily bath ,
clean , loose cotton garments.
Sexual activity.
Return of menstruation .
FP methods for spacing .
Signs of complication.
Baby care especially regarding
hypothermia , cord infection ,
meconium , urine and
immunization .
Provided information about
postpartum check up.
9. Alteration of Patient will Established mutual trust and Demonstrate
family process demonstrate good respect . positive
coping skills. Taught parenting , baby holding , parenting
Acceptance of role of baby care . behaviour .
parent . Provided support system .
Demonstrate positive
parenting behaviour .
Adequate bonding.

Nursing care process for baby

Nursing Expected Nursing interventions Evaluation

diagnosis outcomes (Implementations)
Ineffective Adequate body Kept infant warm with mother. Baby’s body
thermoregulation temperature . Wrapped the baby in a baby sheet temperature is

390
Nursing Expected Nursing interventions Evaluation
diagnosis outcomes (Implementations)
related to heat covering the head and extremities. normal.
loss from Baby is kept clean and dry after
exposure in urination and passing after
postnatal ward . meconium.
Potential risk for Establish Mother is advised regarding the Baby is
ineffective airway breathing risk . crying.
due to pressure of effectively. Support person is informed. Respiration is
mother’s breast Baby is kept under close normal.
and baby’s observation. .
blanket .

Potential risk for No sign of Strict aseptic technique is No sign of

infection related infection maintained while handling the baby infection
to newly clamped .
umbilical cord Eyes are cleaned with sterile
and exposure to swabs.
eyes to vaginal Cord is checked for dry gangrene.
secretions .

Altered nutrition Unaltered Breastfeeding :Initiated with Baby is active

less than body nutritional colostrum . and passed
requirement status . Baby is sucking breast milk urine .
related to properly . .
newborn’s Checked passage of urine .
transition to Checked baby’s body weight .
extrauterine life.

Altered Normal Checked passage of urine . Baby has

elimination elimination Checked passage of meconium . passed urine
pattern related to pattern . and
newborn’s meconium.
transition to
extrauterine life.

Potential risk for Early diagnosis A thorough physical examination Nothing

congenital of any done . abnormalities
anomalies or any abnormality or All physical parameters checked. found
abnormality anomalies All reflexes checked

Potential risk for Parents will Helped to allay anxiety related to Demonstrates
ineffective accept the role sex . positive

391
Nursing Expected Nursing interventions Evaluation
diagnosis outcomes (Implementations)
parenting related of parent . Taught parenting , parenting
to sex of baby. behaviour.

Health seeking Demonstrate Advice given focusing on normal Parents asked

behaviour related positive newborn's problems regarding : more
to needs of a parenting newborn's normal behaviour and questions and
normal newborn behaviour. abnormal one, e.g. sleep pattern, clarifies their
during hospital Adequate condition and colour of skin, doughts
and after bonding. crying, elimination, stabilization. regarding
discharge form Exclusive breast feeding for 6 baby care.
the hospital. months.
Activity / hygiene / clothing /
saftery / security / bonding.
Immunization schedule : Inj. BCG,
Hep B and '0' dose polio given at
hospital.
Advice to continue rest of the
schedule in time.
Attendance at well baby clinic.

Signature of student Signature of supervisor

392
 POSTNATAL ASSESSMENT

Case No-4
IDENTIFICATION DATA

Name of the hospital : NRSMC&H Registration : 911201

Name of the client : Mehera Bibi Age :18 yrs Religion : Muslim
Address with husband’s name : w/o-Monirul Hossain , 96, Tilpara Road,Kol-46
GPAL: G1P0A0L0 Period of gestation : 38 weeks
Date and time of admission : 03/11/2019 at 2.36 AM
Unit : II Under Dr : R.K.Mondal
Date and time of delivery : 13/11/2019 at 10.45 pm
Mode of delivery : ND with episiotomy Sex of baby : Female
Condition of baby at birth : Baby cried immediately after birth
Disc no of mother and baby : 585 Post natal day :1st postnatal day

MOTHER
Brief History
Type of family : Nuclear Total family members : 3
Support person in the family : Mother in low
Social : Education: Husband : Class XII Wife : Class VIII
Occupation: Husband : Private company Wife: House wife
Personal : Any drug allergy: Any drug allergy not identified
Medical and surgical : Past: Nothing significant Present: Nothing significant
Family: Nothing significant
Diet (Any harmful cultural practices after child birth) : Non - veg .She takes adequate diet
during pregnancy . No harmful cultural practice after child birth is present .
Bowel and bladder: Bladder and bowel empty

Past Obstetric History : LCB :

No. of Year Abortion Any Mode of Place of Sex Baby Any Remarks with
pregna (with problem delivery delivery (alive/ problem the history of
ncy period) during stillbirth) during breastfeeding
antenatal puerperium immunization .
period
Primigravida

393
Present obstetric history:
Booked/unbooked : Booked No of antenatal check up : 4
Immunization : 2 dose of Inj TT is taken Total weight gain : 9 kg
Any problem arise during pregnancy : Yes / No√ .
If yes treatment given : Nil

Laboratory reports:
Blood group : B Rh : Positive VDRL: Negative PPBS: Not done
Fasting : 73mg/dl Hb% : 11.8gm/dl Others: TSH :1.73mcg/dl
Urine :Sugar : Nil Albumin : Nil
USG report : Single living fetus , Liquor –adequate , Placenta – posterior .

Delivery notes( from records): Normal delivery with mediolateral episiotomy done .A full
term living baby girl was born on 13/11/2019 at 10.45 pm .Inj oxytocin 10 IU given .

Total duration of labour : 12 hours

Removal of placenta : Spontaneous√ /Manual
Treatment: Cap Amoxycillin 500 mg 1 cap TDS , Tab Brufen ,tab metrogyl , Tab famotidine
.
Received of mother at post natal ward at 11.15 pm on 13/11/2019 .

Post natal assessment:

Build: Obese/average/Thin : Average
Gait/ appearance : Normal

Vital signs : Blood pressure ,Temp,Pulse,Resp.— 118/72 mm of hg , 98.40 F , 78 bt/m ,

20 brs/min

Head to toe postnatal examination:

Hair and scalp : Clean
Eyes : Normal Face: Normal
Mouth: Normal Tongue: Hydrated Teeth: Normal
Ear: NAD Nose: NAD Throat: NAD
Neck glands: NAD Extremities: NAD Nails: Clean and no cyanosis

394
Breast and nipple : Soft and secretory Milk secretion: Colostrum present
Chest and heart: NAD
Liver: NAD Spleen: NAD Abdomen: Pain Bladder: Empty
Legs: No edema Homan’s sign: Nil Back and spine: Normal
Personal hygiene: Good
Emotional response: Normal
Postnatal discomforts / compliants : Mild cramping pain .
(sleep , bowel , bladder , thirst , appetite after pain ,etc)

Obstetrical examination:

Inspection: No undue enlargement

Palpation of uterus: Uterus is hard and globular in shape .Fundal height – 15 cm .

(Consistency , shape and descent)

Per Vaginal inspection / examination :

Vulval edema : Nil

Vagina :Lochia rubra present (normal)
(Any vaginal bleeding , clots , warts / mole / infection / discharge )
Perineal area / anus : Intact
(Intact , lacerations or haemorrhoids , any pain )
Inspect REEDA for episiotomy wound: Wound is Healthy , no redness and edema .
(Redness , edema , ecchymosis , discharge and apposition )
Colour and amount of lochia odour: Lochia rubra present, amount – normal Smell- Fishy
smell.
Any complaints : Pain in episiotomy wound site.

395
 BABY
Physical Examination Findings
Condition of the newborn : Good , posture-flexed ,well cried ,alert

Vital signs:
Colour of skin : Pink texture - soft smooth .Dryness over hands and feet .Good turgor .Vernix
present.
Heart rate (Apex bit): 136 beats/ min
Respiration : 38 breaths/ min

Physical measurement:
Weight: 2.5 kg
Length : 50 cm
Head circumference : 33 cm
Chest circumference : 30cm

Head to foot examination:

Examination of head:
Frontanelles/sutures/caput: Anterior frontanelle dimond shaped , 2.5X3cm. No overriding of
suture, No moulding.
Face: Normal
Eyes: Clean and healthy. Sclera –White, Iris – Dark gray
Ears: Top of the pinna of ears is in a horizontal plane to the outer cantus .
Pinna is firm ,cartilage felt along with edge. Instant recoil .
Nose: Nasal passage is patent
Mouth: No precocious teeth , no epstain pearl , uvula in midline .No cleft lip or cleft palate .
Neck: Short .No gland is palpable .
Limbs and digits: 10 fingers of hands and toes each .Palmer creases present over 1/3rd portion.
Chests :Clear .
Breast: Breast tissue is more than 10 mm. Areola raised .
Abdomen: Soft .No palpable mass .
Umbilical cord: Umbilical cord is clean and no bleeding .2 arteries and 1 vein present .

396
Genitalia: Labia majora well developed and completely cover the labia minora .No discharge.
Urethral meatus is located above the vaginal orifice .
Anus: Patent. Spine/back: Normal. Hips(ortoloni’s test): No hip dislocation .
Legs: 10 fingers of toes and sole creases present over a 1/3rd portion .

Reflexes:
Grasp: Present. Moro: Present. Glabellar: Present .
Rooting: Present. Sucking: Present . Planter and Babinski : Present .
Muscle activity: Normal. Urine: Passed. Meconium: Passed .
General impression : Baby is normal .
(Specify if any abnormalities found)

Nursing care process for mother

Nursing diagnosis Expected Nursing interventions Evaluation
outcomes (Implementations)
1.Alteration of body Normal body Checked vital signs . BP: 110/80 mm of hg.
system due to labour system. Checked dehydration level. P-82 bt/m
process. Vital signs within Checked fundal height and R- 22 br/m
Fundal height- 15 cm.
normal range . consistency .
Uterus- Hard, globular.
Fundus firm . Checked lochia – amount , Lochia rubra present in
Lochia scanty to colour. normal amount .
moderate rubra .
2.Pain related to Mother verbalizes Assess for pain relief in mother Suture area is normal .
episiotomy suturing after relief with and administered pain Wound is clean and
. interventions . medication . healthy .
Pain at the level of Discussed reasons of pain and No unbearable pain
toleration . it’s expected duration . present .
Assess perineum Inspected the suture area for
swelling, redness, edema , bleeding .
bleeding . Perineal care provided.
3.Alteration in Mother Provided comfortable position Expressed better
comfort related to experiences and advised early ambulation. feelings.
uterine cramping minimum For uterine cramps Baby is put to breast.
and heaviness of discomfort. administered pain medication.
breast . Promoted perineal exercise.
Assess breast for engorgement.
Instruct to prevent breast
engorgement.
Encouraged proper emptying
by giving colostrums and

397
Nursing diagnosis Expected Nursing interventions Evaluation
outcomes (Implementations)
continue exclusive breast
feeding.

4.Altered nutrition Receive enough Provided normal diet with She had taken diet and
and fatigue due to rest. plenty of water Provided rest. rest.
labour process and Ensured nutrition Advised to adjust sleep timings
sleep pattern with the baby’s sleep timings.
disturbances . Provided support system for
help .

5.Potential alteration Early identification Postnatal assessment done – Normal findings .

in physiological of any deviation . head to foot examination done
process due to
labour process .

6.Altered No bladder Encouraged to empty the No bladder distension.

elimination pattern distension. bladder and bowel. Measured the first void.
due to physiological No full rectum. Mother asked for
process of labour . frequency and amount
of void . She did not
pass stool.
7.Risk for infection . No signs of post- Provided antibiotic as ordered . No phlebitis , no
partum Checked for Homan’s sign . Homan’s sign .
complication . Episiotomy wound
No phlebitis , normal .
Homan’s sign .
Episiotomy wound
infection .

8.Knowledge deficit Mother verbalizes Taught postnatal exercises – Verbalizes

on self care as understanding of abdominal and breathing , foot understanding of verbal
mother states to written and verbal and leg , pelvic floor, bending instructions on self care
whom to consult for instructions on self and straightening alternate activities and breast
post partum checkup care activities and knee. Provided verbal feeding .
and care . breast feeding . instructions about balanced
nutritious diet in increased
amount and rich in high
protein, vitamin and roughage .
Plenty of water to drink .
Personal hygiene , daily bath ,
clean , loose cotton garments.
Sexual activity.

398
Nursing diagnosis Expected Nursing interventions Evaluation
outcomes (Implementations)
Return of menstruation .
FP methods for spacing .
Signs of complication.
Baby care especially regarding
hypothermia , cord infection ,
meconium , urine and
immunization .
Provided information about
postpartum check up.

9. Alteration of Patient will Established mutual trust and Demonstrate positive

family process demonstrate good respect . parenting behaviour .
coping skills . Taught parenting , baby
Acceptance of role holding , baby care .
of parent . Provided support system .
Demonstrate
positive parenting
behaviour .
Adequate bonding.

Nursing care process for baby

Nursing Expected Nursing interventions Evaluation

diagnosis outcomes (Implementations)
Ineffective Adequate body Kept infant warm with mother. Baby’s body
thermoregulation temperature . Wrapped the baby in a baby temperature is
related to heat sheet covering the head and normal.
loss from extremities.
exposure in Baby is kept clean and dry after
postnatal ward . urination and passing after
meconium.

Potential risk for Establish Mother is advised regarding the Baby is

ineffective airway breathing risk . crying.
due to pressure of effectively. Support person is informed. Respiration is
mother’s breast Baby is kept under close normal.
and baby’s observation. .
blanket .

399
Nursing Expected Nursing interventions Evaluation
diagnosis outcomes (Implementations)

Potential risk for No sign of Strict aseptic technique is No sign of

infection related infection maintained while handling the infection
to newly clamped baby .
umbilical cord Eyes are cleaned with sterile
and exposure to swabs.
eyes to vaginal Cord is checked for dry
secretions . gangrene.

Altered nutrition Unaltered Breastfeeding :Initiated with Baby is active

less than body nutritional colostrum . and passed
requirement status . Baby is sucking breast milk urine .
related to properly . .
newborn’s Checked passage of urine .
transition to Checked baby’s body weight .
extrauterine life.

Altered Normal Checked passage of urine . Baby has

elimination elimination Checked passage of meconium . passed urine
pattern related to pattern . and
newborn’s meconium.
transition to
extrauterine life.

Potential risk for Early diagnosis A thorough physical Nothing

congenital of any examination done . abnormalities
anomalies or any abnormality or All physical parameters checked found
abnormality anomalies All reflexes checked

Potential risk for Parents will Helped to allay anxiety related Demonstrates
ineffective accept the role to sex . positive
parenting related of parent . Taught parenting , parenting
to sex of baby . behaviour.

Health seeking Demonstrate Advice given focusing on Parents asked

behaviour related positive normal newborn's problems more
to needs of a parenting regarding : newborn's normal questions and
normal newborn behaviour. behaviour and abnormal one, clarifies their
during hospital Adequate e.g. sleep pattern, condition and doughts
and after bonding. colour of skin, crying, regarding

400
Nursing Expected Nursing interventions Evaluation
diagnosis outcomes (Implementations)
discharge form elimination, stabilization. baby care.
the hospital. Exclusive breast feeding for 6
months.
Activity / hygiene / clothing /
saftery / security / bonding.
Immunization schedule : Inj.
BCG, Hep B and '0' dose polio
given at hospital.
Advice to continue rest of the
schedule in time.
Attendance at well baby clinic.

Signature of student Signature of supervisor

401
 POSTNATAL ASSESSMENT
Case No-5
IDENTIFICATION DATA
Name of the hospital : NRSMC&H Registration : 911220
Name of the client : Shilpa Thakur Age:19 yrs Religion : Hinduism
Address with husband’s name : w/o-Palton Mallick , Moulali,Entally,Kolkata
GPAL: G1P0A0L0 Period of gestation :39 weeks
Date and time of admission : 14/11/2019 at 7.18 AM
Unit: II Dr : T.K. Maity
Date and time of delivery : 14/11/19 at 11.34 pm
Mode of delivery: ND with episiotomy Sex of baby : Female
Condition of baby at birth : Baby cried immediately after birth
Disc no of mother and baby : 55 Postnatal day :1st postnatal day

MOTHER
Brief History
Type of family: Nuclear Total family members : 4
Support person in the family: Father in low
Social: Education: Husband: IX Wife:VI
Occupation: Husband: Shoe maker Wife: House wife
Personal: Any drug allergy: Any drug allergy not identified
Medical and surgical :
Past : Nothing significant
Present : Nothing significant
Family : Nothing significant
Diet (Any harmful cultural practices after child birth): Non –veg .She takes adequate diet
during pregnancy . No harmful cultural practice after child birth is present .
Bowel and bladder: Bladder and bowel emptied .

Past Obstetric History : LCB :

No. of Year Abortion Any Mode of Place of Sex Baby Any Remarks with
pregna (with problem delivery delivery (alive/ problem the history of
ncy period) during stillbirth) during breastfeeding
antenatal puerperium immunization .
period
Primigravida

402
Present obstetric history:
Booked/unbooked : Booked No of antenatal check up: 3
Immunization : 2 dose of Inj TT is taken Total weight gain : 9 kg
Any problem arise during pregnancy: Yes / No√ .
If yes treatment given: Nil

Laboratory reports:
Blood group: B Rh: Positive VDRL: Negative PPBS: Not done
Fasting: 71 mg/dl Hb%: 11.4 gm/dl Others: TSH :1.74mcg/dl
Urine :Sugar: Nil Albumin: Nil
USG report: Single living fetus , Liquor –adequate , Placenta – posterior .

Delivery notes( from records):Normal delivery with mediolateral episiotomy done .A full
term living baby girl was born on 14/11/2019 at 11.34 pm .Inj oxytocin 10 IU given .
Total duration of labour : 13 hours
Removal of placenta : Spontaneous√ /Manual
Treatment: Cap Amoxycillin 500 mg 1 cap TDS , Tab Brufen ,Tab metrogyl , Tab famotidine
.
Received of mother at post natal ward at 11.58pm on 14/11/2019.

Post natal assessment:

Build: Obese/average/Thin : Obese
Gait/ appearance: Normal

Vital signs : Blood pressure ,Temp,Pulse,Resp.— 110/72 mm of Hg , 98 0 F , 82 bt/m ,

20 brs/min
Head to toe postnatal examination:
Hair and scalp: Clean
Eyes: Normal Face: Normal
Mouth: Normal Tongue: Hydrated Teeth: Normal
Ear: NAD Nose: NAD Throat: NAD
Neck glands: NAD
Extremities: NAD Nails: Clean and no cyanosis

403
Breast and nipple : Soft and secretory Milk secretion: Colostrum present
Chest and heart: NAD
Liver: NAD Spleen: NAD Abdomen: Pain Bladder: Empty
Legs: No edema Homan’s sign: Nil Back and spine: Normal
Personal hygiene: Good
Emotional response: Normal
Postnatal discomforts / compliants : Mild cramping pain .
(sleep, bowel, bladder, thirst, appetite after pain, etc)

Obstetrical examination:
Inspection: No undue enlargement

Palpation of uterus: Uterus is hard and globular in shape .Fundal height – 13 cm .

(Consistency, shape and descent)
Per vaginal inspection / examination :
Vulval edema : Nil
Vagina :Lochia rubra present (normal)
(Any vaginal bleeding , clots , warts / mole / infection / discharge )
Perineal area / anus : Intact
(Intact , lacerations or haemorrhoids , any pain )
Inspect REEDA for episiotomy wound: Wound is Healthy , no redness and edema .
(Redness , edema , ecchymosis , discharge and apposition )
Colour and amount of lochia odour: Lochia rubra present, Amount- Normal
Smell - Fishy smell

Any complaints : Pain in episiotomy wound site

404
 BABY
Physical Examination Findings
Condition of the newborn : Good , posture-flexed ,well cried ,alert
Vital signs:
Colour of skin : Pink texture - soft smooth .Dryness over hands and feet .Good turgor .Vernix
present.
Heart rate (Apex bit):138 beats/ min
Respiration : 40 breaths/ min
Physical measurement:
Weight: 2.6 kg
Length : 49 cm
Head circumference : 34 cm
Chest circumference : 31 cm

Head to foot examination:

Examination of head:
Frontanelles/sutures/caput: Anterior frontanelle dimond shaped , 2.5X3cm. No overriding of
suture, No moulding.
Face: Normal
Eyes: Clean and healthy. Sclera –White, Iris – Dark gray
Ears: Top of the pinna of ears is in a horizontal plane to the outer cantus .
Pinna is firm ,cartilage felt along with edge .Instant recoil .
Nose: Nasal passage is patent
Mouth:No precocious teeth , no epstain pearl , uvula in midline .No cleft lip or cleft palate .
Neck: Short .No gland is palpable .
Limbs and digits: 10 fingers of hands and toes each .Palmer creases present over 1/3rd portion.
Chests : Clear .
Breast:Breast tissue is more than 10 mm. Areola raised.
Abdomen: Soft. No palpable mass.
Umbilical cord: Umbilical cord is clean and no bleeding. 2 arteries and 1 vein present.
Genitalia : Labia majora well developed and completely cover the labia minora. No discharge.
Urethral meatus is located above the vaginal orifice.
Anus: Patent. Spine/back: Normal. Hips (ortoloni’s test): No hip dislocation .

405
Legs: 10 fingers of toes and sole creases present over a 1/3rd portion .

Reflexes:
Grasp: Present Moro: Present Glabellar: Present
Rooting: present Sucking: Present Planter and Babinski : Present
Muscle activity: Normal Urine: Passed Meconium: Passed
General impression : Baby is normal
(Specify if any abnormalities found)

Nursing Care Process for Mother

Nursing diagnosis Expected Nursing interventions Evaluation
outcomes (Implementations)
1.Alteration of body Normal body Checked vital signs . BP: 110/80 mm
system due to labour system. Checked dehydration level. of Hg.
process. Vital signs within Checked fundal height and P-82 bt/m
R- 22 br/m
normal range . consistency .
Fundal height- 13
Fundus firm . Checked lochia – amount , cm.
Lochia scanty to colour. Uterus- Hard ,
moderate rubra . globular .
Lochia rubra
present in normal
amount .
2.Pain related to Mother verbalizes Assess for pain relief in mother Suture area is
episiotomy suturing after relief with and administered pain normal .
. interventions . medication . Wound is clean
Pain at the level of Discussed reasons of pain and and healthy .
toleration . it’s expected duration . No unbearable
Assess perineum Inspected the suture area for pain present .
swelling, redness, edema , bleeding .
bleeding . Perineal care provided.
3.Alteration in Mother Provided comfortable position Expressed better
comfort related to experiences and advised early ambulation. feelings.
uterine cramping minimum For uterine cramps Baby is put to
and heaviness of discomfort. administered pain medication. breast.
breast . Promoted perineal exercise.
Assess breast for engorgement.
Instruct to prevent breast
engorgement.
Encouraged proper emptying
by giving colostrums and
continue exclusive breast

406
Nursing diagnosis Expected Nursing interventions Evaluation
outcomes (Implementations)
feeding.
4.Altered nutrition Receive enough Provided normal diet with She had taken diet
and fatigue due to rest. plenty of water Provided rest. and rest.
labour process and Ensured nutrition Advised to adjust sleep timings
sleep pattern with the baby’s sleep timings.
disturbances . Provided support system for
help .
5.Potential alteration Early identification Postnatal assessment done – Normal findings .
in physiological of any deviation . head to foot examination done
process due to
labour process .
6.Altered No bladder Encouraged to empty the No bladder
elimination pattern distension. bladder and bowel. distension.
due to physiological No full rectum. Measured the first
process of labour . void .
Mother asked for
frequency and
amount of void .
She did not pass
stool.
7.Risk for infection . No signs of post- Provided antibiotic as ordered . No phlebitis , no
partum Checked for Homan’s sign . Homan’s sign .
complication . Episiotomy
No phlebitis , wound normal .
Homan’s sign .
Episiotomy wound
infection .
8.Knowledge deficit Mother verbalizes Taught postnatal exercises – Verbalizes
on self care as understanding of abdominal and breathing , foot understanding of
mother states to written and verbal and leg , pelvic floor, bending verbal
whom to consult for instructions on self and straightening alternate instructions on
post partum checkup care activities and knee. Provided verbal self care activities
and care . breast feeding . instructions about balanced and breast feeding
nutritious diet in increased .
amount and rich in high
protein, vitamin and roughage .
Plenty of water to drink .
Personal hygiene , daily bath ,
clean , loose cotton garments.
Sexual activity.
Return of menstruation .

407
Nursing diagnosis Expected Nursing interventions Evaluation
outcomes (Implementations)
FP methods for spacing .
Signs of complication.
Baby care especially regarding
hypothermia , cord infection ,
meconium , urine and
immunization .
Provided information about
postpartum check up.

9. Alteration of Patient will Established mutual trust and Demonstrate

family process demonstrate good respect . positive parenting
coping skills . Taught parenting , baby behaviour .
Acceptance of role holding , baby care .
of parent . Provided support system .
Demonstrate
positive parenting
behaviour .
Adequate bonding.

Nursing care process for baby

Nursing Expected Nursing interventions Evaluation

diagnosis outcomes (Implementations)
Ineffective Adequate body Kept infant warm with mother. Baby’s body
thermoregulation temperature . Wrapped the baby in a baby temperature is
related to heat sheet covering the head and normal.
loss from extremities.
exposure in Baby is kept clean and dry after
postnatal ward . urination and passing after
meconium.

Potential risk for Establish Mother is advised regarding the Baby is

ineffective airway breathing risk . crying.
due to pressure of effectively. Support person is informed. Respiration is
mother’s breast Baby is kept under close normal.
and baby’s observation. .
blanket .

408
Nursing Expected Nursing interventions Evaluation
diagnosis outcomes (Implementations)

Potential risk for No sign of Strict aseptic technique is No sign of

infection related infection maintained while handling the infection
to newly clamped baby .
umbilical cord Eyes are cleaned with sterile
and exposure to swabs.
eyes to vaginal Cord is checked for dry
secretions . gangrene.

Altered nutrition Unaltered Breastfeeding :Initiated with Baby is active

less than body nutritional colostrum . and passed
requirement status . Baby is sucking breast milk urine .
related to properly . .
newborn’s Checked passage of urine .
transition to Checked baby’s body weight .
extrauterine life.

Altered Normal Checked passage of urine . Baby has

elimination elimination Checked passage of meconium . passed urine
pattern related to pattern . and
newborn’s meconium.
transition to
extrauterine life.

Potential risk for Early diagnosis A thorough physical Nothing

congenital of any examination done . abnormalities
anomalies or any abnormality or All physical parameters found
abnormality anomalies checked.
All reflexes checked

Potential risk for Parents will Helped to allay anxiety related Demonstrates
ineffective accept the role to sex . positive
parenting related of parent . Taught parenting , parenting
to sex of baby . behaviour.

Health seeking Demonstrate Advice given focusing on Parents asked

behaviour related positive normal newborn's problems more
to needs of a parenting regarding : newborn's normal questions and
normal newborn behaviour. behaviour and abnormal one, clarifies their
during hospital Adequate e.g. sleep pattern, condition and doughts
and after bonding. colour of skin, crying, regarding

409
Nursing Expected Nursing interventions Evaluation
diagnosis outcomes (Implementations)
discharge form elimination, stabilization. baby care.
the hospital. Exclusive breast feeding for 6
months.
Activity / hygiene / clothing /
saftery / security / bonding.
Immunization schedule : Inj.
BCG, Hep B and '0' dose polio
given at hospital.
Advice to continue rest of the
schedule in time.
Attendance at well baby clinic.

Signature of student Signature of supervisor

410
 POSTNATAL ASSESSMENT

Case No-6

IDENTIFICATION DATA

Name of the hospital : NRSMC&H Registration : 905252

Name of the client : Laila Bibi Age:19 yrs Religion: Muslim
Address with husband’s name : w/o-Mijanur Sk , Vill-Raghunathpur, P.O- Bhangar,
P.S.-Bhangar , Dist- North-24 Parganas.
GPAL: G1P0A0L0 Period of gestation :40 weeks
Date and time of admission : 16/11/2019 at 2pm
Unit:I Dr: T. Mondal
Date and time of delivery: 16/11/2019 at 10.58 am
Mode of delivery : ND with episiotomy Sex of baby: Female
Condition of baby at birth : Baby cried immediately after birth
Disc no of mother and baby: F/410
Post natal day:1st postnatal day

MOTHER
Brief History
Type of family: Nuclear Total family members : 4
Support person in the family: Mother in low
Social: Education: Husband: X Wife: VII
Occupation: Husband: Labour Wife: House wife
Personal: Any drug allergy: Any drug allergy not identified

Medical and surgical :

Past: Nothing significant Present: Nothing significant

Family: Nothing significant
Diet (Any harmful cultural practices after child birth): Non –veg .She takes adequate diet
during pregnancy . No harmful cultural practice after child birth is present .
Bowel and bladder: Bladder and bowel emptied .

411
 Past Obstetric History : LCB :
No. of Year Abortion Any Mode of Place of Sex Baby Any Remarks
pregna (with problems delivery delivery (alive/ problem with the
ncy period) during stillbirth) during history of
antenatal puerperium breastfeeding
period immunization
.
Primigravida

Present obstetric history:

Booked/unbooked: Booked No of antenatal check up: 4
Immunization : 2 dose of Inj TT IS Taken Total weight gain: 9 kg
Any problem arise during pregnancy: Yes / No√ .
If yes treatment given: Nil

Laboratory reports:
Blood group: B Rh: Positive VDRL: Negative PPBS: Not done
Fasting: 71 mg/dl Hb% : 11.8 gm/dl Others: TSH : 1.74mcg/dl
Urine : Sugar: Nil Albumin : Nil
USG report : Single living fetus , liquor –adequate , Placenta – posterior .

Delivery notes ( from records): Normal delivery with mediolateral episiotomy done .A full
term living baby girl was born on 16/11/2019 at 10.58 pm .Inj oxytocin 10 IU given .
Total duration of labour: 13 hours
Removal of placenta : Spontaneous√ /Manual
Treatment: Cap Amoxycillin 500 mg 1 cap TDS , Tab Brufen ,Tab metrogyl , Tab famotidine
.Received of mother at post natal ward at 11pm on 16/11/2019

Post natal assessment:

Build: Obese/average/Thin: Average
Gait/ appearance: Normal

Vital signs : Blood pressure, Temp, Pulse,Resp - 110/72 mm of Hg , 98.60 F , 82 bt/m ,

412
 22 br/min

Head to toe postnatal examination:

Hair and scalp: Clean
Eyes: Normal Face: Normal
Mouth: Normal Tongue: Hydrated Teeth: Normal
Ear: NAD Nose: NAD Throat: NAD
Neck glands: NAD
Extremities: NAD Nails: Clean and no cyanosis
Breast and nipple : Soft and secretory Milk secretion: Colostrum present
Chest and heart: NAD
Liver: NAD Spleen: NAD Abdomen: Pain Bladder: Empty
Legs: No edema Homan’s sign: Nil Back and spine: Normal
Personal hygiene: Good
Emotional response: Normal
Postnatal discomforts / compliants : Mild cramping pain .
(sleep , bowel , bladder , thirst , appetite after pain ,etc)

Obstetrical examination:
Inspection: No undue enlargement

Palpation of uterus: Uterus is hard and globular in shape .Fundal height – 15 cm .

(Consistency , shape and descent)

Per vaginal inspection / examination :

Vulval edema : Nil
Vagina : Lochia rubra present (Normal)
(Any vaginal bleeding , clots , warts / mole / infection / discharge )
Perineal area / anus :Intact
(Intact , lacerations or haemorrhoids , any pain )
Inspect REEDA for episiotomy wound: Wound is Healthy , no redness and edema .
(Redness , edema , ecchymosis , discharge and apposition )
Colour and amount of lochia odour: Lochia rubra present , Amount – normal
Smell -Fishy smell

413
Any complaints : Pain in episiotomy wound site

BABY
Physical Examination Findings
Condition of the newborn :Good , posture-flexed ,well cried ,alert

Vital signs:
Colour of skin :Pink texture - soft smooth .Dryness over hands and feet .Good turgor .Vernix
present.
Heart rate (Apex bit): 138 beats/ min Respiration : 40 breaths/ min

Physical measurement:
Weight: 2.8 kg Length : 49 cm Head circumference : 34 cm
Chest circumference : 31 cm

Head to foot examination:

Examination of head:
Frontanelles/sutures/caput: Anterior frontanelle dimond shaped , 2.5X3cm. No overriding of
suture, no moulding.
Face: Normal
Eyes: Clean and healthy;. Sclera –White, Iris – Dark gray
Ears:Top of the pinna of ears is in a horizontal plane to the outer cantus .
Pinna is firm ,cartilage felt along with edge .Instant recoil .
Nose: Nasal passage is patent
Mouth: No precocious teeth , no epstain pearl , uvula in midline .No cleft lip or cleft palate .
Neck: Short .No gland is palpable .
Limbs and digits : 10 fingers of hands and toes each .Palmer creases present over 1/3rd portion.
Chests : Clear .
Breast: Breast tissue is more than 10 mm. Areola raised .
Abdomen: Soft , No palpable mass .
Umbilical cord: Umbilical cord is clean and no bleeding .2 arteries and 1 vein present .
Genitalia : Labia majora well developed and completely cover the labia minora .No discharge
.Urethral meatus is located above the vaginal orifice .
Anus: Patent.
Spine/back: Normal .

414
Hips(ortoloni’s test): No hip dislocation .
Legs: 10 fingers of toes and sole creases present over a 1/3rd portion .
Reflexes:
Grasp: Present Moro: Present Glabellar: Present Rooting: Present
Sucking: Present Planter and Babinski : Present Muscle activity: Normal
Urine: Passed. Meconium: Passed .
General impression : Baby is normal
(Specify if any abnormalities found)

Nursing care process for mother

Nursing diagnosis Expected Nursing interventions Evaluation
outcomes (Implementations)
1.Alteration of body Normal body Checked vital signs . BP: 110/80 mm
system due to labour system. Checked dehydration level.of Hg.
process. Vital signs within Checked fundal height and P-82 bt/m
R- 22 br/m
normal range . consistency .
Fundal height- 15
Fundus firm . Checked lochia – amount , cm.
Lochia scanty to colour. Uterus- Hard ,
moderate rubra . globular .
Lochia rubra
present in normal
amount .
2.Pain related to Mother verbalizes Assess for pain relief in mother Suture area is
episiotomy suturing after relief with and administered pain normal .
. interventions . medication . Wound is clean
Pain at the level of Discussed reasons of pain and and healthy .
toleration . it’s expected duration . No unbearable
Assess perineum Inspected the suture area for pain present .
swelling, redness, edema , bleeding .
bleeding . Perineal care provided.
3.Alteration in Mother Provided comfortable position Expressed better
comfort related to experiences and advised early ambulation. feelings.
uterine cramping minimum For uterine cramps Baby is put to
and heaviness of discomfort. administered pain medication. breast.
breast . Promoted perineal exercise.
Assess breast for engorgement.
Instruct to prevent breast
engorgement.
Encouraged proper emptying
by giving colostrums and

415
Nursing diagnosis Expected Nursing interventions Evaluation
outcomes (Implementations)
continue exclusive breast
feeding.

4.Altered nutrition Receive enough Provided normal diet with She had taken diet
and fatigue due to rest. plenty of water Provided rest. and rest.
labour process and Ensured nutrition Advised to adjust sleep timings
sleep pattern with the baby’s sleep timings.
disturbances . Provided support system for
help .
5.Potential alteration Early identification Postnatal assessment done – Normal findings .
in physiological of any deviation . head to foot examination done
process due to
labour process .
6.Altered No bladder Encouraged to empty the No bladder
elimination pattern distension. bladder and bowel. distension.
due to physiological No full rectum. Measured the first
process of labour . void .
Mother asked for
frequency and
amount of void .
She did not pass
stool.
7.Risk for infection . No signs of post- Provided antibiotic as ordered . No phlebitis , no
partum Checked for Homan’s sign . Homan’s sign .
complication . Episiotomy
No phlebitis , wound normal .
Homan’s sign .
Episiotomy wound
infection .
8.Knowledge deficit Mother verbalizes Taught postnatal exercises – Verbalizes
on self care as understanding of abdominal and breathing , foot understanding of
mother states to written and verbal and leg , pelvic floor, bending verbal
whom to consult for instructions on self and straightening alternate instructions on
post partum checkup care activities and knee. Provided verbal self care activities
and care . breast feeding . instructions about balanced and breast feeding
nutritious diet in increased .
amount and rich in high
protein, vitamin and roughage .
Plenty of water to drink .
Personal hygiene , daily bath ,
clean , loose cotton garments.
Sexual activity.

416
Nursing diagnosis Expected Nursing interventions Evaluation
outcomes (Implementations)
Return of menstruation .
FP methods for spacing .
Signs of complication.
Baby care especially regarding
hypothermia , cord infection ,
meconium , urine and
immunization .
Provided information about
postpartum check up.

9. Alteration of Patient will Established mutual trust and Demonstrate

family process demonstrate good respect . positive parenting
coping skills . Taught parenting , baby behaviour .
Acceptance of role holding , baby care .
of parent . Provided support system .
Demonstrate
positive parenting
behaviour .
Adequate bonding.

Nursing care process for baby

Nursing Expected Nursing interventions Evaluation

diagnosis outcomes (Implementations)
Ineffective Adequate body Kept infant warm with mother. Baby’s body
thermoregulation temperature . Wrapped the baby in a baby temperature is
related to heat sheet covering the head and normal.
loss from extremities.
exposure in Baby is kept clean and dry after
postnatal ward . urination and passing after
meconium.

Potential risk for Establish Mother is advised regarding the Baby is

ineffective airway breathing risk . crying.
due to pressure of effectively. Support person is informed. Respiration is
mother’s breast Baby is kept under close normal.
and baby’s observation. .
blanket .

417
Nursing Expected Nursing interventions Evaluation
diagnosis outcomes (Implementations)

Potential risk for No sign of Strict aseptic technique is No sign of

infection related infection maintained while handling the infection
to newly clamped baby .
umbilical cord Eyes are cleaned with sterile
and exposure to swabs.
eyes to vaginal Cord is checked for dry
secretions . gangrene.
Altered nutrition Unaltered Breastfeeding :Initiated with Baby is active
less than body nutritional colostrum . and passed
requirement status . Baby is sucking breast milk urine .
related to properly . .
newborn’s Checked passage of urine .
transition to Checked baby’s body weight .
extrauterine life.
Altered Normal Checked passage of urine . Baby has
elimination elimination Checked passage of meconium . passed urine
pattern related to pattern . and
newborn’s meconium.
transition to
extrauterine life.
Potential risk for Early diagnosis A thorough physical Nothing
congenital of any examination done . abnormalities
anomalies or any abnormality or All physical parameters checked found
abnormality anomalies .
All reflexes checked
Potential risk for Parents will Helped to allay anxiety related Demonstrates
ineffective accept the role to sex . positive
parenting related of parent . Taught parenting , parenting
to sex of baby . behaviour.
Health seeking Demonstrate Advice given focusing on Parents asked
behaviour related positive normal newborn's problems more
to needs of a parenting regarding : newborn's normal questions and
normal newborn behaviour. behaviour and abnormal one, clarifies their
during hospital Adequate e.g. sleep pattern, condition and doughts
and after bonding. colour of skin, crying, regarding
discharge form elimination, stabilization. baby care.
the hospital. Exclusive breast feeding for 6
months.
Activity / hygiene / clothing /

418
Nursing Expected Nursing interventions Evaluation
diagnosis outcomes (Implementations)
saftery / security / bonding.
Immunization schedule : Inj.
BCG, Hep B and '0' dose polio
given at hospital.
Advice to continue rest of the
schedule in time.
Attendance at well baby clinic.

Signature of student Signature of supervisor

419
 POSTNATAL ASSESSMENT
Case No-7

IDENTIFICATION DATA

Name of the hospital : NRSMC&H Registration : 911345

Name of the client : Rajlakshmi Ghosh Age : 22 yrs
Religion: Hinduism
Address with husband’s name : w/o-Mohinaj Ghosh, 26,Avenu South, Santoshpur, Kol-75

GPAL: G1P0A0L0 Period of gestation : 39weeks

Date and time of admission : 15/11/2019 at 2pm
Unit: IV Dr: B. Bhadra
Date and time of delivery: 16/11/2019 at 6:00 PM
Mode of delivery: ND with episiotomy Sex of baby: Female
Condition of baby at birth: Baby cried immediately after birth
Disc no of mother and baby: F/419
Post natal day: 1st postnatal day

MOTHER

Brief History
Type of family: Nuclear Total family members : 4
Support person in the family: Husband
Social: Education: Husband: VII Wife: VI
Occupation: Husband: Labour Wife: House wife
Personal: Any drug allergy: Any drug allergy not identified

Medical and surgical :

Past: Nothing significant Present: Nothing significant
Family: Nothing significant
Diet (Any harmful cultural practices after child birth): Non –veg .She takes adequate diet
during pregnancy . No harmful cultural practice after child birth is present .
Bowel and bladder: Bladder and bowel emptied .

420
 Past Obstetric History : LCB :
No. of Year Abortion Any Mode of Place of Sex Baby Any Remarks
pregna (with problems delivery delivery (alive/ problem with the
ncy period) during stillbirth) during history of
antenatal puerperium breastfeeding
period immunization
.
Primigravida

Present obstetric history:

Booked/unbooked : Booked No of antenatal check up: 4
Immunization : 2 dose of TT is taken Total weight gain : 10 kg
Any problem arise during pregnancy : Yes / No√ .
If yes treatment given : Nil

Laboratory reports:

Blood group : B Rh : Positive VDRL: Negative PPBS:120 mg/dl

Fasting: 80 mg/dl Hb% : 11.2 gm/dl Others: TSH :1.68 mcg/dl
Urine :Sugar : Nil Albumin : Nil
USG report : Single living fetus , Liquor –adequate , Placenta – posterior .

Delivery notes ( from records):Normal delivery with mediolateral episiotomy done .A full
term living baby girl was born on 16/11/2019 at 6 pm .Inj oxytocin 10 IU given .
Total duration of labour: 13 hours
Removal of placenta : Spontaneous√ /Manual
Treatment: Cap Amoxycillin 500 mg 1 cap TDS , Tab Brufen ,Tab metrogyl , Tab famotidine
.
Received of mother at post natal ward at 6.30 pm on 16/11/2019

Post natal assessment:

Build: Obese/average/Thin: Average
Gait/ appearance: Normal

421
Vital signs : Blood pressure, Temp, Pulse, Resp - 120/80 mm of Hg, 98.4 0 F , 84 bt/m ,
20 br/min
Head to toe postnatal examination:

Hair and scalp : Clean

Eyes : Normal Face : Normal
Mouth: Normal Tongue : Hydrated Teeth : Normal
Ear : NAD Nose : NAD Throat : NAD
Neck glands: NAD
Extremities: NAD Nails: Clean and no cyanosis
Breast and nipple : Soft and secretory Milk secretion: Colostrum present
Chest and heart: NAD
Liver: NAD Spleen: NAD Abdomen: Pain Bladder: Empty
Legs: No edema Homan’s sign: Nil Back and spine: Normal
Personal hygiene: Good
Emotional response: Normal
Postnatal discomforts / compliants : Mild cramping pain .
(sleep , bowel , bladder , thirst , appetite after pain ,etc)

Obstetrical examination:

Inspection: No undue enlargement

Palpation of uterus: Uterus is hard and globular in shape .Fundal height – 13.5 cm .
(Consistency , shape and descent)
Per vaginal inspection / examination :
Vulval edema : Nil
Vagina : Lochia rubra present (Normal)
(Any vaginal bleeding , clots , warts / mole / infection / discharge )
Perineal area / anus : Intact
(Intact , lacerations or haemorrhoids , any pain )
Inspect REEDA for episiotomy wound: Wound is Healthy , no redness and edema .
(Redness , edema , ecchymosis , discharge and apposition )
Colour and amount of lochia odour: Lochia rubra present, Amount – normal
Smell -Fishy smell

422
Any complaints : Pain in episiotomy wound site

BABY
Physical Examination Findings
Condition of the newborn : Good , posture-flexed ,well cried ,alert

Vital signs:
Colour of skin : Pink texture - soft smooth .Dryness over hands and feet .Good turgor .Vernix
present.
Heart rate (Apex bit):142 beats/ min Respiration : 46 breaths/ min

Physical measurement:
Weight: 3 kg Length : 48 cm Head circumference : 33 cm
Chest circumference : 31 cm

Head to foot examination:

Examination of head:
Frontanelles/sutures/caput: Anterior frontanelle dimond shaped , 2.5X3cm. No overriding of
suture, no moulding.
Face: Normal
Eyes: Clean and healthy Sclera –White, Iris – Dark gray
Ears:Top of the pinna of ears is in a horizontal plane to the outer cantus .
Pinna is firm ,cartilage felt along with edge .Instant recoil .
Nose: Nasal passage is patent
Mouth: No precocious teeth , no epstain pearl , uvula in midline .No cleft lip or cleft palate .
Neck: Short .No gland is palpable .
Limbs and digits : 10 fingers of hands and toes each .Palmer creases present over 1/3rd portion.
Chests : Clear
Breast: Breast tissue is more than 10 mm. Areola raised .
Abdomen: Soft , No palpable mass .
Umbilical cord: Umbilical cord is clean and no bleeding .2 arteries and 1 vein present .
Genitalia : Labia majora well developed and completely cover the labia minora .No discharge
.Urethral meatus is located above the vaginal orifice .
Anus : Patent.
Spine/back: Normal .

423
Hips(ortoloni’s test): No hip dislocation .
Legs: 10 fingers of toes and sole creases present over a 1/3rd portion .
Reflexes:
Grasp: Present Moro: Present Glabellar: Present Rooting: present
Sucking: Present Planter and Babinski : Present Muscle activity: Normal .
Urine: Passed Meconium: Passed
General impression : Baby is normal
(Specify if any abnormalities found)

Nursing care process for mother

Nursing diagnosis Expected Nursing interventions Evaluation
outcomes (Implementations)
1.Alteration of body Normal body Checked vital signs . BP: 110/80 mm
system due to labour system. Checked dehydration level.of Hg.
process. Vital signs within Checked fundal height and P-82 bt/m
R- 22 br/m
normal range . consistency .
Fundal height- 15
Fundus firm . Checked lochia – amount , cm.
Lochia scanty to colour. Uterus- Hard ,
moderate rubra . globular .
Lochia rubra
present in normal
amount .
2.Pain related to Mother verbalizes Assess for pain relief in mother Suture area is
episiotomy suturing after relief with and administered pain normal .
. interventions . medication . Wound is clean
Pain at the level of Discussed reasons of pain and and healthy .
toleration . it’s expected duration . No unbearable
Assess perineum Inspected the suture area for pain present .
swelling, redness, edema , bleeding .
bleeding . Perineal care provided.
3.Alteration in Mother Provided comfortable position Expressed better
comfort related to experiences and advised early ambulation. feelings.
uterine cramping minimum For uterine cramps Baby is put to
and heaviness of discomfort. administered pain medication. breast.
breast . Promoted perineal exercise.
Assess breast for engorgement.
Instruct to prevent breast
engorgement.
Encouraged proper emptying
by giving colostrums and

424
Nursing diagnosis Expected Nursing interventions Evaluation
outcomes (Implementations)
continue exclusive breast
feeding.

4.Altered nutrition Receive enough Provided normal diet with She had taken diet
and fatigue due to rest. plenty of water Provided rest. and rest.
labour process and Ensured nutrition Advised to adjust sleep timings
sleep pattern with the baby’s sleep timings.
disturbances . Provided support system for
help .
5.Potential alteration Early identification Postnatal assessment done – Normal findings .
in physiological of any deviation . head to foot examination done
process due to
labour process .
6.Altered No bladder Encouraged to empty the No bladder
elimination pattern distension. bladder and bowel. distension.
due to physiological No full rectum. Measured the first
process of labour . void .
Mother asked for
frequency and
amount of void .
She did not pass
stool.
7.Risk for infection . No signs of post- Provided antibiotic as ordered . No phlebitis , no
partum Checked for Homan’s sign . Homan’s sign .
complication . Episiotomy
No phlebitis , wound normal .
Homan’s sign .
Episiotomy wound
infection .
8.Knowledge deficit Mother verbalizes Taught postnatal exercises – Verbalizes
on self care as understanding of abdominal and breathing , foot understanding of
mother states to written and verbal and leg , pelvic floor, bending verbal
whom to consult for instructions on self and straightening alternate instructions on
post partum checkup care activities and knee. Provided verbal self care activities
and care . breast feeding . instructions about balanced and breast feeding
nutritious diet in increased .
amount and rich in high
protein, vitamin and roughage .
Plenty of water to drink .
Personal hygiene , daily bath ,
clean , loose cotton garments.
Sexual activity.

425
Nursing diagnosis Expected Nursing interventions Evaluation
outcomes (Implementations)
Return of menstruation .
FP methods for spacing .
Signs of complication.
Baby care especially regarding
hypothermia , cord infection ,
meconium , urine and
immunization .
Provided information about
postpartum check up.

9. Alteration of Patient will Established mutual trust and Demonstrate

family process demonstrate good respect . positive parenting
coping skills . Taught parenting , baby behaviour .
Acceptance of role holding , baby care .
of parent . Provided support system .
Demonstrate
positive parenting
behaviour .
Adequate bonding.

Nursing care process for baby

Nursing Expected Nursing interventions Evaluation

diagnosis outcomes (Implementations)
Ineffective Adequate body Kept infant warm with mother. Baby’s body
thermoregulation temperature . Wrapped the baby in a baby temperature is
related to heat sheet covering the head and normal.
loss from extremities.
exposure in Baby is kept clean and dry after
postnatal ward . urination and passing after
meconium.

Potential risk for Establish Mother is advised regarding the Baby is

ineffective airway breathing risk . crying.
due to pressure of effectively. Support person is informed. Respiration is
mother’s breast Baby is kept under close normal.
and baby’s observation. .
blanket .

426
Nursing Expected Nursing interventions Evaluation
diagnosis outcomes (Implementations)

Potential risk for No sign of Strict aseptic technique is No sign of

infection related infection maintained while handling the infection
to newly clamped baby .
umbilical cord Eyes are cleaned with sterile
and exposure to swabs.
eyes to vaginal Cord is checked for dry
secretions . gangrene.
Altered nutrition Unaltered Breastfeeding :Initiated with Baby is active
less than body nutritional colostrum . and passed
requirement status . Baby is sucking breast milk urine .
related to properly . .
newborn’s Checked passage of urine .
transition to Checked baby’s body weight .
extrauterine life.
Altered Normal Checked passage of urine . Baby has
elimination elimination Checked passage of meconium . passed urine
pattern related to pattern . and
newborn’s meconium.
transition to
extrauterine life.
Potential risk for Early diagnosis A thorough physical Nothing
congenital of any examination done . abnormalities
anomalies or any abnormality or All physical parameters checked found
abnormality anomalies .
All reflexes checked
Potential risk for Parents will Helped to allay anxiety related Demonstrates
ineffective accept the role to sex . positive
parenting related of parent . Taught parenting , parenting
to sex of baby . behaviour.
Health seeking Demonstrate Advice given focusing on Parents asked
behaviour related positive normal newborn's problems more
to needs of a parenting regarding : newborn's normal questions and
normal newborn behaviour. behaviour and abnormal one, clarifies their
during hospital Adequate e.g. sleep pattern, condition and doughts
and after bonding. colour of skin, crying, regarding
discharge form elimination, stabilization. baby care.
the hospital. Exclusive breast feeding for 6
months.
Activity / hygiene / clothing /

427
Nursing Expected Nursing interventions Evaluation
diagnosis outcomes (Implementations)
saftery / security / bonding.
Immunization schedule : Inj.
BCG, Hep B and '0' dose polio
given at hospital.
Advice to continue rest of the
schedule in time.
Attendance at well baby clinic.

Signature of student Signature of supervisor

428
 POSTNATAL ASSESSMENT

Case No-8

IDENTIFICATION DATA

Name of the hospital : NRSMC&H Registration :12879

Name of the client : Moumi Pal Age: 23 yrs Religion: Hinduism
Address with husband’s name : w/o-Sourav Pal , 73/1,Park Circus Road, Beniapukur, Kol-14.
GPAL: G1P0A0L0 Period of gestation : 40 weeks
Date and time of admission : 17/11/2019 at 6 am
Unit:II Dr: P. Chatterjee
Date and time of delivery: 17/11/2019 at 8 pm
Mode of delivery: ND with episiotomy Sex of baby: Female
Condition of baby at birth: Baby cried immediately after birth
Disc no of mother and baby: 360
Post natal day:1st postnatal day

MOTHER

Brief History

Type of family: Nuclear Total family members : 4

Support person in the family: Mother in low
Social: Education: Husband: X Wife: VII
Occupation: Husband: Shop keeper Wife: House wife
Personal: Any drug allergy: Any drug allergy not identified

Medical and surgical :

Past: Nothing significant Present: Nothing significant

Family: Nothing significant
Diet (Any harmful cultural practices after child birth): Non –veg .She takes adequate diet
during pregnancy . No harmful cultural practice after child birth is present .
Bowel and bladder: Bladder and bowel emptied .

429
 Past Obstetric History : LCB :
No. of Year Abortion Any Mode of Place of Sex Baby Any Remarks
pregna (with problems delivery delivery (alive/ problem with the
ncy period) during stillbirth) during history of
antenatal puerperium breastfeeding
period immunization
.
Primigravida

Present obstetric history:

Booked/unbooked: Booked No of antenatal check up: 4
Immunization : 2 dose of Inj TT is taken Total weight gain: 9 kg
Any problem arise during pregnancy: Yes / No√ .
If yes treatment given: Nil

Laboratory reports:
Blood group: B Rh: Positive VDRL: Negative PPBS: Not done
Fasting: 76 mg/dl Hb%: 11 gm/dl Others: TSH : 1.74mcg/dl
Urine :Sugar: Nil Albumin: Nil
USG report : Single living fetus , Liquor –adequate , Placenta – posterior .

Delivery notes ( from records):Normal delivery with mediolateral episiotomy done .A full
term living baby girl was born on 17/11/2019 at 8 pm .Inj oxytocin 10 IU given .
Total duration of labour: 13 hours
Removal of placenta : Spontaneous√ /Manual
Treatment: Cap Amoxycillin 500 mg 1 cap TDS , Tab Brufen ,tab metrogyl , Tab famotidine.
Received of mother at post natal ward at 8.30 pm on 17/11/2019

Post natal assessment:

Build: Obese/average/Thin: Average
Gait/ appearance: Normal

Vital signs :Blood pressure ,Temp,Pulse,Resp.- 110/74 mm of Hg, 98.40F , 82 bt/min ,

430
22 br/min

Head to toe postnatal examination:

Hair and scalp: Clean
Eyes: Normal Face: Normal
Mouth: Normal Tongue: Hydrated Teeth: Normal
Ear: NAD Nose: NAD Throat: NAD
Neck glands: NAD
Extremities: NAD Nails: Clean and no cyanosis
Breast and nipple : Soft and secretory Milk secretion: Colostrum present
Chest and heart: NAD
Liver: NAD Spleen: NAD Abdomen: Pain Bladder: Empty
Legs: No edema Homan’s sign: Nil Back and spine: Normal
Personal hygiene: Good
Emotional response: Normal
Postnatal discomforts / compliants : Mild cramping pain .
(sleep, bowel, bladder, thirst, appetite after pain, etc)

Obstetrical examination:
Inspection: No undue enlargement

Palpation of uterus: Uterus is hard and globular in shape .Fundal height – 13.5 cm .
(Consistency , shape and descent)

Per vaginal inspection / examination :

Vulval edema : Nil
Vagina : Lochia rubra present (Normal)
(Any vaginal bleeding, clots, warts / mole / infection / discharge )
Perineal area / anus : Intact
(Intact , lacerations or haemorrhoids , any pain )
Inspect REEDA for episiotomy wound: Wound is Healthy , no redness and edema .
(Redness, edema, ecchymosis, discharge and apposition )
Colour and amount of lochia odour: Lochia rubra present , Amount – normal
Smell -Fishy smell

431
Any complaints : Pain in episiotomy wound site

BABY
Physical Examination Findings
Condition of the newborn : Good, posture-flexed, well cried, alert

Vital signs:
Colour of skin : Pink texture - soft smooth .Dryness over hands and feet .Good turgor .Vernix
present.
Heart rate (Apex bit): 136 beats/ min Respiration : 42 breaths/ min

Physical measurement:
Weight : 2.9 kg Length : 49 cm Head circumference : 34 cm
Chest circumference : 31 cm

Head to foot examination:

Examination of head:
Frontanelles/sutures/caput: Anterior frontanelle dimond shaped , 2.5X3cm. No overriding of
suture, no moulding.
Face: Normal
Eyes: Clean and healthy;. Sclera –White, Iris – Dark gray
Ears:Top of the pinna of ears is in a horizontal plane to the outer cantus .
Pinna is firm ,cartilage felt along with edge .Instant recoil .
Nose: Nasal passage is patent
Mouth:No precocious teeth , no epstain pearl , uvula in midline .No cleft lip or cleft palate .
Neck: Short .No gland is palpable .
Limbs and digits : 10 fingers of hands and toes each .Palmer creases present over 1/3rd portion.
Chests : Clear .
Breast: Breast tissue is more than 10 mm. Areola raised .
Abdomen: Soft , No palpable mass .
Umbilical cord: Umbilical cord is clean and no bleeding .2 arteries and 1 vein present .
Genitalia : Labia majora well developed and completely cover the labia minora .No discharge
.Urethral meatus is located above the vaginal orifice .
Anus: Patent.
Spine/back: Normal .

432
Hips(ortoloni’s test): No hip dislocation .
Legs: 10 fingers of toes and sole creases present over a 1/3rd portion .
Reflexes:
Grasp: Present Moro: Present Glabellar: Present Rooting: Present
Sucking: Present Planter and Babinski : Present Muscle activity: Normal
Urine: Passed. Meconium: Passed
General impression : Baby is normal
(Specify if any abnormalities found)

Nursing care process for mother

Nursing diagnosis Expected Nursing interventions Evaluation
outcomes (Implementations)
1.Alteration of body Normal body Checked vital signs . BP: 110/80 mm
system due to labour system. Checked dehydration level.of Hg.
process. Vital signs within Checked fundal height and P-82 bt/min
R- 22 br/min
normal range . consistency .
Fundal height- 15
Fundus firm . Checked lochia – amount , cm.
Lochia scanty to colour. Uterus- Hard ,
moderate rubra . globular .
Lochia rubra
present in normal
amount .
2.Pain related to Mother verbalizes Assess for pain relief in mother Suture area is
episiotomy suturing after relief with and administered pain normal .
. interventions . medication . Wound is clean
Pain at the level of Discussed reasons of pain and and healthy .
toleration . it’s expected duration . No unbearable
Assess perineum Inspected the suture area for pain present .
swelling, redness, edema , bleeding .
bleeding . Perineal care provided.
3.Alteration in Mother Provided comfortable position Expressed better
comfort related to experiences and advised early ambulation. feelings.
uterine cramping minimum For uterine cramps Baby is put to
and heaviness of discomfort. administered pain medication. breast.
breast . Promoted perineal exercise.
Assess breast for engorgement.
Instruct to prevent breast
engorgement.
Encouraged proper emptying
by giving colostrums and

433
Nursing diagnosis Expected Nursing interventions Evaluation
outcomes (Implementations)
continue exclusive breast
feeding.

4.Altered nutrition Receive enough Provided normal diet with She had taken diet
and fatigue due to rest. plenty of water Provided rest. and rest.
labour process and Ensured nutrition Advised to adjust sleep timings
sleep pattern with the baby’s sleep timings.
disturbances . Provided support system for
help .
5.Potential alteration Early identification Postnatal assessment done – Normal findings .
in physiological of any deviation . head to foot examination done
process due to
labour process .
6.Altered No bladder Encouraged to empty the No bladder
elimination pattern distension. bladder and bowel. distension.
due to physiological No full rectum. Measured the first
process of labour . void .
Mother asked for
frequency and
amount of void .
She did not pass
stool.
7.Risk for infection . No signs of post- Provided antibiotic as ordered . No phlebitis , no
partum Checked for Homan’s sign . Homan’s sign .
complication . Episiotomy
No phlebitis , wound normal .
Homan’s sign .
Episiotomy wound
infection .
8.Knowledge deficit Mother verbalizes Taught postnatal exercises – Verbalizes
on self care as understanding of abdominal and breathing , foot understanding of
mother states to written and verbal and leg , pelvic floor, bending verbal
whom to consult for instructions on self and straightening alternate instructions on
post partum checkup care activities and knee. Provided verbal self care activities
and care . breast feeding . instructions about balanced and breast feeding
nutritious diet in increased .
amount and rich in high
protein, vitamin and roughage .
Plenty of water to drink .
Personal hygiene , daily bath ,
clean , loose cotton garments.
Sexual activity.

434
Nursing diagnosis Expected Nursing interventions Evaluation
outcomes (Implementations)
Return of menstruation .
FP methods for spacing .
Signs of complication.
Baby care especially regarding
hypothermia , cord infection ,
meconium , urine and
immunization .
Provided information about
postpartum check up.

9. Alteration of Patient will Established mutual trust and Demonstrate

family process demonstrate good respect . positive parenting
coping skills . Taught parenting , baby behaviour .
Acceptance of role holding , baby care .
of parent . Provided support system .
Demonstrate
positive parenting
behaviour .
Adequate bonding.

Nursing care process for baby

Nursing Expected Nursing interventions Evaluation

diagnosis outcomes (Implementations)
Ineffective Adequate body Kept infant warm with mother. Baby’s body
thermoregulation temperature . Wrapped the baby in a baby temperature is
related to heat sheet covering the head and normal.
loss from extremities.
exposure in Baby is kept clean and dry after
postnatal ward . urination and passing after
meconium.

Potential risk for Establish Mother is advised regarding the Baby is

ineffective airway breathing risk . crying.
due to pressure of effectively. Support person is informed. Respiration is
mother’s breast Baby is kept under close normal.
and baby’s observation. .
blanket .

435
Nursing Expected Nursing interventions Evaluation
diagnosis outcomes (Implementations)

Potential risk for No sign of Strict aseptic technique is No sign of

infection related infection maintained while handling the infection
to newly clamped baby .
umbilical cord Eyes are cleaned with sterile
and exposure to swabs.
eyes to vaginal Cord is checked for dry
secretions . gangrene.
Altered nutrition Unaltered Breastfeeding :Initiated with Baby is active
less than body nutritional colostrum . and passed
requirement status . Baby is sucking breast milk urine .
related to properly . .
newborn’s Checked passage of urine .
transition to Checked baby’s body weight .
extrauterine life.
Altered Normal Checked passage of urine . Baby has
elimination elimination Checked passage of meconium . passed urine
pattern related to pattern . and
newborn’s meconium.
transition to
extrauterine life.
Potential risk for Early diagnosis A thorough physical Nothing
congenital of any examination done . abnormalities
anomalies or any abnormality or All physical parameters checked found
abnormality anomalies .
All reflexes checked
Potential risk for Parents will Helped to allay anxiety related Demonstrates
ineffective accept the role to sex . positive
parenting related of parent . Taught parenting , parenting
to sex of baby . behaviour.
Health seeking Demonstrate Advice given focusing on Parents asked
behaviour related positive normal newborn's problems more
to needs of a parenting regarding : newborn's normal questions and
normal newborn behaviour. behaviour and abnormal one, clarifies their
during hospital Adequate e.g. sleep pattern, condition and doughts
and after bonding. colour of skin, crying, regarding
discharge form elimination, stabilization. baby care.
the hospital. Exclusive breast feeding for 6
months.
Activity / hygiene / clothing /

436
Nursing Expected Nursing interventions Evaluation
diagnosis outcomes (Implementations)
saftery / security / bonding.
Immunization schedule : Inj.
BCG, Hep B and '0' dose polio
given at hospital.
Advice to continue rest of the
schedule in time.
Attendance at well baby clinic.

Signature of student Signature of supervisor

437
 POSTNATAL ASSESSMENT
Case No-9

IDENTIFICATION DATA

Name of the hospital : NRSMC&H Registration : 91312

Name of the client : Majeda Bibi Age :19 yrs Religion : Muslim
Address with husband’s name : w/o-Mijanur Sk , Pragati Pally, Subhasgram, Kol-14
.
GPAL: G1P0A0L0 Period of gestation : 37 weeks
Date and time of admission : 18/11/2019 at 2am
Unit: III Dr: S. Mondal
Date and time of delivery: 18/11/2019 at 2 pm
Mode of delivery:ND with episiotomy Sex of baby: Female
Condition of baby at birth: Baby cried immediately after birth
Disc no of mother and baby: 302
Post natal day:1st postnatal day

MOTHER

Brief History
Type of family: Nuclear Total family members : 4
Support person in the family: Husband
Social: Education: Husband: x Wife: VII
Occupation: Husband: Private company Wife: House wife
Personal: Any drug allergy: Any drug allergy not identified

Medical and surgical :

Past: Nothing significant Present: Nothing significant

Family: Nothing significant
Diet (Any harmful cultural practices after child birth): Non –veg .She takes adequate diet
during pregnancy . No harmful cultural practice after child birth is present .
Bowel and bladder: Bladder and bowel emptied .

438
 Past Obstetric History : LCB :
No. of Year Abortion Any Mode of Place of Sex Baby Any Remarks
pregna (with problems delivery delivery (alive/ problem with the
ncy period) during stillbirth) during history of
antenatal puerperium breastfeeding
period immunization
.
Primigravida

Present obstetric history:

Booked/unbooked : Booked No of antenatal check up : 3
Immunization : 2 dose of Inj TT is taken Total weight gain : 11 kg
Any problem arise during pregnancy : Yes / No√ .
If yes treatment given : Nil

Laboratory reports:
Blood group: B Rh: Positive VDRL: Negative PPBS: Not done
Fasting : 82 mg/dl Hb% : 11.2 gm/dl Others: TSH :1.70mcg/dl
Urine : Sugar: Nil Albumin: Nil
USG report : Single living fetus , liquor –adequate , Placenta – posterior .

Delivery notes ( from records):Normal delivery with mediolateral episiotomy done .A full
term living baby girl was born on 18/11/2019 at 2 pm. Inj oxytocin 10 IU given .
Total duration of labour: 13 hours
Removal of placenta : Spontaneous√ /Manual
Treatment: Cap Amoxycillin 500 mg 1 cap TDS , Tab Brufen ,Tab metrogyl , Tab famotidine
.
Received of mother at post natal ward at 2.30 pm on 18/11/2019

Post natal assessment:

Build: Obese/average/Thin: Average
Gait/ appearance: Normal

Vital signs :Blood pressure ,Temp,Pulse,Resp.- 120/78 mm of Hg, 98.6 0 F, 84 bt/min,

439
20 br/min

Head to toe postnatal examination:

Hair and scalp: Clean
Eyes: Normal Face: Normal
Mouth: Normal Tongue: Hydrated Teeth: Normal
Ear: NAD Nose: NAD Throat: NAD
Neck glands: NAD
Extremities: NAD Nails: Clean and no cyanosis
Breast and nipple : Soft and secretory Milk secretion: Colostrum present
Chest and heart: NAD
Liver: NAD Spleen: NAD Abdomen: Pain Bladder: Empty
Legs: No edema Homan’s sign: Nil Back and spine: Normal
Personal hygiene: Good
Emotional response: Normal
Postnatal discomforts / compliants : Mild cramping pain .
(sleep , bowel , bladder , thirst , appetite after pain ,etc)

Obstetrical examination:
Inspection: No undue enlargement

Palpation of uterus: Uterus is hard and globular in shape .Fundal height – 15 cm .

(Consistency , shape and descent)

Per vaginal inspection / examination :

Vulval edema : Nil
Vagina : Lochia rubra present (Normal)
(Any vaginal bleeding , clots , warts / mole / infection / discharge )
Perineal area / anus :Intact
(Intact , lacerations or haemorrhoids , any pain )
Inspect REEDA for episiotomy wound: Wound is Healthy , no redness and edema .
(Redness , edema , ecchymosis , discharge and apposition )
Colour and amount of lochia odour: Lochia rubra present , Amount – normal
Smell -Fishy smell

440
Any complaints : Pain in episiotomy wound site

BABY
Physical Examination Findings
Condition of the newborn : Good , posture-flexed ,well cried ,alert

Vital signs:
Colour of skin : Pink texture - soft smooth .Dryness over hands and feet .Good turgor .Vernix
present.
Heart rate (Apex bit): 134 beats/ min Respiration : 42 breaths/ min

Physical measurement:
Weight: 2.7 kg Length : 49 cm Head circumference : 33 cm
Chest circumference : 31 cm

Head to foot examination:

Examination of head:
Frontanelles/sutures/caput: Anterior frontanelle dimond shaped , 2.5X3cm. No overriding of
suture, no moulding.
Face: Normal
Eyes: Clean and healthy;. Sclera –White, Iris – Dark gray
Ears:Top of the pinna of ears is in a horizontal plane to the outer cantus .
Pinna is firm ,cartilage felt along with edge .Instant recoil .
Nose: Nasal passage is patent
Mouth:No precocious teeth , no epstain pearl , uvula in midline .No cleft lip or cleft palate .
Neck: Short .No gland is palpable .
Limbs and digits : 10 fingers of hands and toes each .Palmer creases present over 1/3rd portion.
Chests :Clear .
Breast: Breast tissue is more than 10 mm. Areola raised .
Abdomen: Soft , No palpable mass .
Umbilical cord: Umbilical cord is clean and no bleeding .2 arteries and 1 vein present .
Genitalia : Labia majora well developed and completely cover the labia minora .No discharge.
Urethral meatus is located above the vaginal orifice .
Anus: Patent.
Spine/back: Normal .

441
Hips(ortoloni’s test): No hip dislocation .
Legs: 10 fingers of toes and sole creases present over a 1/3rd portion .
Reflexes:
Grasp: Present . Moro: Present . Glabellar: Present . Rooting: Present .
Sucking: Present . Planter and Babinski : Present . Muscle activity: Normal .
Urine: Passed. Meconium: Passed .
General impression : Baby is normal .
(Specify if any abnormalities found)

Nursing care process for mother

Nursing diagnosis Expected Nursing interventions Evaluation
outcomes (Implementations)
1.Alteration of body Normal body Checked vital signs . BP: 110/80 mm
system due to labour system. Checked dehydration level. of Hg.
process. Vital signs within Checked fundal height and P-82 bt/m
R- 22 br/m
normal range . consistency .
Fundal height- 15
Fundus firm . Checked lochia – amount , cm.
Lochia scanty to colour. Uterus- Hard ,
moderate rubra . globular .
Lochia rubra
present in normal
amount .
2.Pain related to Mother verbalizes Assess for pain relief in mother Suture area is
episiotomy suturing after relief with and administered pain normal .
. interventions . medication . Wound is clean
Pain at the level of Discussed reasons of pain and and healthy .
toleration . it’s expected duration . No unbearable
Assess perineum Inspected the suture area for pain present .
swelling, redness, edema , bleeding .
bleeding . Perineal care provided.
4.Altered nutrition Receive enough Provided normal diet with She had taken diet
and fatigue due to rest. plenty of water Provided rest. and rest.
labour process and Ensured nutrition Advised to adjust sleep timings
sleep pattern with the baby’s sleep timings.
disturbances . Provided support system for
help .
5.Potential alteration Early identification Postnatal assessment done – Normal findings .
in physiological of any deviation . head to foot examination done
process due to
labour process .

442
Nursing diagnosis Expected Nursing interventions Evaluation
outcomes (Implementations)
6.Altered No bladder Encouraged to empty the No bladder
elimination pattern distension. bladder and bowel. distension.
due to physiological No full rectum. Measured the first
process of labour . void .
Mother asked for
frequency and
amount of void .
She did not pass
stool.
7.Risk for infection . No signs of post- Provided antibiotic as ordered . No phlebitis , no
partum Checked for Homan’s sign . Homan’s sign .
complication . Episiotomy
No phlebitis ,
wound normal .
Homan’s sign .
Episiotomy wound
infection .
8.Knowledge deficit Mother verbalizes Taught postnatal exercises – Verbalizes
on self care as understanding of abdominal and breathing , foot understanding of
mother states to written and verbaland leg , pelvic floor, bending verbal
whom to consult for instructions on self and straightening alternate instructions on
post partum checkup care activities and knee. Provided verbal self care activities
and care . breast feeding . instructions about balanced and breast feeding
nutritious diet in increased .
amount and rich in high
protein, vitamin and roughage .
Plenty of water to drink .
Personal hygiene , daily bath ,
clean , loose cotton garments.
Sexual activity.
Return of menstruation .
FP methods for spacing .
Signs of complication.
Baby care especially regarding
hypothermia , cord infection ,
meconium , urine and
immunization .
Provided information about
postpartum check up.
9. Alteration of Patient will Established mutual trust and Demonstrate
family process demonstrate good respect . positive parenting
coping skills . Taught parenting , baby behaviour .
Acceptance of role
holding , baby care .
of parent .
Demonstrate Provided support system .

443
Nursing diagnosis Expected Nursing interventions Evaluation
outcomes (Implementations)
positive parenting
behaviour .
Adequate bonding.
Nursing care process for baby
Nursing Expected Nursing interventions Evaluation
diagnosis outcomes (Implementations)
Ineffective Adequate body Kept infant warm with mother. Baby’s body
thermoregulation temperature . Wrapped the baby in a baby temperature is
related to heat sheet covering the head and normal.
loss from extremities.
exposure in Baby is kept clean and dry after
postnatal ward . urination and passing after
meconium.

Potential risk for Establish Mother is advised regarding the Baby is

ineffective airway breathing risk . crying.
due to pressure of effectively. Support person is informed. Respiration is
mother’s breast Baby is kept under close normal.
and baby’s observation. .
blanket .

Potential risk for No sign of Strict aseptic technique is No sign of

infection related infection maintained while handling the infection
to newly clamped baby .
umbilical cord Eyes are cleaned with sterile
and exposure to swabs.
eyes to vaginal Cord is checked for dry
secretions . gangrene.
Altered nutrition Unaltered Breastfeeding :Initiated with Baby is active
less than body nutritional colostrum . and passed
requirement status . Baby is sucking breast milk urine .
related to properly . .
newborn’s Checked passage of urine .
transition to Checked baby’s body weight .
extrauterine life.
Altered Normal Checked passage of urine . Baby has
elimination elimination Checked passage of meconium . passed urine
pattern related to pattern . and
newborn’s meconium.
transition to

444
Nursing Expected Nursing interventions Evaluation
diagnosis outcomes (Implementations)
extrauterine life.
Potential risk for Early diagnosis A thorough physical Nothing
congenital of any examination done . abnormalities
anomalies or any abnormality or All physical parameters checked found
abnormality anomalies .
All reflexes checked
Potential risk for Parents will Helped to allay anxiety related Demonstrates
ineffective accept the role to sex . positive
parenting related of parent . Taught parenting , parenting
to sex of baby . behaviour.
Health seeking Demonstrate Advice given focusing on Parents asked
behaviour related positive normal newborn's problems more
to needs of a parenting regarding : newborn's normal questions and
normal newborn behaviour. behaviour and abnormal one, clarifies their
during hospital Adequate e.g. sleep pattern, condition and doughts
and after bonding. colour of skin, crying, regarding
discharge form elimination, stabilization. baby care.
the hospital. Exclusive breast feeding for 6
months.
Activity / hygiene / clothing /
saftery / security / bonding.
Immunization schedule : Inj.
BCG, Hep B and '0' dose polio
given at hospital.
Advice to continue rest of the
schedule in time.
Attendance at well baby clinic.

Signature of student Signature of supervisor

445
 POSTNATAL ASSESSMENT
Case No-10

IDENTIFICATION DATA

Name of the hospital : NRSMC&H Registration : 914350

Name of the client : Parichiti Bibi Age : 23 yrs Religion : Muslim
Address with husband’s name : w/o-Mijanur Sk , 36/A Kabi Sukanta Road, Santoshpur,
Kolkata -700075
GPAL: G1P0A0L0 Period of gestation : 39 weeks
Date and time of admission : 18/11/2019 at 5am
Unit:I Under: Dr: D.Saha
Date and time of delivery: 18/11/2019 at 7:00 PM
Mode of delivery: ND with episiotomy Sex of baby: Female
Condition of baby at birth: Baby cried immediately after birth
Disc no of mother and baby: F/415
Post natal day:1st postnatal day

MOTHER
Brief History
Type of family: Nuclear Total family members : 4
Support person in the family: Father in low
Social: Education : Husband : XI Wife: X
Occupation: Husband: Sells man Wife: House wife
Personal: Any drug allergy: Any drug allergy not identified

Medical and surgical :

Past: Nothing significant Present: Nothing significant

Family: Nothing significant
Diet (Any harmful cultural practices after child birth): Non –veg .She takes adequate diet
during pregnancy . No harmful cultural practice after child birth is present .
Bowel and bladder: Bladder and bowel emptied .

446
 Past Obstetric History : LCB :
No. of Year Abortion Any Mode of Place of Sex Baby Any Remarks
pregna (with problems delivery delivery (alive/ problem with the
ncy period) during stillbirth) during history of
antenatal puerperium breastfeeding
period immunization
.
Primigravida

Present obstetric history:

Booked/unbooked : Booked No of antenatal check up : 4
Immunization : 2 dose of Inj TT is taken Total weight gain : 9 kg
Any problem arise during pregnancy: Yes / No√ .
If yes treatment given: Nil

Laboratory reports:
Blood group: B Rh: Positive VDRL: Negative PPBS: Not done
Fasting: 70 mg/dl Hb%: 10.8 gm/dl Others: TSH :1.71mcg/dl
Urine :Sugar: Nil Albumin: Nil
USG report : Single living fetus , liquor –adequate , Placenta – posterior .

Delivery notes ( from records):Normal delivery with mediolateral episiotomy done .A full
term living baby girl was born on 18/11/2019 at 7 pm .Inj oxytocin 10 IU given .
Total duration of labour: 13 hours
Removal of placenta : Spontaneous√ /Manual
Treatment: Cap Amoxycillin 500 mg 1 cap TDS , Tab Brufen ,tab metrogyl , Tab famotidine
Received of mother at post natal ward at 7.30 pm on 18/11/2019

Post natal assessment:

Build: Obese/average/Thin: Average
Gait/ appearance: Normal

Vital signs : Blood pressure - 110/80 mm of Hg , Temp-98.4 0F , Pulse -84 bt/min ,

Resp.-22 br/min

447
Head to toe postnatal examination:
Hair and scalp: Clean
Eyes: Normal Face: Normal
Mouth: Normal Tongue: Hydrated Teeth: Normal
Ear: NAD Nose: NAD Throat: NAD
Neck glands: NAD
Extremities: NAD Nails: Clean and no cyanosis
Breast and nipple : Soft and secretory Milk secretion: Colostrum present
Chest and heart: NAD
Liver: NAD Spleen: NAD Abdomen: Pain Bladder: Empty
Legs: No edema Homan’s sign: Nil Back and spine: Normal
Personal hygiene: Good
Emotional response: Normal
Postnatal discomforts / compliants : Mild cramping pain .
(sleep , bowel , bladder , thirst , appetite after pain ,etc)

Obstetrical examination:
Inspection: No undue enlargement

Palpation of uterus: Uterus is hard and globular in shape .Fundal height – 14cm .
(Consistency , shape and descent)
Per vaginal inspection / examination :
Vulval edema : Nil
Vagina : Lochia rubra present (Normal)
(Any vaginal bleeding , clots , warts / mole / infection / discharge )
Perineal area / anus : Intact
(Intact , lacerations or haemorrhoids , any pain )
Inspect REEDA for episiotomy wound: Wound is Healthy , no redness and edema .
(Redness , edema , ecchymosis , discharge and apposition )
Colour and amount of lochia odour: Lochia rubra present , Amount – normal
Smell -Fishy smell
Any complaints : Pain in episiotomy wound site

448
BABY
Physical Examination Findings
Condition of the newborn : Good , posture-flexed ,well cried ,alert

Vital signs:
Colour of skin : Pink texture - soft smooth .Dryness over hands and feet .Good turgor .Vernix
present.
Heart rate (Apex bit): 144 beats/ min Respiration : 44 breaths/ min

Physical measurement:
Weight: 3 kg Length : 50 cm Head circumference : 33 cm
Chest circumference :31 cm

Head to foot examination:

Examination of head:
Frontanelles/sutures/caput: Anterior frontanelle dimond shaped , 2.5X3cm. No overriding of
suture, no moulding.
Face: Normal
Eyes: Clean and healthy;. Sclera –White, Iris – Dark gray
Ears:Top of the pinna of ears is in a horizontal plane to the outer cantus .
Pinna is firm ,cartilage felt along with edge .Instant recoil .
Nose: Nasal passage is patent
Mouth:No precocious teeth , no epstain pearl , uvula in midline .No cleft lip or cleft palate .
Neck: Short .No gland is palpable .
Limbs and digits : 10 fingers of hands and toes each .Palmer creases present over 1/3rd portion.
Chests :Clear .
Breast: Breast tissue is more than 10 mm. Areola raised .
Abdomen: Soft , No palpable mass .
Umbilical cord: Umbilical cord is clean and no bleeding .2 arteries and 1 vein present .
Genitalia : Labia majora well developed and completely cover the labia minora .No discharge
.Urethral meatus is located above the vaginal orifice .
Anus: Patent.
Spine/back: Normal .
Hips(ortoloni’s test): No hip dislocation .

449
Legs: 10 fingers of toes and sole creases present over a 1/3rd portion .
Reflexes:
Grasp: Present . Moro: Present . Glabellar: Present . Rooting: Present .
Sucking: Present . Planter and Babinski : Present . Muscle activity: Normal .
Urine: Passed. Meconium: Passed .
General impression : Baby is normal .
(Specify if any abnormalities found)
Nursing care process for mother
Nursing diagnosis Expected Nursing interventions Evaluation
outcomes (Implementations)
1.Alteration of body Normal body Checked vital signs . BP: 110/80 mm
system due to labour system. Checked dehydration level. of hg.
process. Vital signs within Checked fundal height and P-82 b/m
R- 22 b/m
normal range . consistency .
Fundal height- 15
Fundus firm . Checked lochia – amount , cm.
Lochia scanty to colour. Uterus- Hard ,
moderate rubra . globular .
Lochia rubra
present in normal
amount .
2.Pain related to Mother verbalizes Assess for pain relief in mother Suture area is
episiotomy suturing after relief with and administered pain normal .
. interventions . medication . Wound is clean
Pain at the level of Discussed reasons of pain and and healthy .
toleration . it’s expected duration . No unbearable
Assess perineum Inspected the suture area for pain present .
swelling, redness, edema , bleeding .
bleeding . Perineal care provided.
3.Alteration in Mother Provided comfortable position Expressed better
comfort related to experiences and advised early ambulation. feelings.
uterine cramping minimum For uterine cramps Baby is put to
and heaviness of discomfort. administered pain medication. breast.
breast . Promoted perineal exercise.
Assess breast for engorgement.
Instruct to prevent breast
engorgement.
Encouraged proper emptying
by giving colostrums and
continue exclusive breast
feeding.

450
Nursing diagnosis Expected Nursing interventions Evaluation
outcomes (Implementations)
4.Altered nutrition Receive enough Provided normal diet with She had taken diet
and fatigue due to rest. plenty of water Provided rest. and rest.
labour process and Ensured nutrition Advised to adjust sleep timings
sleep pattern with the baby’s sleep timings.
disturbances . Provided support system for
help .
5.Potential alteration Early identification Postnatal assessment done – Normal findings .
in physiological of any deviation . head to foot examination done
process due to
labour process .
6.Altered No bladder Encouraged to empty the No bladder
elimination pattern distension. bladder and bowel. distension.
due to physiological No full rectum. Measured the first
process of labour . void .
Mother asked for
frequency and
amount of void .
She did not pass
stool.
7.Risk for infection . No signs of post- Provided antibiotic as ordered . No phlebitis , no
partum Checked for Homan’s sign . Homan’s sign .
complication . Episiotomy
No phlebitis , wound normal .
Homan’s sign .
Episiotomy wound
infection .
8.Knowledge deficit Mother verbalizes Taught postnatal exercises – Verbalizes
on self care as understanding of abdominal and breathing , foot understanding of
mother states to written and verbal and leg , pelvic floor, bending verbal
whom to consult for instructions on self and straightening alternate instructions on
post partum checkup care activities and knee. Provided verbal self care activities
and care . breast feeding . instructions about balanced and breast feeding
nutritious diet in increased .
amount and rich in high
protein, vitamin and roughage .
Plenty of water to drink .
Personal hygiene , daily bath ,
clean , loose cotton garments.
Sexual activity.
Return of menstruation .
FP methods for spacing .

451
 Nursing diagnosis Expected Nursing interventions Evaluation
outcomes (Implementations)
Signs of complication.
Baby care especially regarding
hypothermia , cord infection ,
meconium , urine and
immunization .
Provided information about
postpartum check up.

9. Alteration of Patient will Established mutual trust and Demonstrate

family process demonstrate good respect . positive parenting
coping skills . Taught parenting , baby behaviour .
Acceptance of role holding , baby care .
of parent . Provided support system .
Demonstrate
positive parenting
behaviour .
Adequate bonding.

Nursing care process for baby

Nursing diagnosis Expected Nursing interventions Evaluation
outcomes (Implementations)
Ineffective Adequate body Kept infant warm with mother. Baby’s body
thermoregulation temperature . Wrapped the baby in a baby temperature is
related to heat loss sheet covering the head and normal.
from exposure in extremities.
postnatal ward . Baby is kept clean and dry after
urination and passing after
meconium.

Potential risk for Establish Mother is advised regarding the Baby is

ineffective airway breathing risk . crying.
due to pressure of effectively. Support person is informed. Respiration is
mother’s breast and Baby is kept under close normal.
baby’s blanket . observation. .

Potential risk for No sign of Strict aseptic technique is No sign of

infection related to infection maintained while handling the infection
newly clamped baby .
umbilical cord and Eyes are cleaned with sterile
exposure to eyes to swabs.
vaginal secretions . Cord is checked for dry

452
Nursing diagnosis Expected Nursing interventions Evaluation
outcomes (Implementations)
gangrene.
Altered nutrition Unaltered Breastfeeding :Initiated with Baby is active
less than body nutritional colostrum . and passed
requirement related status . Baby is sucking breast milk urine .
to newborn’s properly . .
transition to Checked passage of urine .
extrauterine life. Checked baby’s body weight .

Altered elimination Normal Checked passage of urine . Baby has

pattern related to elimination Checked passage of meconium . passed urine
newborn’s pattern . and
transition to meconium.
extrauterine life.
Potential risk for Early diagnosis A thorough physical Nothing
congenital of any examination done . abnormalities
anomalies or any abnormality or All physical parameters found
abnormality anomalies checked.
All reflexes checked
Potential risk for Parents will Helped to allay anxiety related Demonstrates
ineffective accept the role to sex . positive
parenting related to of parent . Taught parenting , parenting
sex of baby . behaviour.
Health seeking Demonstrate Advice given focusing on Parents asked
behaviour related to positive normal newborn's problems more
needs of a normal parenting regarding : newborn's normal questions and
newborn during behaviour. behaviour and abnormal one, clarifies their
hospital and after Adequate e.g. sleep pattern, condition and doughts
discharge form the bonding. colour of skin, crying, regarding
hospital. elimination, stabilization. baby care.
Exclusive breast feeding for 6
months.
Activity / hygiene / clothing /
saftery / security / bonding.
Immunization schedule : Inj.
BCG, Hep B and '0' dose polio
given at hospital.
Advice to continue rest of the
schedule in time.
Attendance at well baby clinic.

Signature of student Signature of supervisor

453
 POSTNATAL ASSESSMENT

Case No-11

IDENTIFICATION DATA

Name of the hospital : NRSMC&H Registration :12879

Name of the client : Laila Bibi Age :19 yrs Religion : Muslim
Address with husband’s name : w/o-Mijanur Sk , 18B/1, Park Circus Avenue, Kol-14
GPAL: G1P0A0L0 Period of gestation : 40 weeks
Date and time of admission : 16/11/2019 at 7:00 AM
Unit : III Dr : P. Mondal
Date and time of delivery : 16/11/2019 at 8:00 PM
Mode of delivery : ND with episiotomy Sex of baby: Female
Condition of baby at birth : Baby cried immediately after birrth
Disc no of mother and baby : 340
Post natal day : 1st postnatal day

MOTHER

Brief History
Type of family : Nuclear Total family members : 3
Support person in the family : Father in low
Social: Education: Husband : X Wife : VII
Occupation: Husband: Hawcker Wife : House wife
Personal : Any drug allergy : Any drug allergy not identified

Medical and surgical :

Past: Nothing significant Present : Nothing significant

Family : Nothing significant
Diet (Any harmful cultural practices after child birth) : Non –veg .She takes adequate diet
during pregnancy . No harmful cultural practice after child birth is present .
Bowel and bladder: Bladder and bowel emptied .

454
 Past Obstetric History : LCB :
No. of Year Abortion Any Mode of Place of Sex Baby Any Remarks
pregna (with problems delivery delivery (alive/ problem with the
ncy period) during stillbirth) during history of
antenatal puerperium breastfeeding
period immunization
.
Primigravida

Present obstetric history:

Booked/unbooked : Booked No of antenatal check up : 4

Immunization : 2 dose of Inj TT is taken Total weight gain : 9 kg
Any problem arise during pregnancy : Yes / No√ .
If yes treatment given : Nil

Laboratory reports:

Blood group : B Rh : Positive VDRL: Negative PPBS:Not done

Fasting : 81 mg/dl Hb% : 11.4 gm/dl Others: TSH :1.64mcg/dl
Urine : Sugar: Nil Albumin: Nil
USG report : Single living fetus , Liquor –adequate , Placenta – posterior .
Delivery notes ( from records):Normal delivery with mediolateral episiotomy done .A full
term living baby girl was born on 16/11/19 at 8 pm .Inj oxytocin 10 IU given .
Total duration of labour : 13 hours
Removal of placenta : Spontaneous√ /Manual
Treatment : Cap Amoxycillin 500 mg 1 cap TDS , Tab Brufen ,tab metrogyl , Tab famotidine
Received of mother at post natal ward at 8.30pm on 16/11/19

Post natal assessment:

Build: Obese/average/Thin : Average

Gait/ appearance : Normal

455
Vital signs :Blood pressure ,Temp,Pulse,Resp - 110/80 mm of Hg, 98.40 F, 76 bt/min ,
24 br/min

Head to toe postnatal examination:

Hair and scalp: Clean

Eyes: Normal Face: Normal
Mouth: Normal Tongue: Hydrated Teeth: Normal
Ear : NAD Nose: NAD Throat: NAD
Neck glands : NAD
Extremities : NAD Nails: Clean and no cyanosis
Breast and nipple : Soft and secretory Milk secretion: Colostrum present
Chest and heart: NAD
Liver : NAD Spleen : NAD Abdomen: Pain Bladder: Empty
Legs: No edema Homan’s sign: Nil Back and spine: Normal
Personal hygiene: Good
Emotional response: Normal
Postnatal discomforts / compliants : Mild cramping pain .
(sleep , bowel , bladder , thirst , appetite after pain ,etc)

Obstetrical examination:

Inspection: No undue enlargement

Palpation of uterus: Uterus is hard and globular in shape .Fundal height – 15 cm .
(Consistency , shape and descent)

Per vaginal inspection / examination :

Vulval edema : Nil

Vagina : Lochia rubra present (Normal)
(Any vaginal bleeding , clots , warts / mole / infection / discharge )
Perineal area / anus :Intact
(Intact , lacerations or haemorrhoids , any pain )
Inspect REEDA for episiotomy wound: Wound is Healthy , no redness and edema .
(Redness , edema , ecchymosis , discharge and apposition )
Colour and amount of lochia odour: Lochia rubra present , Amount – normal

456
Smell -Fishy smell
Any complaints : Pain in episiotomy wound site

BABY
Physical Examination Findings
Condition of the newborn : Good , posture-flexed ,well cried ,alert

Vital signs:
Colour of skin : Pink texture - soft smooth .Dryness over hands and feet .Good turgor .Vernix
present.
Heart rate (Apex bit):146 beats/ min Respiration : 44 breaths/ min

Physical measurement:
Weight: 2.7 kg Length : 49 cm Head circumference : 34 cm
Chest circumference : 31 cm

Head to foot examination:

Examination of head:
Frontanelles/sutures/caput: Anterior frontanelle dimond shaped , 2.5X3cm. No overriding of
suture, no moulding.
Face: Normal
Eyes: Clean and healthy;. Sclera –White, Iris – Dark gray
Ears:Top of the pinna of ears is in a horizontal plane to the outer cantus .
Pinna is firm ,cartilage felt along with edge .Instant recoil .
Nose : Nasal passage is patent
Mouth: No precocious teeth , no epstain pearl , uvula in midline .No cleft lip or cleft palate .
Neck: Short .No gland is palpable .
Limbs and digits : 10 fingers of hands and toes each .Palmer creases present over 1/3rd portion.
Chests : Clear .
Breast: Breast tissue is more than 10 mm. Areola raised .
Abdomen : Soft , No palpable mass .
Umbilical cord : Umbilical cord is clean and no bleeding .2 arteries and 1 vein present .
Genitalia : Labia majora well developed and completely cover the labia minora.No discharge.
Urethral meatus is located above the vaginal orifice .
Anus: Patent.

457
Spine/back: Normal .
Hips(ortoloni’s test): No hip dislocation .
Legs: 10 fingers of toes and sole creases present over a 1/3rd portion .
Reflexes:
Grasp: Present Moro: Present Glabellar: Present Rooting: Present
Sucking: Present Planter and Babinski : Present Muscle activity: Normal
Urine: Passed Meconium: Passed
General impression : Baby is normal
(Specify if any abnormalities found)

Nursing care process for mother

Nursing diagnosis Expected Nursing interventions Evaluation
outcomes (Implementations)
1.Alteration of body Normal body Checked vital signs . BP: 112/80 mm
system due to labour system. Checked dehydration level.of Hg.
process. Vital signs within Checked fundal height and P-80 bt/min
R- 22 br/min
normal range . consistency .
Fundal height- 14
Fundus firm . Checked lochia – amount , cm.
Lochia scanty to colour. Uterus- Hard ,
moderate rubra . globular .
Lochia rubra
present in normal
amount .
2.Pain related to Mother verbalizes Assess for pain relief in mother Suture area is
episiotomy suturing after relief with and administered pain normal .
. interventions . medication . Wound is clean
Pain at the level of Discussed reasons of pain and and healthy .
toleration . it’s expected duration . No unbearable
Assess perineum Inspected the suture area for pain present .
swelling, redness, edema , bleeding .
bleeding . Perineal care provided.
3.Alteration in Mother Provided comfortable position Expressed better
comfort related to experiences and advised early ambulation. feelings.
uterine cramping minimum For uterine cramps Baby is put to
and heaviness of discomfort. administered pain medication. breast.
breast . Promoted perineal exercise.
Assess breast for engorgement.
Instruct to prevent breast
engorgement.
Encouraged proper emptying

458
Nursing diagnosis Expected Nursing interventions Evaluation
outcomes (Implementations)
by giving colostrums and
continue exclusive breast
feeding.

4.Altered nutrition Receive enough Provided normal diet with She had taken diet
and fatigue due to rest. plenty of water Provided rest. and rest.
labour process and Ensured nutrition Advised to adjust sleep timings
sleep pattern with the baby’s sleep timings.
disturbances . Provided support system for
help .
5.Potential alteration Early identification Postnatal assessment done – Normal findings .
in physiological of any deviation . head to foot examination done
process due to
labour process .
6.Altered No bladder Encouraged to empty the No bladder
elimination pattern distension. bladder and bowel. distension.
due to physiological No full rectum. Measured the first
process of labour . void .
Mother asked for
frequency and
amount of void .
She did not pass
stool.
7.Risk for infection . No signs of post- Provided antibiotic as ordered . No phlebitis , no
partum Checked for Homan’s sign . Homan’s sign .
complication . Episiotomy
No phlebitis , wound normal .
Homan’s sign .
Episiotomy wound
infection .
8.Knowledge deficit Mother verbalizes Taught postnatal exercises – Verbalizes
on self care as understanding of abdominal and breathing , foot understanding of
mother states to written and verbal and leg , pelvic floor, bending verbal
whom to consult for instructions on self and straightening alternate instructions on
post partum checkup care activities and knee. Provided verbal self care activities
and care . breast feeding . instructions about balanced and breast feeding
nutritious diet in increased
amount and rich in high
protein, vitamin and roughage .
Plenty of water to drink .
Personal hygiene , daily bath ,
clean , loose cotton garments.

459
 Nursing diagnosis Expected Nursing interventions Evaluation
outcomes (Implementations)
Sexual activity.
Return of menstruation .
FP methods for spacing .
Signs of complication.
Baby care especially regarding
hypothermia , cord infection ,
meconium , urine and
immunization .
Provided information about
postpartum check up.

9. Alteration of Patient will Established mutual trust and Demonstrate

family process demonstrate good respect . positive parenting
coping skills . Taught parenting , baby behaviour .
Acceptance of role holding , baby care .
of parent . Provided support system .
Demonstrate
positive parenting
behaviour .
Adequate bonding.
Nursing care process for baby
Nursing diagnosis Expected Nursing interventions Evaluation
outcomes (Implementations)
Ineffective Adequate body Kept infant warm with mother. Baby’s body
thermoregulation temperature . Wrapped the baby in a baby sheet temperature is
related to heat loss covering the head and extremities. normal.
from exposure in Baby is kept clean and dry after
postnatal ward . urination and passing after meconium.

Potential risk for Establish Mother is advised regarding the risk . Baby is
ineffective airway breathing Support person is informed. crying.
due to pressure of effectively. Baby is kept under close observation. Respiration is
mother’s breast and normal.
baby’s blanket . .

Potential risk for No sign of Strict aseptic technique is maintained No sign of

infection related to infection while handling the baby . infection
newly clamped Eyes are cleaned with sterile swabs.
umbilical cord and Cord is checked for dry gangrene.
exposure to eyes to

460
Nursing diagnosis Expected Nursing interventions Evaluation
outcomes (Implementations)
vaginal secretions .
Altered nutrition less Unaltered Breastfeeding :Initiated with colostrum Baby is active
than body nutritional . and passed
requirement related status . Baby is sucking breast milk properly . urine .
to newborn’s Checked passage of urine . .
transition to Checked baby’s body weight .
extrauterine life.
Altered elimination Normal Checked passage of urine . Baby has
pattern related to elimination Checked passage of meconium . passed urine
newborn’s transition pattern . and
to extrauterine life. meconium.

Potential risk for Early diagnosis A thorough physical examination done Nothing
congenital anomalies of any . abnormalities
or any abnormality abnormality or All physical parameters checked . found
anomalies All reflexes checked
Potential risk for Parents will Helped to allay anxiety related to sex . Demonstrates
ineffective parenting accept the role Taught parenting , positive
related to sex of baby of parent . parenting
. behaviour.
Health seeking Demonstrate Advice given focusing on normal Parents asked
behaviour related to positive newborn's problems regarding : more
needs of a normal parenting newborn's normal behaviour and questions and
newborn during behaviour. abnormal one, e.g. sleep pattern, clarifies their
hospital and after Adequate condition and colour of skin, crying, doughts
discharge form the bonding. elimination, stabilization. regarding
hospital. Exclusive breast feeding for 6 months. baby care.
Activity / hygiene / clothing / saftery /
security / bonding.
Immunization schedule : Inj. BCG,
Hep B and '0' dose polio given at
hospital.
Advice to continue rest of the schedule
in time.
Attendance at well baby clinic.

Signature of student Signature of supervisor

461
 POSTNATAL ASSESSMENT
Case No-12

IDENTIFICATION DATA

Name of the hospital : NRSMC&H Registration :12879

Name of the client : Ritu Pramanik Age: 22 yrs Religion: Hinduism
Address with husband’s name : w/o-Bijon Pramanik, Salua, Rajarhat, Kolkata
GPAL: G1P0A0L0 Period of gestation : 39 weeks
Date and time of admission : 14/11/2019 at 2:00 PM
Unit:II Dr: D. Char
Date and time of delivery: 14/11/2019 at 4 am
Mode of delivery:ND Sex of baby: Female
Condition of baby at birth: Baby cried immediately after birrth
Disc no of mother and baby: 200
Post natal day: 1st postnatal day

MOTHER

Brief History

Type of family: Nuclear Total family members : 4

Support person in the family: Husband
Social: Education: Husband: IX Wife: VI
Occupation: Husband: Labour Wife: House wife
Personal: Any drug allergy: Any drug allergy not identified

Medical and surgical :

Past: Nothing significant Present: Nothing significant

Family: Nothing significant
Diet (Any harmful cultural practices after child birth): Non –veg .She takes adequate diet
during pregnancy . No harmful cultural practice after child birth is present .
Bowel and bladder: Bladder and bowel emptied .

462
 Past Obstetric History : LCB :
No. of Year Abortion Any Mode of Place of Sex Baby Any Remarks
pregna (with problems delivery delivery (alive/ problem with the
ncy period) during stillbirth) during history of
antenatal puerperium breastfeeding
period immunization
.
Primigravida

Present obstetric history:

Booked/unbooked: Booked No of antenatal check up: 4

Immunization : 2 dose of Inj TT is taken Total weight gain: 9 kg
Any problem arise during pregnancy: Yes / No√ .
If yes treatment given: Nil

Laboratory reports:

Blood group: B Rh: Positive VDRL: Negative PPBS:Not done

Fasting: 74 mg/dl Hb%: 11.4 gm/dl Others: TSH :1.76mcg/dl
Urine :Sugar: Nil Albumin: Nil
USG report : Single living fetus , liquor –adequate , Placenta – posterior .

Delivery notes ( from records):Normal delivery with mediolateral episiotomy done .A full
term living baby girl was born on 14/11/19 at 4 am .Inj oxytocin 10 IU given .
Total duration of labour: 13 hours
Removal of placenta : Spontaneous√ /Manual
Treatment: Cap Amoxycillin 500 mg 1 cap TDS , Tab Brufen ,tab metrogyl , tab famotidine .
Received of mother at post natal ward at 4 am on 14/11/2019

Post natal assessment:

Build: Obese/average/Thin: Average
Gait/ appearance: Normal

Vital signs : Blood pressure - 120/80 mm of Hg, ,Temp - 98 0F, Pulse - 80 bt/min,

463
Resp- 20 br/min
Head to toe postnatal examination:
Hair and scalp: Clean
Eyes: Normal Face: Normal
Mouth: Normal Tongue: Hydrated Teeth: Normal
Ear: NAD Nose: NAD Throat: NAD
Neck glands: NAD
Extremities: NAD Nails: Clean and no cyanosis
Breast and nipple : Soft and secretory Milk secretion: Colostrum present
Chest and heart: NAD
Liver: NAD Spleen: NAD Abdomen: Pain Bladder: Empty
Legs: No edema Homan’s sign: Nil Back and spine: Normal
Personal hygiene: Good
Emotional response: Normal
Postnatal discomforts / compliants : Mild cramping pain .
(sleep , bowel , bladder , thirst , appetite after pain ,etc)

Obstetrical examination:
Inspection: No undue enlargement

Palpation of uterus: Uterus is hard and globular in shape .Fundal height – 14 cm .

(Consistency , shape and descent)

Per vaginal inspection / examination :

Vulval edema : Nil
Vagina : Lochia rubra present (Normal)
(Any vaginal bleeding , clots , warts / mole / infection / discharge )
Perineal area / anus : Intact
(Intact , lacerations or haemorrhoids , any pain )
Inspect REEDA for episiotomy wound: Wound is Healthy , no redness and edema .
(Redness , edema , ecchymosis , discharge and apposition )
Colour and amount of lochia odour: Lochia rubra present , Amount – normal
Smell -Fishy smell
Any complaints : Pain in episiotomy wound site

464
BABY
Physical Examination Findings
Condition of the newborn :Good , posture-flexed ,well cried ,alert

Vital signs:
Colour of skin :Pink texture - soft smooth .Dryness over hands and feet .Good turgor .Vernix
present.
Heart rate (Apex bit): 138 beats/ min Respiration : 40 breaths/ min

Physical measurement:
Weight: 2.8 kg Length : 49 cm Head circumference : 34 cm
Chest circumference : 31 cm

Head to foot examination:

Examination of head:
Frontanelles/sutures/caput: Anterior frontanelle dimond shaped , 2.5X3cm. No overriding of
suture, no moulding.
Face: Normal
Eyes: Clean and healthy Sclera –White Iris – Dark gray
Ears:Top of the pinna of ears is in a horizontal plane to the outer cantus .
Pinna is firm ,cartilage felt along with edge .Instant recoil .
Nose: Nasal passage is patent
Mouth:No precocious teeth , no epstain pearl , uvula in midline .No cleft lip or cleft palate .
Neck: Short .No gland is palpable .
Limbs and digits : 10 fingers of hands and toes each .Palmer creases present over 1/3rd portion.
Chests : Clear .
Breast: Breast tissue is more than 10 mm. Areola raised .
Abdomen: Soft , No palpable mass .
Umbilical cord: Umbilical cord is clean and no bleeding .2 arteries and 1 vein present .
Genitalia : Labia majora well developed and completely cover the labia minora.No discharge.
Urethral meatus is located above the vaginal orifice .
Anus: Patent.
Spine/back: Normal .
Hips(ortoloni’s test): No hip dislocation .

465
Legs: 10 fingers of toes and sole creases present over a 1/3rd portion .
Reflexes:
Grasp: Present . Moro: Present . Glabellar: Present . Rooting: Present .
Sucking: Present . Planter and Babinski : Present . Muscle activity: Normal .
Urine: Passed. Meconium: Passed .
General impression : Baby is normal .
(Specify if any abnormalities found)

Nursing care process for mother

Nursing diagnosis Expected Nursing interventions Evaluation
outcomes (Implementations)
1.Alteration of body Normal body Checked vital signs . BP: 110/80 mm
system due to labour system. Checked dehydration level. of Hg.
process. Vital signs within Checked fundal height and P-82 bt/min
R- 22 br/min
normal range . consistency .
Fundal height- 14
Fundus firm . Checked lochia – amount , cm.
Lochia scanty to colour. Uterus- Hard ,
moderate rubra . globular .
Lochia rubra
present in normal
amount .
2.Pain related to Mother verbalizes Assess for pain relief in mother Suture area is
episiotomy suturing after relief with and administered pain normal .
. interventions . medication . Wound is clean
Pain at the level of Discussed reasons of pain and and healthy .
toleration . it’s expected duration . No unbearable
Assess perineum Inspected the suture area for pain present .
swelling, redness, edema , bleeding .
bleeding . Perineal care provided.
3.Alteration in Mother Provided comfortable position Expressed better
comfort related to experiences and advised early ambulation. feelings.
uterine cramping minimum For uterine cramps Baby is put to
and heaviness of discomfort. administered pain medication. breast.
breast . Promoted perineal exercise.
Assess breast for engorgement.
Instruct to prevent breast
engorgement.
Encouraged proper emptying
by giving colostrums and
continue exclusive breast
feeding.

466
Nursing diagnosis Expected Nursing interventions Evaluation
outcomes (Implementations)

4.Altered nutrition Receive enough Provided normal diet with She had taken diet
and fatigue due to rest. plenty of water Provided rest. and rest.
labour process and Ensured nutrition Advised to adjust sleep timings
sleep pattern with the baby’s sleep timings.
disturbances . Provided support system for
help .
5.Potential alteration Early identification Postnatal assessment done – Normal findings .
in physiological of any deviation . head to foot examination done
process due to
labour process .
6.Altered No bladder Encouraged to empty the No bladder
elimination pattern distension. bladder and bowel. distension.
due to physiological No full rectum. Measured the first
process of labour . void .
Mother asked for
frequency and
amount of void .
She did not pass
stool.
7.Risk for infection . No signs of post- Provided antibiotic as ordered . No phlebitis , no
partum Checked for Homan’s sign . Homan’s sign .
complication . Episiotomy
No phlebitis , wound normal .
Homan’s sign .
Episiotomy wound
infection .
8.Knowledge deficit Mother verbalizes Taught postnatal exercises – Verbalizes
on self care as understanding of abdominal and breathing , foot understanding of
mother states to written and verbal and leg , pelvic floor, bending verbal
whom to consult for instructions on self and straightening alternate instructions on
post partum checkup care activities and knee. Provided verbal self care activities
and care . breast feeding . instructions about balanced and breast feeding
nutritious diet in increased .
amount and rich in high
protein, vitamin and roughage .
Plenty of water to drink .
Personal hygiene , daily bath ,
clean , loose cotton garments.
Sexual activity.
Return of menstruation .
FP methods for spacing .

467
Nursing diagnosis Expected Nursing interventions Evaluation
outcomes (Implementations)
Signs of complication.
Baby care especially regarding
hypothermia , cord infection ,
meconium , urine and
immunization .
Provided information about
postpartum check up.

9. Alteration of Patient will Established mutual trust and Demonstrate

family process demonstrate good respect . positive parenting
coping skills . Taught parenting , baby behaviour .
Acceptance of role holding , baby care .
of parent . Provided support system .
Demonstrate
positive parenting
behaviour .
Adequate bonding.
Nursing care process for baby
Nursing diagnosis Expected Nursing interventions Evaluation
outcomes (Implementations)
Ineffective Adequate Kept infant warm with mother. Baby’s body
thermoregulation body Wrapped the baby in a baby sheet temperature is
related to heat loss temperature . covering the head and extremities. normal.
from exposure in Baby is kept clean and dry after
postnatal ward . urination and passing after
meconium.

Potential risk for Establish Mother is advised regarding the risk . Baby is crying.
ineffective airway breathing Support person is informed. Respiration is
due to pressure of effectively. Baby is kept under close observation. normal.
mother’s breast and .
baby’s blanket .

Potential risk for No sign of Strict aseptic technique is maintained No sign of

infection related to infection while handling the baby . infection
newly clamped Eyes are cleaned with sterile swabs.
umbilical cord and Cord is checked for dry gangrene.
exposure to eyes to
vaginal secretions .
Altered nutrition Unaltered Breastfeeding :Initiated with Baby is active

468
Nursing diagnosis Expected Nursing interventions Evaluation
outcomes (Implementations)
less than body nutritional colostrum . and passed urine .
requirement related status . Baby is sucking breast milk properly .
to newborn’s .
transition to Checked passage of urine .
extrauterine life. Checked baby’s body weight .

Altered elimination Normal Checked passage of urine . Baby has passed

pattern related to elimination Checked passage of meconium . urine and
newborn’s pattern . meconium.
transition to
extrauterine life.
Potential risk for Early A thorough physical examination Nothing
congenital diagnosis of done . abnormalities
anomalies or any any All physical parameters checked . found
abnormality abnormality All reflexes checked
or anomalies
Potential risk for Parents will Helped to allay anxiety related to sex Demonstrates
ineffective accept the . positive
parenting related to role of parent Taught parenting , parenting
sex of baby . . behaviour.
Health seeking Demonstrate Advice given focusing on normal Parents asked
behaviour related to positive newborn's problems regarding : more questions
needs of a normal parenting newborn's normal behaviour and and clarifies their
newborn during behaviour. abnormal one, e.g. sleep pattern, doughts
hospital and after Adequate condition and colour of skin, crying, regarding baby
discharge form the bonding. elimination, stabilization. care.
hospital. Exclusive breast feeding for 6
months.
Activity / hygiene / clothing / saftery
/ security / bonding.
Immunization schedule : Inj. BCG,
Hep B and '0' dose polio given at
hospital.
Advice to continue rest of the
schedule in time.
Attendance at well baby clinic.

Signature of student Signature of supervisor

469
 POSTNATAL ASSESSMENT
Case No-13

IDENTIFICATION DATA

Name of the hospital : NRSMC&H Registration :12879

Name of the client : Kakoli Majumder Age:22 yrs Religion: Hinduism
Address with husband’s name : w/o-Mijanur Sk, 40, Cristopher Road, Kolkata
GPAL: G1P0A0L0 Period of gestation :40 weeks
Date and time of admission : 10/11/2019 at 5:00 AM
Unit:II Dr: R.Bal
Date and time of delivery: 10/11/2019 at 9:00 PM
Mode of delivery: ND Sex of baby: Female
Condition of baby at birth: Baby cried immediately after birrth
Disc no of mother and baby:F/374
Post natal day: 1st postnatal day

MOTHER

Brief History

Type of family: Nuclear Total family members : 4

Support person in the family: Husband
Social: Education: Husband: IX Wife: VI
Occupation: Husband: Labour Wife: House wife
Personal: Any drug allergy: Any drug allergy not identified

Medical and surgical :

Past: Nothing significant Present: Nothing significant

Family: Nothing significant
Diet (Any harmful cultural practices after child birth): Non –veg .She takes adequate diet
during pregnancy . No harmful cultural practice after child birth is present .
Bowel and bladder: Bladder and bowel emptied .

470
 Past Obstetric History : LCB :
No. of Year Abortion Any Mode of Place of Sex Baby Any Remarks
pregna (with problems delivery delivery (alive/ problem with the
ncy period) during stillbirth) during history of
antenatal puerperium breastfeeding
period immunization
.
Primigravida

Present obstetric history:

Booked/unbooked: Booked No of antenatal check up: 4
Immunization : 2 dose of Inj TT is taken Total weight gain: 9 kg
Any problem arise during pregnancy: Yes / No√ .
If yes treatment given: Nil

Laboratory reports:
Blood group: B Rh: Positive VDRL: Negative PPBS:Not done
Fasting: 84 mg/dl Hb%: 11 gm/dl Others: TSH :1.74mcg/dl
Urine :Sugar: Nil Albumin: Nil
USG report : Single living fetus , liquor –adequate , Placenta – posterior .

Delivery notes ( from records):Normal delivery with mediolateral episiotomy done .A full
term living baby girl was born on 10/11/19 at 9 pm .Inj oxytocin 10 IU given .
Total duration of labour: 13 hours
Removal of placenta : Spontaneous√ /Manual
Treatment: Cap Amoxycillin 500 mg 1 cap TDS , Tab Brufen ,Tab metrogyl , tab famotidine
Received of mother at post natal ward at 9 pm on 10/11/2019

Post natal assessment:

Build: Obese/average/Thin: Average
Gait/ appearance: Normal

Vital signs : Blood pressure ,Temp,Pulse,Resp.- 110/70 mm of Hg , 98.4 0F , 80 bt/min,

18 br/min

471
Head to toe postnatal examination:
Hair and scalp: Clean
Eyes: Normal Face: Normal
Mouth: Normal Tongue: Hydrated Teeth: Normal
Ear: NAD Nose: NAD Throat: NAD
Neck glands: NAD
Extremities: NAD Nails: Clean and no cyanosis
Breast and nipple : Soft and secretory Milk secretion: Colostrum present
Chest and heart: NAD
Liver: NAD Spleen: NAD Abdomen: Pain Bladder: Empty
Legs: No edema Homan’s sign: Nil Back and spine: Normal
Personal hygiene: Good
Emotional response: Normal
Postnatal discomforts / compliants : Mild cramping pain .
(sleep , bowel , bladder , thirst , appetite after pain ,etc)

Obstetrical examination:
Inspection: No undue enlargement

Palpation of uterus: Uterus is hard and globular in shape .Fundal height – 13.5 cm .
(Consistency , shape and descent)

Per vaginal inspection / examination :

Vulval edema : Nil
Vagina : Lochia rubra present (Normal)
(Any vaginal bleeding , clots , warts / mole / infection / discharge )
Perineal area / anus :Intact
(Intact , lacerations or haemorrhoids , any pain )
Inspect REEDA for episiotomy wound: Wound is Healthy , no redness and edema .
(Redness , edema , ecchymosis , discharge and apposition )
Colour and amount of lochia odour: Lochia rubra present , Amount – normal
Smell -Fishy smell
Any complaints : Pain in episiotomy wound site

472
BABY
Physical Examination Findings
Condition of the newborn :Good , posture-flexed ,well cried ,alert

Vital signs:
Colour of skin :Pink texture - soft smooth .Dryness over hands and feet .Good turgor .Vernix
present.
Heart rate (Apex bit): 138 beats/ min Respiration : 40 breaths/ min

Physical measurement:
Weight: 2.7 kg Length : 48 cm Head circumference : 33 cm
Chest circumference :30 cm

Head to foot examination:

Examination of head:
Frontanelles/sutures/caput: Anterior frontanelle dimond shaped , 2.5X3cm. No overriding of
suture, no moulding.
Face: Normal
Eyes: Clean and healthy;. Sclera –White, Iris – Dark gray
Ears:Top of the pinna of ears is in a horizontal plane to the outer cantus .
Pinna is firm ,cartilage felt along with edge .Instant recoil .
Nose: Nasal passage is patent
Mouth: No precocious teeth , no epstain pearl , uvula in midline .No cleft lip or cleft palate .
Neck: Short .No gland is palpable .
Limbs and digits : 10 fingers of hands and toes each .Palmer creases present over 1/3rd portion.
Chests :Clear .
Breast: Breast tissue is more than 10 mm. Areola raised .
Abdomen: Soft , No palpable mass .
Umbilical cord: Umbilical cord is clean and no bleeding .2 arteries and 1 vein present .
Genitalia : Labia majora well developed and completely cover the labia minora .No discharge
.Urethral meatus is located above the vaginal orifice .
Anus: Patent.
Spine/back: Normal .
Hips(ortoloni’s test): No hip dislocation .

473
Legs: 10 fingers of toes and sole creases present over a 1/3rd portion .
Reflexes:
Grasp: Present . Moro: Present . Glabellar: Present . Rooting: Present .
Sucking: Present . Planter and Babinski : Present . Muscle activity: Normal .
Urine: Passed. Meconium: Passed .
General impression : Baby is normal .
(Specify if any abnormalities found)

Nursing care process for mother

Nursing diagnosis Expected Nursing interventions Evaluation
outcomes (Implementations)
1.Alteration of body Normal body Checked vital signs . BP: 110/80 mm
system due to labour system. Checked dehydration level. of hg.
process. Vital signs within Checked fundal height and P-82 b/m
R- 22 b/m
normal range . consistency .
Fundal height- 15
Fundus firm . Checked lochia – amount , cm.
Lochia scanty to colour. Uterus- Hard ,
moderate rubra . globular .
Lochia rubra
present in normal
amount .
2.Pain related to Mother verbalizes Assess for pain relief in mother Suture area is
episiotomy suturing after relief with and administered pain normal .
interventions . medication . Wound is clean
Pain at the level of Discussed reasons of pain and and healthy .
toleration . it’s expected duration . No unbearable
Assess perineum Inspected the suture area for pain present .
swelling, redness, edema , bleeding .
bleeding . Perineal care provided.
3.Alteration in Mother Provided comfortable position Expressed better
comfort related to experiences and advised early ambulation. feelings.
uterine cramping minimum For uterine cramps Baby is put to
and heaviness of discomfort. administered pain medication. breast.
breast . Promoted perineal exercise.
Assess breast for engorgement.
Instruct to prevent breast
engorgement.
Encouraged proper emptying
by giving colostrums and
continue exclusive breast
feeding.

474
Nursing diagnosis Expected Nursing interventions Evaluation
outcomes (Implementations)

4.Altered nutrition Receive enough Provided normal diet with She had taken diet
and fatigue due to rest. plenty of water Provided rest. and rest.
labour process and Ensured nutrition Advised to adjust sleep timings
sleep pattern with the baby’s sleep timings.
disturbances . Provided support system for
help .
5.Potential alteration Early identification Postnatal assessment done – Normal findings .
in physiological of any deviation . head to foot examination done
process due to
labour process .
6.Altered No bladder Encouraged to empty the No bladder
elimination pattern distension. bladder and bowel. distension.
due to physiological No full rectum. Measured the first
process of labour . void .
Mother asked for
frequency and
amount of void .
She did not pass
stool.
7.Risk for infection . No signs of post- Provided antibiotic as ordered . No phlebitis , no
partum Checked for Homan’s sign . Homan’s sign .
complication . Episiotomy
No phlebitis , wound normal .
Homan’s sign .
Episiotomy wound
infection .
8.Knowledge deficit Mother verbalizes Taught postnatal exercises – Verbalizes
on self care as understanding of abdominal and breathing , foot understanding of
mother states to written and verbal and leg , pelvic floor, bending verbal
whom to consult for instructions on self and straightening alternate instructions on
post partum checkup care activities and knee. Provided verbal self care activities
and care . breast feeding . instructions about balanced and breast feeding
nutritious diet in increased .
amount and rich in high
protein, vitamin and roughage .
Plenty of water to drink .
Personal hygiene , daily bath ,
clean , loose cotton garments.
Sexual activity.
Return of menstruation .
FP methods for spacing .

475
Nursing diagnosis Expected Nursing interventions Evaluation
outcomes (Implementations)
Signs of complication.
Baby care especially regarding
hypothermia , cord infection ,
meconium , urine and
immunization .
Provided information about
postpartum check up.

9. Alteration of Patient will Established mutual trust and Demonstrate

family process demonstrate good respect . positive parenting
coping skills . Taught parenting , baby behaviour .
Acceptance of role holding , baby care .
of parent . Provided support system .
Demonstrate
positive parenting
behaviour .
Adequate bonding.
Nursing care process for baby
Nursing Expected Nursing interventions Evaluation
diagnosis outcomes (Implementations)
Ineffective Adequate body Kept infant warm with mother. Baby’s body
thermoregulation temperature . Wrapped the baby in a baby temperature is
related to heat sheet covering the head and normal.
loss from extremities.
exposure in Baby is kept clean and dry after
postnatal ward . urination and passing after
meconium.

Potential risk for Establish Mother is advised regarding the Baby is

ineffective airway breathing risk . crying.
due to pressure of effectively. Support person is informed. Respiration is
mother’s breast Baby is kept under close normal.
and baby’s observation. .
blanket .
Potential risk for No sign of Strict aseptic technique is No sign of
infection related infection maintained while handling the infection
to newly clamped baby .
umbilical cord Eyes are cleaned with sterile
and exposure to swabs.
eyes to vaginal Cord is checked for dry
secretions . gangrene.

476
Nursing Expected Nursing interventions Evaluation
diagnosis outcomes (Implementations)
Altered nutrition Unaltered Breastfeeding :Initiated with Baby is active
less than body nutritional colostrum . and passed
requirement status . Baby is sucking breast milk urine .
related to properly . .
newborn’s Checked passage of urine .
transition to Checked baby’s body weight .
extrauterine life.
Altered Normal Checked passage of urine . Baby has
elimination elimination Checked passage of meconium . passed urine
pattern related to pattern . and
newborn’s meconium.
transition to
extrauterine life.
Potential risk for Early diagnosis A thorough physical Nothing
congenital of any examination done . abnormalities
anomalies or any abnormality or All physical parameters checked found
abnormality anomalies .
All reflexes checked
Potential risk for Parents will Helped to allay anxiety related Demonstrates
ineffective accept the role to sex . positive
parenting related of parent . Taught parenting , parenting
to sex of baby . behaviour.
Health seeking Demonstrate Advice given focusing on Parents asked
behaviour related positive normal newborn's problems more
to needs of a parenting regarding : newborn's normal questions and
normal newborn behaviour. behaviour and abnormal one, clarifies their
during hospital Adequate e.g. sleep pattern, condition and doughts
and after bonding. colour of skin, crying, regarding
discharge form elimination, stabilization. baby care.
the hospital. Exclusive breast feeding for 6
months.
Activity / hygiene / clothing /
saftery / security / bonding.
Immunization schedule : Inj.
BCG, Hep B and '0' dose polio
given at hospital.
Advice to continue rest of the
schedule in time.
Attendance at well baby clinic.

Signature of student Signature of supervisor

477
 POSTNATAL ASSESSMENT

Case No - 14

IDENTIFICATION DATA

Name of the hospital : NRSMC&H Registration :12879

Name of the client : Bijoli Bibi Age: 24 yrs Religion: Muslim
Address with husband’s name : w/o-Ripon Sk , 2/4,Topsia,Kol-39
GPAL: G1P0A0L0 Period of gestation : 37 weeks
Date and time of admission : 12/11/2019 at 8 am
Unit:I Dr: T. Mondal
Date and time of delivery: 12/11/2019 at 10 pm
Mode of delivery: ND with episiotomy Sex of baby: Female
Condition of baby at birth: Baby cried immediately after birrth
Disc no of mother and baby: 219
Post natal day:1st postnatal day

MOTHER
Brief History
Type of family: Nuclear Total family members : 3
Support person in the family: Mother in low
Social: Education: Husband: X Wife: VII
Occupation: Husband: Shoe maker Wife: House wife
Personal: Any drug allergy: Any drug allergy not identified

Medical and surgical :

Past: Nothing significant Present: Nothing significant
Family: Nothing significant
Diet (Any harmful cultural practices after child birth): Non –veg .She takes adequate diet
during pregnancy . No harmful cultural practice after child birth is present .
Bowel and bladder: Bladder and bowel emptied .

478
 Past Obstetric History : LCB :
No. of Year Abortion Any Mode of Place of Sex Baby Any Remarks
pregna (with problems delivery delivery (alive/ problem with the
ncy period) during stillbirth) during history of
antenatal puerperium breastfeeding
period immunization
.
Primigravida

Present obstetric history:

Booked/unbooked: Booked No of antenatal check up: 5
Immunization : 2 dose of Inj TT is taken Total weight gain: 10 kg
Any problem arise during pregnancy: Yes / No√
If yes treatment given: Nil

Laboratory reports:
Blood group: B Rh: Positive VDRL: Negative PPBS: Not done
Fasting: 79 mg/dl Hb%: 11 gm/dl Others: TSH : 1.78mcg/dl
Urine :Sugar: Nil Albumin: Nil
USG report : Single living fetus , Liquor –adequate , Placenta – posterior .

Delivery notes ( from records):Normal delivery with mediolateral episiotomy done .A full
term living baby girl was born on 12/11/2019 at 10 pm .Inj oxytocin 10 IU given .
Total duration of labour: 13 hours
Removal of placenta : Spontaneous√ /Manual
Treatment: Cap Amoxycillin 500 mg 1 cap TDS , Tab Brufen, Tab metrogyl,Ttab famotidine
.
Received of mother at post natal ward at 10.30pm on 12/11/2019

Post natal assessment:

Build: Obese/average/Thin: Average
Gait/ appearance: Normal

479
Vital signs :Blood pressure ,Temp,Pulse,Resp.- 120/72 mm of hg , 98.40F , 82 bt/min ,
18 br/min

Head to toe postnatal examination:

Hair and scalp: Clean
Eyes: Normal Face: Normal
Mouth: Normal Tongue: Hydrated Teeth: Normal
Ear: NAD Nose: NAD Throat: NAD
Neck glands: NAD
Extremities: NAD Nails: Clean and no cyanosis
Breast and nipple : Soft and secretory Milk secretion: Colostrum present
Chest and heart: NAD
Liver: NAD Spleen: NAD Abdomen: Pain Bladder: Empty
Legs: No edema Homan’s sign: Nil Back and spine: Normal
Personal hygiene: Good
Emotional response: Normal
Postnatal discomforts / compliants : Mild cramping pain .
(sleep , bowel , bladder , thirst , appetite after pain ,etc)
Obstetrical examination:
Inspection: No undue enlargement

Palpation of uterus: Uterus is hard and globular in shape .Fundal height – 13.5 cm .
(Consistency , shape and descent)
Per vaginal inspection / examination :
Vulval edema : Nil
Vagina : Lochia rubra present (Normal)
(Any vaginal bleeding , clots , warts / mole / infection / discharge )
Perineal area / anus :Intact
(Intact , lacerations or haemorrhoids , any pain )
Inspect REEDA for episiotomy wound: Wound is Healthy , no redness and edema .
(Redness , edema , ecchymosis , discharge and apposition )
Colour and amount of lochia odour: Lochia rubra present , Amount – normal
Smell -Fishy smell

480
Any complaints : Pain in episiotomy wound site
BABY
Physical Examination Findings
Condition of the newborn :Good , posture-flexed ,well cried ,alert

Vital signs:
Colour of skin :Pink texture - soft smooth .Dryness over hands and feet .Good turgor .Vernix
present.
Heart rate (Apex bit): 142 beats/ min Respiration : 44 breaths/ min

Physical measurement:
Weight: 268 kg Length : 48 cm Head circumference : 33 cm
Chest circumference : 30 cm

Head to foot examination:

Examination of head:
Frontanelles/sutures/caput: Anterior frontanelle dimond shaped , 2.5X3cm. No overriding of
suture, no moulding.
Face: Normal
Eyes: Clean and healthy;. Sclera –White, Iris – Dark gray
Ears:Top of the pinna of ears is in a horizontal plane to the outer cantus .
Pinna is firm ,cartilage felt along with edge .Instant recoil .
Nose: Nasal passage is patent
Mouth:No precocious teeth , no epstain pearl , uvula in midline .No cleft lip or cleft palate .
Neck: Short .No gland is palpable .
Limbs and digits : 10 fingers of hands and toes each .Palmer creases present over 1/3rd portion.
Chests : Clear .
Breast: Breast tissue is more than 10 mm. Areola raised .
Abdomen: Soft , No palpable mass .
Umbilical cord: Umbilical cord is clean and no bleeding .2 arteries and 1 vein present .
Genitalia : Labia majora well developed and completely cover the labia minora .No discharge
.Urethral meatus is located above the vaginal orifice .
Anus: Patent.
Spine/back: Normal .
Hips(ortoloni’s test): No hip dislocation .

481
Legs: 10 fingers of toes and sole creases present over a 1/3rd portion .
Reflexes:
Grasp: Present Moro: Present Glabellar: Present Rooting: Present
Sucking: Present Planter and Babinski : Present Muscle activity: Normal
Urine: Passed Meconium: Passed
General impression : Baby is normal
(Specify if any abnormalities found)

Nursing care process for mother

Nursing diagnosis Expected Nursing interventions Evaluation
outcomes (Implementations)
1.Alteration of body Normal body Checked vital signs . BP: 110/80 mm
system due to labour system. Checked dehydration level. of hg.
process. Vital signs within Checked fundal height and P-80 b/m
R- 22 b/m
normal range . consistency .
Fundal height-
Fundus firm . Checked lochia – amount , 13.5 cm.
Lochia scanty to colour. Uterus- Hard ,
moderate rubra . globular .
Lochia rubra
present in normal
amount .
2.Pain related to Mother verbalizes Assess for pain relief in mother Suture area is
episiotomy suturing after relief with and administered pain normal .
interventions . medication . Wound is clean
Pain at the level of Discussed reasons of pain and and healthy .
toleration . it’s expected duration . No unbearable
Assess perineum Inspected the suture area for pain present .
swelling, redness, edema , bleeding .
bleeding . Perineal care provided.
3.Alteration in Mother Provided comfortable position Expressed better
comfort related to experiences and advised early ambulation. feelings.
uterine cramping minimum For uterine cramps Baby is put to
and heaviness of discomfort. administered pain medication. breast.
breast . Promoted perineal exercise.
Assess breast for engorgement.
Instruct to prevent breast
engorgement.
Encouraged proper emptying
by giving colostrums and
continue exclusive breast
feeding.

482
Nursing diagnosis Expected Nursing interventions Evaluation
outcomes (Implementations)

4.Altered nutrition Receive enough Provided normal diet with She had taken diet
and fatigue due to rest. plenty of water Provided rest. and rest.
labour process and Ensured nutrition Advised to adjust sleep timings
sleep pattern with the baby’s sleep timings.
disturbances . Provided support system for
help .
5.Potential alteration Early identification Postnatal assessment done – Normal findings .
in physiological of any deviation . head to foot examination done
process due to
labour process .
6.Altered No bladder Encouraged to empty the No bladder
elimination pattern distension. bladder and bowel. distension.
due to physiological No full rectum. Measured the first
process of labour . void .
Mother asked for
frequency and
amount of void .
She did not pass
stool.
7.Risk for infection . No signs of post- Provided antibiotic as ordered . No phlebitis , no
partum Checked for Homan’s sign . Homan’s sign .
complication . Episiotomy
No phlebitis , wound normal .
Homan’s sign .
Episiotomy wound
infection .
8.Knowledge deficit Mother verbalizes Taught postnatal exercises – Verbalizes
on self care as understanding of abdominal and breathing , foot understanding of
mother states to written and verbal and leg , pelvic floor, bending verbal
whom to consult for instructions on self and straightening alternate instructions on
post partum checkup care activities and knee. Provided verbal self care activities
and care . breast feeding . instructions about balanced and breast feeding
nutritious diet in increased .
amount and rich in high
protein, vitamin and roughage .
Plenty of water to drink .
Personal hygiene , daily bath ,
clean , loose cotton garments.
Sexual activity.
Return of menstruation .
FP methods for spacing .

483
 Nursing diagnosis Expected Nursing interventions Evaluation
outcomes (Implementations)
Signs of complication.
Baby care especially regarding
hypothermia , cord infection ,
meconium , urine and
immunization .
Provided information about
postpartum check up.

9. Alteration of Patient will Established mutual trust and Demonstrate

family process demonstrate good respect . positive parenting
coping skills . Taught parenting , baby behaviour .
Acceptance of role holding , baby care .
of parent . Provided support system .
Demonstrate
positive parenting
behaviour .
Adequate bonding.
Nursing care process for baby
Nursing diagnosis Expected Nursing interventions Evaluation
outcomes (Implementations)
Ineffective Adequate body Kept infant warm with mother. Baby’s body
thermoregulation temperature . Wrapped the baby in a baby temperature is
related to heat loss sheet covering the head and normal.
from exposure in extremities.
postnatal ward . Baby is kept clean and dry after
urination and passing after
meconium.

Potential risk for Establish Mother is advised regarding the Baby is

ineffective airway due breathing risk . crying.
to pressure of mother’s effectively. Support person is informed. Respiration is
breast and baby’s Baby is kept under close normal.
blanket . observation.

Potential risk for No sign of Strict aseptic technique is No sign of

infection related to infection maintained while handling the infection
newly clamped baby .
umbilical cord and Eyes are cleaned with sterile
exposure to eyes to swabs.
vaginal secretions . Cord is checked for dry

484
Nursing diagnosis Expected Nursing interventions Evaluation
outcomes (Implementations)
gangrene.
Altered nutrition less Unaltered Breastfeeding :Initiated with Baby is active
than body requirement nutritional colostrum . and passed
related to newborn’s status . Baby is sucking breast milk urine .
transition to properly .
extrauterine life. Checked passage of urine .
Checked baby’s body weight .

Altered elimination Normal Checked passage of urine . Baby has

pattern related to elimination Checked passage of meconium . passed urine
newborn’s transition to pattern . and
extrauterine life. meconium.

Potential risk for Early diagnosis A thorough physical Nothing

congenital anomalies of any examination done . abnormalities
or any abnormality abnormality or All physical parameters checked found.
anomalies .
All reflexes checked
Potential risk for Parents will Helped to allay anxiety related Demonstrates
ineffective parenting accept the role to sex . positive
related to sex of baby . of parent . Taught parenting , parenting
behaviour.
Health seeking Demonstrate Advice given focusing on Parents asked
behaviour related to positive normal newborn's problems more
needs of a normal parenting regarding : newborn's normal questions and
newborn during behaviour. behaviour and abnormal one, clarifies their
hospital and after Adequate e.g. sleep pattern, condition and doughts
discharge form the bonding. colour of skin, crying, regarding
hospital. elimination, stabilization. baby care.
Exclusive breast feeding for 6
months.
Activity / hygiene / clothing /
saftery / security / bonding.
Immunization schedule : Inj.
BCG, Hep B and '0' dose polio
given at hospital.
Advice to continue rest of the
schedule in time.
Attendance at well baby clinic.

Signature of student Signature of supervisor

485
 POSTNATAL ASSESSMENT
Case No-15

IDENTIFICATION DATA

Name of the hospital : NRSMC&H Registration :12879

Name of the client : Soma Dey Age:22 yrs Religion: Hinduism
Address with husband’s name : w/o-Mohan Dey , Rabindra PallyCanning 24 Parganas
(South)
GPAL: G1P0A0L0 Period of gestation : 40 weeks
Date and time of admission : 10/11/2019 at 2pm
Unit:I Dr: T. Mondal
Date and time of delivery : 12/11/2019 at 10.58 am
Mode of delivery: ND with episiotomy Sex of baby : Female
Condition of baby at birth: Baby cried immediately after birrth
Disc no of mother and baby : F/405
Post natal day : 1st postnatal day
MOTHER
Brief History

Type of family : Nuclear Total family members : 4

Support person in the family : Husband
Social: Education: Husband : IX Wife: VI
Occupation: Husband: Labour Wife : House wife
Personal: Any drug allergy : Any drug allergy not identified

Medical and surgical :

Past: Nothing significant Present : Nothing significant

Family: Nothing significant
Diet (Any harmful cultural practices after child birth): Non –veg .She takes adequate diet
during pregnancy . No harmful cultural practice after child birth is present .
Bowel and bladder: Bladder and bowel emptied .

486
 Past Obstetric History : LCB :
No. of Year Abortion Any Mode of Place of Sex Baby Any Remarks
pregna (with problems delivery delivery (alive/ problem with the
ncy period) during stillbirth) during history of
antenatal puerperium breastfeeding
period immunization
.
Primigravida

Present obstetric history:

Booked/unbooked : Booked No of antenatal check up : 4
Immunization : 2 dose of TT is taken Total weight gain : 9 kg
Any problem arise during pregnancy : Yes / No√ .
If yes treatment given : Nil
Laboratory reports:
Blood group : B Rh : Positive VDRL: Negative PPBS : Not done
Fasting: 71 mg/dl Hb%: 11.8 gm/dl Others: TSH :1.64mcg/dl
Urine : Sugar: Nil Albumin: Nil
USG report : Single living fetus , liquor –adequate , Placenta – posterior .

Delivery notes ( from records):Normal delivery with mediolateral episiotomy done .A full
term living baby girl was born on 12/11/2019 at 10.58 pm .Inj oxytocin 10 IU given .
Total duration of labour: 13 hours
Removal of placenta : Spontaneous√ /Manual
Treatment: Cap Amoxycillin 500 mg 1 cap TDS , Tab Brufen ,Tab metrogyl , Tab famotidine
.
Received of mother at post natal ward at 11pm On 12/11/2019
Post natal assessment:
Build : Obese/average/Thin : Average
Gait/ appearance : Normal
Vital signs : Blood pressure ,Temp,Pulse,Resp - 110/72 mm of hg , 98 degree F , 82 bt/min ,
22 br/min
Head to toe postnatal examination:

487
Hair and scalp : Clean
Eyes : Normal Face : Normal
Mouth : Normal Tongue: Hydrated Teeth : Normal
Ear: NAD Nose: NAD Throat : NAD
Neck glands: NAD
Extremities: NAD Nails : Clean and no cyanosis
Breast and nipple : Soft and secretory Milk secretion : Colostrum present
Chest and heart : NAD
Liver : NAD Spleen : NAD Abdomen : Pain Bladder : Empty
Legs: No edema Homan’s sign: Nil Back and spine: Normal
Personal hygiene: Good
Emotional response: Normal
Postnatal discomforts / compliants : Mild cramping pain .
(sleep , bowel , bladder , thirst , appetite after pain ,etc)

Obstetrical examination:
Inspection: No undue enlargement

Palpation of uterus: Uterus is hard and globular in shape .Fundal height – 14 cm .

(Consistency , shape and descent)

Per vaginal inspection / examination :

Vulval edema : Nil
Vagina : Lochia rubra present (Normal)
(Any vaginal bleeding , clots , warts / mole / infection / discharge )
Perineal area / anus : Intact
(Intact , lacerations or haemorrhoids , any pain )
Inspect REEDA for episiotomy wound : Wound is Healthy , no redness and edema .
(Redness , edema , ecchymosis , discharge and apposition )
Colour and amount of lochia odour: Lochia rubra present , Amount – normal
Smell -Fishy smell
Any complaints : Pain in episiotomy wound site

488
BABY
Physical Examination Findings
Condition of the newborn :Good , posture-flexed ,well cried ,alert

Vital signs:
Colour of skin :Pink texture - soft smooth .Dryness over hands and feet .Good turgor .Vernix
present.
Heart rate (Apex bit): 138 beats/ min Respiration : 40 breaths/ min

Physical measurement:
Weight : 2.8 kg Length : 49 cm Head circumference : 34 cm
Chest circumference : 31 cm

Head to foot examination:

Examination of head:
Frontanelles/sutures/caput: Anterior frontanelle dimond shaped , 2.5X3cm. No overriding of
suture, no moulding.
Face: Normal
Eyes: Clean and healthy;. Sclera –White, Iris – Dark gray
Ears:Top of the pinna of ears is in a horizontal plane to the outer cantus .
Pinna is firm ,cartilage felt along with edge .Instant recoil .
Nose: Nasal passage is patent
Mouth:No precocious teeth , no epstain pearl , uvula in midline .No cleft lip or cleft palate .
Neck: Short .No gland is palpable .
Limbs and digits : 10 fingers of hands and toes each .Palmer creases present over 1/3rd portion.
Chests :Clear .
Breast: Breast tissue is more than 10 mm. Areola raised .
Abdomen: Soft , No palpable mass .
Umbilical cord: Umbilical cord is clean and no bleeding .2 arteries and 1 vein present .
Genitalia : Labia majora well developed and completely cover the labia minora .No discharge
.Urethral meatus is located above the vaginal orifice .
Anus: Patent.
Spine/back: Normal .

489
Hips(ortoloni’s test): No hip dislocation .
Legs: 10 fingers of toes and sole creases present over a 1/3rd portion .
Reflexes:
Grasp: Present Moro: Present Glabellar: Present Rooting: Present
Sucking: Present Planter and Babinski : Present Muscle activity: Normal
Urine: Passed Meconium: Passed
General impression : Baby is normal
(Specify if any abnormalities found)
Nursing care process for mother
Nursing diagnosis Expected Nursing interventions Evaluation
outcomes (Implementations)
1.Alteration of body Normal body Checked vital signs . BP: 110/80 mm
system due to labour system. Checked dehydration level.of hg.
process. Vital signs within Checked fundal height and P-82 b/m
R- 22 b/m
normal range . consistency .
Fundal height- 14
Fundus firm . Checked lochia – amount , cm.
Lochia scanty to colour. Uterus- Hard ,
moderate rubra . globular .
Lochia rubra
present in normal
amount .
2.Pain related to Mother verbalizes Assess for pain relief in mother Suture area is
episiotomy suturing after relief with and administered pain normal .
. interventions . medication . Wound is clean
Pain at the level of Discussed reasons of pain and and healthy .
toleration . it’s expected duration . No unbearable
Assess perineum Inspected the suture area for pain present .
swelling, redness, edema , bleeding .
bleeding . Perineal care provided.
3.Alteration in Mother Provided comfortable position Expressed better
comfort related to experiences and advised early ambulation. feelings.
uterine cramping minimum For uterine cramps Baby is put to
and heaviness of discomfort. administered pain medication. breast.
breast . Promoted perineal exercise.
Assess breast for engorgement.
Instruct to prevent breast
engorgement.
Encouraged proper emptying
by giving colostrums and
continue exclusive breast
feeding.

490
Nursing diagnosis Expected Nursing interventions Evaluation
outcomes (Implementations)

4.Altered nutrition Receive enough Provided normal diet with She had taken diet
and fatigue due to rest. plenty of water Provided rest. and rest.
labour process and Ensured nutrition Advised to adjust sleep timings
sleep pattern with the baby’s sleep timings.
disturbances . Provided support system for
help .
5.Potential alteration Early identification Postnatal assessment done – Normal findings .
in physiological of any deviation . head to foot examination done
process due to
labour process .
6.Altered No bladder Encouraged to empty the No bladder
elimination pattern distension. bladder and bowel. distension.
due to physiological No full rectum. Measured the first
process of labour . void .
Mother asked for
frequency and
amount of void .
She did not pass
stool.
7.Risk for infection . No signs of post- Provided antibiotic as ordered . No phlebitis , no
partum Checked for Homan’s sign . Homan’s sign .
complication . Episiotomy
No phlebitis , wound normal .
Homan’s sign .
Episiotomy wound
infection .
8.Knowledge deficit Mother verbalizes Taught postnatal exercises – Verbalizes
on self care as understanding of abdominal and breathing , foot understanding of
mother states to written and verbal and leg , pelvic floor, bending verbal
whom to consult for instructions on self and straightening alternate instructions on
post partum checkup care activities and knee. Provided verbal self care activities
and care . breast feeding . instructions about balanced and breast feeding
nutritious diet in increased .
amount and rich in high
protein, vitamin and roughage .
Plenty of water to drink .
Personal hygiene , daily bath ,
clean , loose cotton garments.
Sexual activity.
Return of menstruation .
FP methods for spacing .

491
 Nursing diagnosis Expected Nursing interventions Evaluation
outcomes (Implementations)
Signs of complication.
Baby care especially regarding
hypothermia , cord infection ,
meconium , urine and
immunization .
Provided information about
postpartum check up.

9. Alteration of Patient will Established mutual trust and Demonstrate

family process demonstrate good respect . positive parenting
coping skills . Taught parenting , baby behaviour .
Acceptance of role holding , baby care .
of parent . Provided support system .
Demonstrate
positive parenting
behaviour .
Adequate bonding.
Nursing care process for baby
Nursing diagnosis Expected Nursing interventions Evaluation
outcomes (Implementations)
Ineffective Adequate body Kept infant warm with mother. Baby’s body
thermoregulation temperature . Wrapped the baby in a baby temperature is
related to heat loss sheet covering the head and normal.
from exposure in extremities.
postnatal ward . Baby is kept clean and dry after
urination and passing after
meconium.

Potential risk for Establish Mother is advised regarding the Baby is

ineffective airway due breathing risk . crying.
to pressure of mother’s effectively. Support person is informed. Respiration is
breast and baby’s Baby is kept under close normal.
blanket . observation. .

Potential risk for No sign of Strict aseptic technique is No sign of

infection related to infection maintained while handling the infection
newly clamped baby .
umbilical cord and Eyes are cleaned with sterile
exposure to eyes to swabs.
vaginal secretions . Cord is checked for dry

492
Nursing diagnosis Expected Nursing interventions Evaluation
outcomes (Implementations)
gangrene.
Altered nutrition less Unaltered Breastfeeding :Initiated with Baby is active
than body requirement nutritional colostrum . and passed
related to newborn’s status . Baby is sucking breast milk urine .
transition to properly . .
extrauterine life. Checked passage of urine .
Checked baby’s body weight .

Altered elimination Normal Checked passage of urine . Baby has

pattern related to elimination Checked passage of meconium . passed urine
newborn’s transition to pattern . and
extrauterine life. meconium.

Potential risk for Early diagnosis A thorough physical Nothing

congenital anomalies of any examination done . abnormalities
or any abnormality abnormality or All physical parameters checked found
anomalies .
All reflexes checked
Potential risk for Parents will Helped to allay anxiety related Demonstrates
ineffective parenting accept the role to sex . positive
related to sex of baby . of parent . Taught parenting , parenting
behaviour.
Health seeking Demonstrate Advice given focusing on Parents asked
behaviour related to positive normal newborn's problems more
needs of a normal parenting regarding : newborn's normal questions and
newborn during behaviour. behaviour and abnormal one, clarifies their
hospital and after Adequate e.g. sleep pattern, condition and doughts
discharge form the bonding. colour of skin, crying, regarding
hospital. elimination, stabilization. baby care.
Exclusive breast feeding for 6
months.
Activity / hygiene / clothing /
saftery / security / bonding.
Immunization schedule : Inj.
BCG, Hep B and '0' dose polio
given at hospital.
Advice to continue rest of the
schedule in time.
Attendance at well baby clinic.

Signature of student Signature of supervisor

493
 POSTNATAL ASSESSMENT

Case No-16

IDENTIFICATION DATA

Name of the hospital : NRSMC&H Registration :12879

Name of the client : Kakon Sikder Age: 20 yrs Religion: Hinduism
Address with husband’s name : w/o-Monoj Sikder , 36/A Kabi Sukanta
Road,Santosh,Kolkata-75
GPAL:G1P0A0L0 Period of gestation : 40 weeks
Date and time of admission : 10/11/2019 at 6:00 AM
Unit:II Dr: D. Saha
Date and time of delivery: 10/11/2019 at 9.30 PM
Mode of delivery: ND with episiotomy Sex of baby: Female
Condition of baby at birth: Baby cried immediately after birth
Disc no of mother and baby: 302
Post natal day: 1st postnatal day

MOTHER

Brief History
Type of family: Nuclear Total family members : 3
Support person in the family: Husband
Social: Education: Husband: VII Wife: VI
Occupation: Husband: Shoe makeer Wife: House wife
Personal: Any drug allergy: Any drug allergy not identified

Medical and surgical :

Past: Nothing significant Present: Nothing significant
Family: Nothing significant
Diet (Any harmful cultural practices after child birth): Non –veg .She takes adequate diet
during pregnancy . No harmful cultural practice after child birth is present .
Bowel and bladder: Bladder and bowel emptied .

494
 Past Obstetric History : LCB :
No. of Year Abortion Any Mode Place of Sex Baby Any Remarks
pregna (with problems of delivery (alive/ problem with the
ncy period) during delivery stillbirth) during history of
antenatal puerperium breastfeeding
period immunization
.
Primigravida

Present obstetric history:

Booked/unbooked : Booked No of antenatal check up : 4
Immunization : 2 dose of Inj TT is taken Total weight gain : 10 kg
Any problem arise during pregnancy : Yes / No√ .
If yes treatment given : Nil

Laboratory reports:
Blood group : B Rh : Positive VDRL: Negative PPBS: Not done
Fasting : 80 mg/dl Hb% : 11 gm/dl Others: TSH : 1.72mcg/dl
Urine : Sugar : Nil Albumin : Nil
USG report : Single living fetus , liquor –adequate , Placenta – posterior .

Delivery notes ( from records):Normal delivery with mediolateral episiotomy done .A full
term living baby girl was born on 10/11/19 at 9.30pm .Inj oxytocin 10 IU given .
Total duration of labour : 14 hours
Removal of placenta : Spontaneous√ /Manual
Treatment: Cap Amoxycillin 500 mg 1 cap TDS , Tab Brufen ,tab metrogyl , Tab famotidine
.
Received of mother at post natal ward at 10pm On 10/11/2019

Post natal assessment:

Build: Obese/average/Thin : Average
Gait/ appearance : Normal

495
Vital signs : Blood pressure, Temp, Pulse,Resp - 110/70 mm of hg , 98.40 F , 76 bt/min ,
20 br/min
Head to toe postnatal examination:
Hair and scalp : Clean
Eyes : Normal Face : Normal
Mouth : Normal Tongue : Hydrated Teeth : Normal
Ear : NAD Nose : NAD Throat : NAD
Neck glands: NAD
Extremities : NAD Nails : Clean and no cyanosis
Breast and nipple : Soft and secretory Milk secretion : Colostrum present
Chest and heart : NAD
Liver : NAD Spleen : NAD Abdomen : Pain Bladder : Empty
Legs : No edema Homan’s sign : Nil Back and spine : Normal
Personal hygiene : Good
Emotional response : Normal
Postnatal discomforts / compliants : Mild cramping pain .
(sleep , bowel , bladder , thirst , appetite after pain ,etc)

Obstetrical examination:
Inspection: No undue enlargement

Palpation of uterus : Uterus is hard and globular in shape. Fundal height – 14cm .
(Consistency , shape and descent)

Per vaginal inspection / examination :

Vulval edema : Nil
Vagina : Lochia rubra present (Normal)
(Any vaginal bleeding , clots , warts / mole / infection / discharge )
Perineal area / anus :Intact
(Intact , lacerations or haemorrhoids , any pain )
Inspect REEDA for episiotomy wound : Wound is Healthy , no redness and edema .
(Redness , edema , ecchymosis , discharge and apposition )
Colour and amount of lochia odour : Lochia rubra present , Amount – normal
Smell -Fishy smell

496
Any complaints : Pain in episiotomy wound site

BABY
Physical Examination Findings
Condition of the newborn : Good , posture-flexed ,well cried , alert
Vital signs:
Colour of skin : Pink texture - soft smooth. Dryness over hands and feet .Good turgor .Vernix
present.
Heart rate (Apex bit) : 136 beats/ min Respiration : 42 breaths/ min
Physical measurement:
Weight : 2.7 kg Length : 48cm Head circumference : 33 cm
Chest circumference : 31 cm

Head to foot examination:

Examination of head:
Frontanelles/sutures/caput: Anterior frontanelle dimond shaped , 2.5X3cm. No overriding of
suture, no moulding.
Face: Normal
Eyes: Clean and healthy Sclera –White Iris – Dark gray
Ears:Top of the pinna of ears is in a horizontal plane to the outer cantus .
Pinna is firm, cartilage felt along with edge. Instant recoil .
Nose : Nasal passage is patent
Mouth: No precocious teeth , no epstain pearl , uvula in midline .No cleft lip or cleft palate .
Neck : Short. No gland is palpable .
Limbs and digits : 10 fingers of hands and toes each . Palmer creases present over 1/3rd portion.
Chests : Clear .
Breast : Breast tissue is more than 10 mm. Areola raised .
Abdomen : Soft, No palpable mass .
Umbilical cord : Umbilical cord is clean and no bleeding. 2 arteries and 1 vein present .
Genitalia : Labia majora well developed and completely cover the labia minora.No discharge.
Urethral meatus is located above the vaginal orifice .
Anus: Patent. Spine/back: Normal .
Hips(ortoloni’s test): No hip dislocation .
Legs: 10 fingers of toes and sole creases present over a 1/3rd portion .

497
Reflexes:
Grasp : Present Moro : Present Glabellar : Present Rooting : Present
Sucking : Present Planter and Babinski : Present Muscle activity : Normal
Urine: Passed Meconium : Passed
General impression : Baby is normal
(Specify if any abnormalities found)
Nursing care process for mother
Nursing diagnosis Expected Nursing interventions Evaluation
outcomes (Implementations)
1.Alteration of body Normal body Checked vital signs . BP: 110/70 mm
system due to labour system. Checked dehydration level. of Hg.
process. Vital signs within Checked fundal height and P-80 bt/min
R- 20 br/min
normal range . consistency .
Fundal height-
Fundus firm . Checked lochia – amount , 154cm.
Lochia scanty to colour. Uterus- Hard ,
moderate rubra . globular .
Lochia rubra
present in normal
amount .
2.Pain related to Mother verbalizes Assess for pain relief in mother Suture area is
episiotomy suturing after relief with and administered pain normal .
. interventions . medication . Wound is clean
Pain at the level of Discussed reasons of pain and and healthy .
toleration . it’s expected duration . No unbearable
Assess perineum Inspected the suture area for pain present .
swelling, redness, edema , bleeding .
bleeding . Perineal care provided.
3.Alteration in Mother Provided comfortable position Expressed better
comfort related to experiences and advised early ambulation. feelings.
uterine cramping minimum For uterine cramps Baby is put to
and heaviness of discomfort. administered pain medication. breast.
breast . Promoted perineal exercise.
Assess breast for engorgement.
Instruct to prevent breast
engorgement.
Encouraged proper emptying
by giving colostrums and
continue exclusive breast
feeding.

4.Altered nutrition Receive enough Provided normal diet with She had taken diet
and fatigue due to rest. plenty of water Provided rest. and rest.

498
Nursing diagnosis Expected Nursing interventions Evaluation
outcomes (Implementations)
labour process and Ensured nutrition Advised to adjust sleep timings
sleep pattern with the baby’s sleep timings.
disturbances . Provided support system for
help .
5.Potential alteration Early identification Postnatal assessment done – Normal findings .
in physiological of any deviation . head to foot examination done
process due to
labour process .
6.Altered No bladder Encouraged to empty the No bladder
elimination pattern distension. bladder and bowel. distension.
due to physiological No full rectum. Measured the first
process of labour . void .
Mother asked for
frequency and
amount of void .
She did not pass
stool.
7.Risk for infection . No signs of post- Provided antibiotic as ordered . No phlebitis , no
partum Checked for Homan’s sign . Homan’s sign .
complication . Episiotomy
No phlebitis , wound normal .
Homan’s sign .
Episiotomy wound
infection .
8.Knowledge deficit Mother verbalizes Taught postnatal exercises – Verbalizes
on self care as understanding of abdominal and breathing , foot understanding of
mother states to written and verbal and leg , pelvic floor, bending verbal
whom to consult for instructions on self and straightening alternate instructions on
post partum checkup care activities and knee. Provided verbal self care activities
and care . breast feeding . instructions about balanced and breast
nutritious diet in increased feeding.
amount and rich in high
protein, vitamin and roughage .
Plenty of water to drink .
Personal hygiene , daily bath ,
clean , loose cotton garments.
Sexual activity.
Return of menstruation .
FP methods for spacing .
Signs of complication.
Baby care especially regarding

499
Nursing diagnosis Expected Nursing interventions Evaluation
outcomes (Implementations)
hypothermia , cord infection ,
meconium , urine and
immunization .
Provided information about
postpartum check up.

9. Alteration of Patient will Established mutual trust and Demonstrate

family process demonstrate good respect . positive parenting
coping skills . Taught parenting , baby behaviour .
Acceptance of role holding , baby care .
of parent . Provided support system .
Demonstrate
positive parenting
behaviour .
Adequate bonding.
Nursing care process for baby
Nursing Expected Nursing interventions Evaluation
diagnosis outcomes (Implementations)
Ineffective Adequate body Kept infant warm with mother. Baby’s body
thermoregulation temperature . Wrapped the baby in a baby temperature is
related to heat sheet covering the head and normal.
loss from extremities.
exposure in Baby is kept clean and dry after
postnatal ward . urination and passing after
meconium.

Potential risk for Establish Mother is advised regarding the Baby is

ineffective airway breathing risk . crying.
due to pressure of effectively. Support person is informed. Respiration is
mother’s breast Baby is kept under close normal.
and baby’s observation.
blanket .

Potential risk for No sign of Strict aseptic technique is No sign of

infection related infection maintained while handling the infection.
to newly clamped baby .
umbilical cord Eyes are cleaned with sterile
and exposure to swabs.
eyes to vaginal Cord is checked for dry
secretions . gangrene.

500
Nursing Expected Nursing interventions Evaluation
diagnosis outcomes (Implementations)
Altered nutrition Unaltered Breastfeeding :Initiated with Baby is active
less than body nutritional colostrum . and passed
requirement status . Baby is sucking breast milk urine .
related to properly .
newborn’s Checked passage of urine .
transition to Checked baby’s body weight .
extrauterine life.
Altered Normal Checked passage of urine . Baby has
elimination elimination Checked passage of meconium . passed urine
pattern related to pattern . and
newborn’s meconium.
transition to
extrauterine life.
Potential risk for Early diagnosis A thorough physical Nothing
congenital of any examination done . abnormalities
anomalies or any abnormality or All physical parameters checked found.
abnormality anomalies .
All reflexes checked
Potential risk for Parents will Helped to allay anxiety related Demonstrates
ineffective accept the role to sex . positive
parenting related of parent . Taught parenting , parenting
to sex of baby . behaviour.
Health seeking Demonstrate Advice given focusing on Parents asked
behaviour related positive normal newborn's problems more
to needs of a parenting regarding : newborn's normal questions and
normal newborn behaviour. behaviour and abnormal one, clarifies their
during hospital Adequate e.g. sleep pattern, condition and doughts
and after bonding. colour of skin, crying, regarding
discharge form elimination, stabilization. baby care.
the hospital. Exclusive breast feeding for 6
months.
Activity / hygiene / clothing /
saftery / security / bonding.
Immunization schedule : Inj.
BCG, Hep B and '0' dose polio
given at hospital.
Advice to continue rest of the
schedule in time.
Attendance at well baby clinic.

Signature of student Signature of supervisor

501
 POSTNATAL ASSESSMENT

Case No-17

IDENTIFICATION DATA

Name of the hospital : NRSMC&H Registration :12879

Name of the client : Mitali Bose Age:22 yrs Religion: Hinduism
Address with husband’s name : w/o-Dipak Bose, 137/B, Ananda Palit Road,Kol-14

GPAL: G1P0A0L0 Period of gestation : 38 weeks

Date and time of admission : 11/11/2019 at 5:00 AM
Unit : I Dr : B. Bose
Date and time of delivery: 11/11/2019 at 9:00 PM
Mode of delivery: ND with episiotomy Sex of baby : Female
Condition of baby at birth: Baby cried immediately after birrth
Disc no of mother and baby : 234
Post natal day : 1st postnatal day

MOTHER

Brief History
Type of family : Nuclear Total family members : 4
Support person in the family : Mother in low
Social : Education: Husband : XI Wife : X
Occupation : Husband : Private company Wife: House wife
Personal: Any drug allergy: Any drug allergy not identified

Medical and surgical :

Past: Nothing significant Present: Nothing significant
Family: Nothing significant
Diet (Any harmful cultural practices after child birth): Non –veg .She takes adequate diet
during pregnancy . No harmful cultural practice after child birth is present .
Bowel and bladde r: Bladder and bowel emptied .

502
 Past Obstetric History : LCB :
No. of Year Abortion Any Mode of Place of Sex Baby Any Remarks
pregna (with problems delivery delivery (alive/ problem with the
ncy period) during stillbirth) during history of
antenatal puerperium breastfeeding
period immunization
.
Primigravida

Present obstetric history:

Booked/unbooked : Booked No of antenatal check up : 4
Immunization : 2 dose of Inj TT is taken Total weight gain : 9 kg
Any problem arise during pregnancy : Yes / No√
If yes treatment given : Nil

Laboratory reports:
Blood group : B Rh : Positive VDRL: Negative PPBS: Not done
Fasting : 80 mg/dl Hb% : 11.2 gm/dl Others: TSH :1.74mcg/dl
Urine : Sugar : Nil Albumin : Nil
USG report : Single living fetus , liquor –adequate , Placenta – posterior .

Delivery notes ( from records): Normal delivery with mediolateral episiotomy done .A full
term living baby girl was born on 11/11/2019 at 9pm .Inj oxytocin 10 IU given .
Total duration of labour : 12 hours
Removal of placenta : Spontaneous√ /Manual
Treatment: Cap Amoxycillin 500 mg 1 cap TDS , Tab Brufen , Tab metrogyl , Tab
Famotidine. Received of mother at post natal ward at 9.30 PM on 11/11/2019

Post natal assessment:

Build: Obese/average/Thin : Average
Gait/ appearance : Normal

Vital signs: Blood pressure, Temp, Pulse, Resp - 112/72 mm of Hg , 98.6 0 F , 80 bt/min,

503
 22 br/min

Head to toe postnatal examination:

Hair and scalp : Clean

Eyes : Normal Face : Normal
Mouth : Normal Tongue : Hydrated Teeth : Normal
Ear : NAD Nose : NAD Throat : NAD
Neck glands : NAD
Extremities : NAD Nails : Clean and no cyanosis
Breast and nipple : Soft and secretory Milk secretion : Colostrum present
Chest and heart: NAD
Liver : NAD Spleen : NAD Abdomen: Pain Bladder : Empty
Legs : No edema Homan’s sign : Nil Back and spine : Normal
Personal hygiene : Good
Emotional response : Normal
Postnatal discomforts / compliants : Mild cramping pain .
(sleep , bowel , bladder , thirst , appetite after pain ,etc)

Obstetrical examination:

Inspection: No undue enlargement

Palpation of uterus: Uterus is hard and globular in shape .Fundal height – 15 cm .

(Consistency , shape and descent)

Per vaginal inspection / examination :

Vulval edema : Nil
Vagina : Lochia rubra present (Normal)
(Any vaginal bleeding , clots , warts / mole / infection / discharge )
Perineal area / anus :Intact
(Intact , lacerations or haemorrhoids , any pain )
Inspect REEDA for episiotomy wound: Wound is Healthy , no redness and edema .
(Redness , edema , ecchymosis , discharge and apposition )
Colour and amount of lochia odour: Lochia rubra present , Amount – normal
Smell -Fishy smell

504
Any complaints : Pain in episiotomy wound site

BABY
Physical Examination Findings
Condition of the newborn :Good , posture-flexed ,well cried ,alert
Vital signs:
Colour of skin :Pink texture - soft smooth .Dryness over hands and feet .Good turgor .Vernix
present.
Heart rate (Apex bit): 140beats/ min Respiration : 44 breaths/ min
Physical measurement:
Weight: 2.9 kg Length : 48 cm Head circumference : 33 cm
Chest circumference : 31 cm
Head to foot examination:
Examination of head:
Frontanelles/sutures/caput: Anterior frontanelle dimond shaped , 2.5X3cm. No overriding of
suture, no moulding.
Face: Normal
Eyes: Clean and healthy;. Sclera –White, Iris – Dark gray
Ears:Top of the pinna of ears is in a horizontal plane to the outer cantus .
Pinna is firm ,cartilage felt along with edge .Instant recoil .
Nose: Nasal passage is patent
Mouth: No precocious teeth , no epstain pearl , uvula in midline .No cleft lip or cleft palate .
Neck: Short .No gland is palpable .
Limbs and digits : 10 fingers of hands and toes each. Palmer creases present over 1/3rd portion.
Chests : Clear.
Breast: Breast tissue is more than 10 mm. Areola raised .
Abdomen: Soft , No palpable mass .
Umbilical cord: Umbilical cord is clean and no bleeding. 2 arteries and 1 vein present .
Genitalia : Labia majora well developed and completely cover the labia minora .No discharge.
Urethral meatus is located above the vaginal orifice .
Anus: Patent.
Spine/back: Normal .
Hips(ortoloni’s test): No hip dislocation .
Legs: 10 fingers of toes and sole creases present over a 1/3rd portion .

505
Reflexes:
Grasp: Present Moro: Present Glabellar: Present Rooting: Present
Sucking: Present Planter and Babinski : Present Muscle activity: Normal
Urine: Passed Meconium: Passed
General impression : Baby is normal
(Specify if any abnormalities found)

Nursing care process for mother

Nursing diagnosis Expected Nursing interventions Evaluation
outcomes (Implementations)
1.Alteration of body Normal body Checked vital signs . BP: 110/80 mm
system due to labour system. Checked dehydration level. of Hg.
process. Vital signs within Checked fundal height and P-82 bt/min
R- 22 br/min
normal range . consistency .
Fundal height- 15
Fundus firm . Checked lochia – amount , cm.
Lochia scanty to colour. Uterus- Hard ,
moderate rubra . globular .
Lochia rubra
present in normal
amount .
2.Pain related to Mother verbalizes Assess for pain relief in mother Suture area is
episiotomy suturing after relief with and administered pain normal .
. interventions . medication . Wound is clean
Pain at the level of Discussed reasons of pain and and healthy .
toleration . it’s expected duration . No unbearable
Assess perineum Inspected the suture area for pain present .
swelling, redness, edema , bleeding .
bleeding . Perineal care provided.
3.Alteration in Mother Provided comfortable position Expressed better
comfort related to experiences and advised early ambulation. feelings.
uterine cramping minimum For uterine cramps Baby is put to
and heaviness of discomfort. administered pain medication. breast.
breast . Promoted perineal exercise.
Assess breast for engorgement.
Instruct to prevent breast
engorgement.
Encouraged proper emptying
by giving colostrums and
continue exclusive breast
feeding.

506
Nursing diagnosis Expected Nursing interventions Evaluation
outcomes (Implementations)
4.Altered nutrition Receive enough Provided normal diet with She had taken diet
and fatigue due to rest. plenty of water Provided rest. and rest.
labour process and Ensured nutrition Advised to adjust sleep timings
sleep pattern with the baby’s sleep timings.
disturbances . Provided support system for
help .
5.Potential alteration Early identification Postnatal assessment done – Normal findings .
in physiological of any deviation . head to foot examination done
process due to
labour process .
6.Altered No bladder Encouraged to empty the No bladder
elimination pattern distension. bladder and bowel. distension.
due to physiological No full rectum. Measured the first
process of labour . void .
Mother asked for
frequency and
amount of void .
She did not pass
stool.
7.Risk for infection . No signs of post- Provided antibiotic as ordered . No phlebitis , no
partum Checked for Homan’s sign . Homan’s sign .
complication . Episiotomy
No phlebitis , wound normal .
Homan’s sign .
Episiotomy wound
infection .
8.Knowledge deficit Mother verbalizes Taught postnatal exercises – Verbalizes
on self care as understanding of abdominal and breathing , foot understanding of
mother states to written and verbal and leg , pelvic floor, bending verbal
whom to consult for instructions on self and straightening alternate instructions on
post partum checkup care activities and knee. Provided verbal self care activities
and care . breast feeding . instructions about balanced and breast feeding
nutritious diet in increased .
amount and rich in high
protein, vitamin and roughage .
Plenty of water to drink .
Personal hygiene , daily bath ,
clean , loose cotton garments.
Sexual activity.
Return of menstruation .
FP methods for spacing .

507
 Nursing diagnosis Expected Nursing interventions Evaluation
outcomes (Implementations)
Signs of complication.
Baby care especially regarding
hypothermia , cord infection ,
meconium , urine and
immunization .
Provided information about
postpartum check up.

9. Alteration of Patient will Established mutual trust and Demonstrate

family process demonstrate good respect . positive parenting
coping skills . Taught parenting , baby behaviour .
Acceptance of role holding , baby care .
of parent . Provided support system .
Demonstrate
positive parenting
behaviour .
Adequate bonding.
Nursing care process for baby
Nursing diagnosis Expected Nursing interventions Evaluation
outcomes (Implementations)
Ineffective Adequate body Kept infant warm with mother. Baby’s body
thermoregulation temperature . Wrapped the baby in a baby temperature is
related to heat loss sheet covering the head and normal.
from exposure in extremities.
postnatal ward . Baby is kept clean and dry after
urination and passing after
meconium.

Potential risk for Establish Mother is advised regarding the Baby is

ineffective airway breathing risk . crying.
due to pressure of effectively. Support person is informed. Respiration is
mother’s breast and Baby is kept under close normal.
baby’s blanket . observation. .

Potential risk for No sign of Strict aseptic technique is No sign of

infection related to infection maintained while handling the infection
newly clamped baby .
umbilical cord and Eyes are cleaned with sterile
exposure to eyes to swabs.
vaginal secretions . Cord is checked for dry

508
Nursing diagnosis Expected Nursing interventions Evaluation
outcomes (Implementations)
gangrene.
Altered nutrition less Unaltered Breastfeeding :Initiated with Baby is active
than body nutritional colostrum . and passed
requirement related status . Baby is sucking breast milk urine .
to newborn’s properly . .
transition to Checked passage of urine .
extrauterine life. Checked baby’s body weight .

Altered elimination Normal Checked passage of urine . Baby has

pattern related to elimination Checked passage of meconium . passed urine
newborn’s transition pattern . and
to extrauterine life. meconium.

Potential risk for Early diagnosis A thorough physical Nothing

congenital anomalies of any examination done . abnormalities
or any abnormality abnormality or All physical parameters checked found
anomalies .
All reflexes checked
Potential risk for Parents will Helped to allay anxiety related Demonstrates
ineffective parenting accept the role to sex . positive
related to sex of baby of parent . Taught parenting , parenting
. behaviour.
Health seeking Demonstrate Advice given focusing on Parents asked
behaviour related to positive normal newborn's problems more
needs of a normal parenting regarding : newborn's normal questions and
newborn during behaviour. behaviour and abnormal one, clarifies their
hospital and after Adequate e.g. sleep pattern, condition and doughts
discharge form the bonding. colour of skin, crying, regarding
hospital. elimination, stabilization. baby care.
Exclusive breast feeding for 6
months.
Activity / hygiene / clothing /
saftery / security / bonding.
Immunization schedule : Inj.
BCG, Hep B and '0' dose polio
given at hospital.
Advice to continue rest of the
schedule in time.
Attendance at well baby clinic.

Signature of student Signature of supervisor

509
 POSTNATAL ASSESSMENT
Case No-18

IDENTIFICATION DATA

Name of the hospital : NRSMC&H Registration :12879

Name of the client : Sutapa Gain Age :24 yrs Religion : Muslim
Address with husband’s name : w/o-Biren Gain , Pragati Pally, Subhasnagar, kol-147
GPAL: G1P0A0L0 Period of gestation : 40 weeks
Date and time of admission : 12/11/2019 at 2:00 PM
Unit : I Dr : P. Choudhury
Date and time of delivery : 13/11/2019 at 10:00 AM
Mode of delivery : ND with episiotomy Sex of baby : Female
Condition of baby at birth : Baby cried immediately after birrth
Disc no of mother and baby: 234
Post natal day : 1st postnatal day

MOTHER

Brief History
Type of family: Nuclear Total family members : 3
Support person in the family: Mother in low
Social : Education: Husband : VIII Class Wife : VI Class
Occupation: Husband : Labour Wife: House wife
Personal: Any drug allergy : Any drug allergy not identified

Medical and surgical:

Past: Nothing significant Present: Nothing significant

Family: Nothing significant
Diet (Any harmful cultural practices after child birth): Non –veg .She takes adequate diet
during pregnancy . No harmful cultural practice after child birth is present .
Bowel and bladder: Bladder and bowel emptied .

510
 Past Obstetric History : LCB :
No. of Year Abortion Any Mode of Place of Sex Baby Any Remarks
pregna (with problems delivery delivery (alive/ problem with the
ncy period) during stillbirth) during history of
antenatal puerperium breastfeeding
period immunization
.
Primigravida

Present obstetric history:

Booked/unbooked : Booked No of antenatal check up : 4
Immunization : 2 dose of Inj TT is taken Total weight gain: 10 kg
Any problem arise during pregnancy: Yes / No√
If yes treatment given : Nil

Laboratory reports:
Blood group : B Rh : Positive VDRL: Negative PPBS : Not done
Fasting : 78 mg/dl Hb% : 10.8 gm/dl Others: TSH :1.76 mcg/dl
Urine :Sugar: Nil Albumin: Nil
USG report : Single living fetus , Liquor –Adequate , Placenta – Posterior .

Delivery notes ( from records):Normal delivery with mediolateral episiotomy done .A full
term living baby girl was born on 13/11/19 at 10:00 Am .Inj Oxytocin 10 IU given .
Total duration of labour: 13 hours
Removal of placenta : Spontaneous√ /Manual
Treatment: Cap Amoxycillin 500 mg 1 Cap TDS , Tab Brufen ,Tab Metrogyl ,
Tab Famotidine
Received of mother at post natal ward at 11:00 AM On 13/11/2019

Post natal assessment:

Build: Obese/average/Thin : Average
Gait/ appearance : Normal

511
Vital signs : Blood pressure, Temp, Pulse, Resp - 114/72 mm of Hg, 98.20F , 78 bt/min ,
20 br/min
Head to toe postnatal examination:
Hair and scalp : Clean
Eyes : Normal Face : Normal
Mouth : Normal Tongue : Hydrated Teeth: Normal
Ear : NAD Nose : NAD Throat : NAD
Neck glands : NAD
Extremities : NAD Nails : Clean and no cyanosis
Breast and nipple : Soft and secretory Milk secretion : Colostrum present
Chest and heart : NAD
Liver: NAD Spleen: NAD Abdomen: Pain Bladder: Empty
Legs: No edema Homan’s sign: Nil Back and spine: Normal
Personal hygiene: Good
Emotional response: Normal
Postnatal discomforts / compliants : Mild cramping pain .
(sleep , bowel , bladder , thirst , appetite after pain ,etc)

Obstetrical examination:
Inspection: No undue enlargement

Palpation of uterus: Uterus is hard and globular in shape .Fundal height – 14 cm .

(Consistency , shape and descent)

Per vaginal inspection / examination :

Vulval edema : Nil
Vagina : Lochia rubra present (Normal)
(Any vaginal bleeding , clots , warts / mole / infection / discharge )
Perineal area / anus :Intact
(Intact , lacerations or haemorrhoids , any pain )
Inspect REEDA for episiotomy wound: Wound is Healthy , no redness and edema .
(Redness , edema , ecchymosis , discharge and apposition )
Colour and amount of lochia odour: Lochia rubra present , Amount – normal
Smell -Fishy smell

512
Any complaints : Pain in episiotomy wound site

BABY
Physical Examination Findings
Condition of the newborn :Good, posture-flexed, well cried, alert
Vital signs:
Colour of skin :Pink texture - soft smooth. Dryness over hands and feet .Good turgor .Vernix
present.
Heart rate (Apex bit):138 beats/ min Respiration : 40 breaths/ min
Physical measurement:
Weight: 2.8 kg Length : 49 cm Head circumference : 34 cm
Chest circumference : 31 cm
Head to foot examination:
Examination of head:
Frontanelles/sutures/caput : Anterior frontanelle dimond shaped , 2.5X3cm. No overriding of
suture, no moulding.
Face: Normal
Eyes: Clean and healthy Sclera –White, Iris – Dark gray
Ears:Top of the pinna of ears is in a horizontal plane to the outer cantus .
Pinna is firm ,cartilage felt along with edge .Instant recoil .
Nose: Nasal passage is patent
Mouth:No precocious teeth , no epstain pearl , uvula in midline .No cleft lip or cleft palate .
Neck: Short .No gland is palpable .
Limbs and digits : 10 fingers of hands and toes each .Palmer creases present over 1/3rd portion.
Chests : Clear .
Breast: Breast tissue is more than 10 mm. Areola raised .
Abdomen: Soft , No palpable mass .
Umbilical cord: Umbilical cord is clean and no bleeding .2 arteries and 1 vein present .
Genitalia : Labia majora well developed and completely cover the labia minora .No discharge.
Urethral meatus is located above the vaginal orifice .
Anus: Patent. Spine/back: Normal .
Hips(ortoloni’s test): No hip dislocation .
Legs: 10 fingers of toes and sole creases present over a 1/3rd portion .
Reflexes:

513
Grasp: Present Moro: Present Glabellar: Present Rooting: Present
Sucking: Present Planter and Babinski : Present Muscle activity: Normal
Urine: Passed Meconium: Passed
General impression : Baby is normal
(Specify if any abnormalities found)

Nursing care process for mother

Nursing diagnosis Expected Nursing interventions Evaluation
outcomes (Implementations)
1.Alteration of body Normal body Checked vital signs . BP: 110/80 mm
system due to labour system. Checked dehydration level. of Hg.
process. Vital signs within Checked fundal height and P-82 bt/min
R- 22 br/min
normal range . consistency .
Fundal height- 14
Fundus firm . Checked lochia – amount , cm.
Lochia scanty to colour. Uterus- Hard ,
moderate rubra . globular .
Lochia rubra
present in normal
amount .
2.Pain related to Mother verbalizes Assess for pain relief in mother Suture area is
episiotomy suturing after relief with and administered pain normal .
. interventions . medication . Wound is clean
Pain at the level of Discussed reasons of pain and and healthy .
toleration . it’s expected duration . No unbearable
Assess perineum Inspected the suture area for pain present .
swelling, redness, edema , bleeding .
bleeding . Perineal care provided.
3.Alteration in Mother Provided comfortable position Expressed better
comfort related to experiences and advised early ambulation. feelings.
uterine cramping minimum For uterine cramps Baby is put to
and heaviness of discomfort. administered pain medication. breast.
breast . Promoted perineal exercise.
Assess breast for engorgement.
Instruct to prevent breast
engorgement.
Encouraged proper emptying
by giving colostrums and
continue exclusive breast
feeding.

4.Altered nutrition Receive enough Provided normal diet with She had taken diet
and fatigue due to rest. plenty of water Provided rest. and rest.

514
Nursing diagnosis Expected Nursing interventions Evaluation
outcomes (Implementations)
labour process and Ensured nutrition Advised to adjust sleep timings
sleep pattern with the baby’s sleep timings.
disturbances . Provided support system for
help .
5.Potential alteration Early identification Postnatal assessment done – Normal findings .
in physiological of any deviation . head to foot examination done
process due to
labour process .
6.Altered No bladder Encouraged to empty the No bladder
elimination pattern distension. bladder and bowel. distension.
due to physiological No full rectum. Measured the first
process of labour . void .
Mother asked for
frequency and
amount of void .
She did not pass
stool.
7.Risk for infection . No signs of post- Provided antibiotic as ordered . No phlebitis , no
partum Checked for Homan’s sign . Homan’s sign .
complication . Episiotomy
No phlebitis , wound normal .
Homan’s sign .
Episiotomy wound
infection .
8.Knowledge deficit Mother verbalizes Taught postnatal exercises – Verbalizes
on self care as understanding of abdominal and breathing , foot understanding of
mother states to written and verbal and leg , pelvic floor, bending verbal
whom to consult for instructions on self and straightening alternate instructions on
post partum checkup care activities and knee. Provided verbal self care activities
and care . breast feeding . instructions about balanced and breast feeding
nutritious diet in increased .
amount and rich in high
protein, vitamin and roughage .
Plenty of water to drink .
Personal hygiene , daily bath ,
clean , loose cotton garments.
Sexual activity.
Return of menstruation .
FP methods for spacing .
Signs of complication.
Baby care especially regarding

515
Nursing diagnosis Expected Nursing interventions Evaluation
outcomes (Implementations)
hypothermia , cord infection ,
meconium , urine and
immunization .
Provided information about
postpartum check up.

9. Alteration of Patient will Established mutual trust and Demonstrate

family process demonstrate good respect . positive parenting
coping skills . Taught parenting , baby behaviour .
Acceptance of role holding , baby care .
of parent . Provided support system .
Demonstrate
positive parenting
behaviour .
Adequate bonding.
Nursing care process for baby
Nursing Expected Nursing interventions Evaluation
diagnosis outcomes (Implementations)
Ineffective Adequate body Kept infant warm with mother. Baby’s body
thermoregulation temperature . Wrapped the baby in a baby temperature is
related to heat sheet covering the head and normal.
loss from extremities.
exposure in Baby is kept clean and dry after
postnatal ward . urination and passing after
meconium.

Potential risk for Establish Mother is advised regarding the Baby is

ineffective airway breathing risk . crying.
due to pressure of effectively. Support person is informed. Respiration is
mother’s breast Baby is kept under close normal.
and baby’s observation.
blanket .

Potential risk for No sign of Strict aseptic technique is No sign of

infection related infection maintained while handling the infection
to newly clamped baby .
umbilical cord Eyes are cleaned with sterile
and exposure to swabs.
eyes to vaginal Cord is checked for dry
secretions . gangrene.

516
Nursing Expected Nursing interventions Evaluation
diagnosis outcomes (Implementations)
Altered nutrition Unaltered Breastfeeding :Initiated with Baby is active
less than body nutritional colostrum . and passed
requirement status . Baby is sucking breast milk urine .
related to properly .
newborn’s Checked passage of urine .
transition to Checked baby’s body weight .
extrauterine life.
Altered Normal Checked passage of urine . Baby has
elimination elimination Checked passage of meconium . passed urine
pattern related to pattern . and
newborn’s meconium.
transition to
extrauterine life.
Potential risk for Early diagnosis A thorough physical Nothing
congenital of any examination done . abnormalities
anomalies or any abnormality or All physical parameters checked found.
abnormality anomalies .
All reflexes checked
Potential risk for Parents will Helped to allay anxiety related Demonstrates
ineffective accept the role to sex . positive
parenting related of parent . Taught parenting , parenting
to sex of baby . behaviour.
Health seeking Demonstrate Advice given focusing on Parents asked
behaviour related positive normal newborn's problems more
to needs of a parenting regarding : newborn's normal questions and
normal newborn behaviour. behaviour and abnormal one, clarifies their
during hospital Adequate e.g. sleep pattern, condition and doughts
and after bonding. colour of skin, crying, regarding
discharge form elimination, stabilization. baby care.
the hospital. Exclusive breast feeding for 6
months.
Activity / hygiene / clothing /
saftery / security / bonding.
Immunization schedule : Inj.
BCG, Hep B and '0' dose polio
given at hospital.
Advice to continue rest of the
schedule in time.
Attendance at well baby clinic.

Signature of student Signature of supervisor

517
 POSTNATAL ASSESSMENT
Case No-19

IDENTIFICATION DATA

Name of the hospital : NRSMC&H Registration :12879

Name of the client : Mamtaz Bibi Age: 20 yrs Religion: Muslim
Address with husband’s name : w/o-Monirul Sk , Vill-Raghunathpur,36/A Kabi Sukantam
Road, Santoshpur, Kolkata-75
GPAL: G1P0A0L0 Period of gestation : 37 weeks
Date and time of admission : 4/11/2019 at 5:00 AM
Unit : I Dr : D. Saha
Date and time of delivery : 14/11/2019 at 10:00 PM
Mode of delivery : ND with episiotomy Sex of baby : Female
Condition of baby at birth : Baby cried immediately after birrth
Disc no of mother and baby : 390
Post natal day:1st postnatal day

MOTHER

Brief History
Type of family: Nuclear Total family members : 4
Support person in the family: Husband
Social: Education: Husband: IX Wife: VI
Occupation: Husband: Labour Wife: House wife
Personal: Any drug allergy: Any drug allergy not identified

Medical and surgical :

Past: Nothing significant Present: Nothing significant

Family: Nothing significant
Diet (Any harmful cultural practices after child birth): Non –veg .She takes adequate diet
during pregnancy . No harmful cultural practice after child birth is present .
Bowel and bladder: Bladder and bowel emptied .

518
 Past Obstetric History : LCB :
No. of Year Abortion Any Mode of Place of Sex Baby Any Remarks
pregna (with problems delivery delivery (alive/ problem with the
ncy period) during stillbirth) during history of
antenatal puerperium breastfeeding
period immunization
.
Primigravida

Present obstetric history:

Booked/unbooked : Booked No of antenatal check up : 4
Immunization : 2 dose of Inj TT is taken Total weight gain : 9 kg
Any problem arise during pregnancy : Yes / No√ .
If yes treatment given : Nil

Laboratory reports:
Blood group: B Rh: Positive VDRL: Negative PPBS: Not done
Fasting: 71 mg/dl Hb% : 11.8 gm/dl Others: TSH :1.74mcg/dl
Urine : Sugar : Nil Albumin : Nil
USG report : Single living fetus , Liquor –adequate , Placenta – posterior .

Delivery notes ( from records):Normal delivery with mediolateral episiotomy done. A full
term living baby girl was born on 14/11/2019 at 10pm .Inj oxytocin 10 IU given.
Total duration of labour : 13 hours
Removal of placenta : Spontaneous√ /Manual
Treatment: Cap Amoxycillin 500 mg 1 cap TDS , Tab Brufen ,tab metrogyl , Tab famotidine
.
Received of mother at post natal ward at 11.30 PM On 14/11/2019

Post natal assessment:

Build: Obese/average/Thin : Average
Gait/ appearance : Normal
Vital signs: Blood pressure,Temp, Pulse, Resp - 110/72 mm of Hg , 98.4 0F, 82 bt/min,
22 br/min

519
Head to toe postnatal examination:
Hair and scalp : Clean
Eyes : Normal Face : Normal
Mouth : Normal Tongue: Hydrated Teeth : Normal
Ear: NAD Nose : NAD Throat: NAD
Neck glands: NAD
Extremities: NAD Nails: Clean and no cyanosis
Breast and nipple : Soft and secretory Milk secretion: Colostrum present
Chest and heart: NAD
Liver: NAD Spleen: NAD Abdomen: Pain Bladder: Empty
Legs: No edema Homan’s sign: Nil Back and spine: Normal
Personal hygiene: Good
Emotional response: Normal
Postnatal discomforts / compliants : Mild cramping pain .
(sleep, bowel, bladder, thirst, appetite after pain, etc)

Obstetrical examination:
Inspection: No undue enlargement

Palpation of uterus: Uterus is hard and globular in shape .Fundal height – 15 cm .

(Consistency , shape and descent)

Per vaginal inspection / examination :

Vulval edema : Nil
Vagina : Lochia rubra present (Normal)
(Any vaginal bleeding , clots , warts / mole / infection / discharge )
Perineal area / anus :Intact
(Intact , lacerations or haemorrhoids , any pain )
Inspect REEDA for episiotomy wound: Wound is Healthy , no redness and edema .
(Redness , edema , ecchymosis , discharge and apposition )
Colour and amount of lochia odour: Lochia rubra present , Amount – normal
Smell -Fishy smell

520
Any complaints : Pain in episiotomy wound site

BABY
Physical Examination Findings
Condition of the newborn : Good, posture-flexed, well cried, alert
Vital signs:
Colour of skin : Pink texture - soft smooth. Dryness over hands and feet . Good turgor .Vernix
present.
Heart rate (Apex bit):138 beats/ min Respiration : 40 breaths/ min
Physical measurement:
Weight: 2.8 kg Length : 49 cm Head circumference : 34 cm
Chest circumference : 31 cm
Head to foot examination:
Examination of head:
Frontanelles/sutures/caput: Anterior frontanelle dimond shaped , 2.5X3cm. No overriding of
suture, no moulding.
Face: Normal
Eyes: Clean and healthy;. Sclera –White, Iris – Dark gray
Ears:Top of the pinna of ears is in a horizontal plane to the outer cantus .
Pinna is firm ,cartilage felt along with edge .Instant recoil .
Nose: Nasal passage is patent
Mouth:No precocious teeth , no epstain pearl , uvula in midline .No cleft lip or cleft palate .
Neck: Short .No gland is palpable .
Limbs and digits : 10 fingers of hands and toes each .Palmer creases present over 1/3rd portion.
Chests :Clear .
Breast: Breast tissue is more than 10 mm. Areola raised .
Abdomen: Soft , No palpable mass .
Umbilical cord: Umbilical cord is clean and no bleeding .2 arteries and 1 vein present .
Genitalia : Labia majora well developed and completely cover the labia minora .No discharge
.Urethral meatus is located above the vaginal orifice .
Anus: Patent.
Spine/back: Normal .
Hips(ortoloni’s test): No hip dislocation .
Legs: 10 fingers of toes and sole creases present over a 1/3rd portion .

521
Reflexes:
Grasp: Present Moro: Present Glabellar: Present Rooting: Present
Sucking: Present Planter and Babinski : Present Muscle activity: Normal
Urine: Passed Meconium: Passed
General impression : Baby is normal (Specify if any abnormalities found)

Nursing care process for mother

Nursing diagnosis Expected Nursing interventions Evaluation
outcomes (Implementations)
1.Alteration of body Normal body Checked vital signs . BP: 110/80 mm
system due to labour system. Checked dehydration level. of Hg.
process. Vital signs within Checked fundal height and P-82 bt/min
R- 22 br/min
normal range . consistency .
Fundal height- 15
Fundus firm . Checked lochia – amount , cm.
Lochia scanty to colour. Uterus- Hard ,
moderate rubra . globular .
Lochia rubra
present in normal
amount .
2.Pain related to Mother verbalizes Assess for pain relief in mother Suture area is
episiotomy suturing after relief with and administered pain normal .
. interventions . medication . Wound is clean
Pain at the level of Discussed reasons of pain and and healthy .
toleration . it’s expected duration . No unbearable
Assess perineum Inspected the suture area for pain present .
swelling, redness, edema , bleeding .
bleeding . Perineal care provided.
3.Alteration in Mother Provided comfortable position Expressed better
comfort related to experiences and advised early ambulation. feelings.
uterine cramping minimum For uterine cramps Baby is put to
and heaviness of discomfort. administered pain medication. breast.
breast . Promoted perineal exercise.
Assess breast for engorgement.
Instruct to prevent breast
engorgement.
Encouraged proper emptying
by giving colostrums and
continue exclusive breast
feeding.

4.Altered nutrition Receive enough Provided normal diet with She had taken diet
and fatigue due to rest. plenty of water Provided rest. and rest.

522
Nursing diagnosis Expected Nursing interventions Evaluation
outcomes (Implementations)
labour process and Ensured nutrition Advised to adjust sleep timings
sleep pattern with the baby’s sleep timings.
disturbances . Provided support system for
help .
5.Potential alteration Early identification Postnatal assessment done – Normal findings .
in physiological of any deviation . head to foot examination done
process due to
labour process .
6.Altered No bladder Encouraged to empty the No bladder
elimination pattern distension. bladder and bowel. distension.
due to physiological No full rectum. Measured the first
process of labour . void .
Mother asked for
frequency and
amount of void .
She did not pass
stool.
7.Risk for infection . No signs of post- Provided antibiotic as ordered . No phlebitis , no
partum Checked for Homan’s sign . Homan’s sign .
complication . Episiotomy
No phlebitis , wound normal .
Homan’s sign .
Episiotomy wound
infection .
8.Knowledge deficit Mother verbalizes Taught postnatal exercises – Verbalizes
on self care as understanding of abdominal and breathing , foot understanding of
mother states to written and verbal and leg , pelvic floor, bending verbal
whom to consult for instructions on self and straightening alternate instructions on
post partum checkup care activities and knee. Provided verbal self care activities
and care . breast feeding . instructions about balanced and breast
nutritious diet in increased feeding.
amount and rich in high
protein, vitamin and roughage .
Plenty of water to drink .
Personal hygiene , daily bath ,
clean , loose cotton garments.
Sexual activity.
Return of menstruation .
FP methods for spacing .
Signs of complication.
Baby care especially regarding

523
Nursing diagnosis Expected Nursing interventions Evaluation
outcomes (Implementations)
hypothermia , cord infection ,
meconium , urine and
immunization .
Provided information about
postpartum check up.

9. Alteration of Patient will Established mutual trust and Demonstrate

family process demonstrate good respect . positive parenting
coping skills . Taught parenting , baby behaviour .
Acceptance of role holding , baby care .
of parent . Provided support system .
Demonstrate
positive parenting
behaviour .
Adequate bonding.
Nursing care process for baby
Nursing Expected Nursing interventions Evaluation
diagnosis outcomes (Implementations)
Ineffective Adequate body Kept infant warm with mother. Baby’s body
thermoregulation temperature . Wrapped the baby in a baby temperature is
related to heat sheet covering the head and normal.
loss from extremities.
exposure in Baby is kept clean and dry after
postnatal ward . urination and passing after
meconium.

Potential risk for Establish Mother is advised regarding the Baby is crying.
ineffective airway breathing risk . Respiration is
due to pressure of effectively. Support person is informed. normal.
mother’s breast Baby is kept under close
and baby’s observation.
blanket .

Potential risk for No sign of Strict aseptic technique is No sign of

infection related infection maintained while handling the infection
to newly clamped baby .
umbilical cord Eyes are cleaned with sterile
and exposure to swabs.
eyes to vaginal Cord is checked for dry
secretions . gangrene.

524
Nursing Expected Nursing interventions Evaluation
diagnosis outcomes (Implementations)
Altered nutrition Unaltered Breastfeeding :Initiated with Baby is active and
less than body nutritional colostrum . passed urine .
requirement status . Baby is sucking breast milk .
related to properly .
newborn’s Checked passage of urine .
transition to Checked baby’s body weight .
extrauterine life.
Altered Normal Checked passage of urine . Baby has passed
elimination elimination Checked passage of meconium . urine and
pattern related to pattern . meconium.
newborn’s
transition to
extrauterine life.
Potential risk for Early diagnosis A thorough physical Nothing
congenital of any examination done . abnormalities
anomalies or any abnormality or All physical parameters checked found.
abnormality anomalies .
All reflexes checked
Potential risk for Parents will Helped to allay anxiety related Demonstrates
ineffective accept the role to sex . positive parenting
parenting related of parent . Taught parenting , behaviour.
to sex of baby .
Health seeking Demonstrate Advice given focusing on Parents asked
behaviour related positive normal newborn's problems more questions
to needs of a parenting regarding : newborn's normal and clarifies their
normal newborn behaviour. behaviour and abnormal one, doughts regarding
during hospital Adequate e.g. sleep pattern, condition and baby care.
and after bonding. colour of skin, crying,
discharge form elimination, stabilization.
the hospital. Exclusive breast feeding for 6
months.
Activity / hygiene / clothing /
saftery / security / bonding.
Immunization schedule : Inj.
BCG, Hep B and '0' dose polio
given at hospital.
Advice to continue rest of the
schedule in time.
Attendance at well baby clinic.

Signature of student Signature of supervisor

525
 POSTNATAL ASSESSMENT
Case No-20

IDENTIFICATION DATA

Name of the hospital : NRSMC&H Registration :12879

Name of the client : Selima Bibi Age:19 yrs Religion: Muslim
Address with husband’s name : w/o-Ripon Sk , 18 B/1, Park Circus,Kol-14
GPAL: G1P0A0L0 Period of gestation : 40 weeks
Date and time of admission : 14/11/2019 at 2:00 PM
Unit : I Dr: A.K.Biswas
Date and time of delivery : 14/11/2019 at 6:00 AM
Mode of delivery : ND with episiotomy Sex of baby : Female
Condition of baby at birth : Baby cried immediately after birrth
Disc no of mother and baby : F/405
Post natal day : 1st postnatal day

MOTHER

Brief History
Type of family: Nuclear Total family members : 4
Support person in the family: Husband
Social: Education: Husband: IX Wife: VII
Occupation: Husband: Labour Wife: House wife
Personal: Any drug allergy: Any drug allergy not identified

Medical and surgical :

Past: Nothing significant Present: Nothing significant

Family: Nothing significant
Diet (Any harmful cultural practices after child birth): Non –veg .She takes adequate diet
during pregnancy . No harmful cultural practice after child birth is present .
Bowel and bladder: Bladder and bowel emptied .

526
 Past Obstetric History : LCB :
No. of Year Abortion Any Mode of Place of Sex Baby Any Remarks
pregna (with problems delivery delivery (alive/ problem with the
ncy period) during stillbirth) during history of
antenatal puerperium breastfeeding
period immunization
.
Primigravida

Present obstetric history:

Booked/unbooked: Booked No of antenatal check up: 4
Immunization : 2 dose of Inj TT is taken Total weight gain: 9 kg
Any problem arise during pregnancy: Yes / No√ .
If yes treatment given: Nil

Laboratory reports:
Blood group: B Rh: Positive VDRL: Negative PPBS: Not done
Fasting: 74 mg/dl Hb% : 11 gm/dl Others: TSH : 1.64mcg/dl
Urine :Sugar : Nil Albumin: Nil
USG report : Single living fetus , liquor –adequate , Placenta – posterior .

Delivery notes ( from records):Normal delivery with mediolateral episiotomy done .A full
term living baby girl was born on 14/11/2019 at 6am .Inj oxytocin 10 IU given .
Total duration of labour: 12 hours 30 mins
Removal of placenta : Spontaneous√ /Manual
Treatment: Cap Amoxycillin 500 mg 1 cap TDS , Tab Brufen ,Tab metrogyl , Tab famotidine
.
Received of mother at post natal ward at 6.30 am on 14/11/2019

Post natal assessment:

Build: Obese/average/Thin: Average
Gait/ appearance: Normal

Vital signs : Blood pressure ,Temp,Pulse,Resp.- 110/74 mm of hg , 98.40F , 82 bt/min ,

527
22 br/min
Head to toe postnatal examination:
Hair and scalp: Clean
Eyes: Normal Face: Normal
Mouth: Normal Tongue: Hydrated Teeth: Normal
Ear: NAD Nose: NAD Throat: NAD
Neck glands: NAD
Extremities: NAD Nails: Clean and no cyanosis
Breast and nipple : Soft and secretory Milk secretion: Colostrum present
Chest and heart: NAD
Liver: NAD Spleen: NAD Abdomen: Pain Bladder: Empty
Legs: No edema Homan’s sign: Nil Back and spine: Normal
Personal hygiene: Good
Emotional response: Normal
Postnatal discomforts / compliants : Mild cramping pain .
(sleep , bowel , bladder , thirst , appetite after pain ,etc)

Obstetrical examination:
Inspection: No undue enlargement

Palpation of uterus: Uterus is hard and globular in shape .Fundal height – 15 cm .

(Consistency , shape and descent)

Per vaginal inspection / examination :

Vulval edema : Nil

Vagina : Lochia rubra present (Normal)
(Any vaginal bleeding , clots , warts / mole / infection / discharge )
Perineal area / anus : Intact
(Intact , lacerations or haemorrhoids , any pain )
Inspect REEDA for episiotomy wound: Wound is Healthy , no redness and edema .
(Redness , edema , ecchymosis , discharge and apposition )
Colour and amount of lochia odour: Lochia rubra present , Amount – normal
Smell -Fishy smell
Any complaints : Pain in episiotomy wound site

528
BABY
Physical Examination Findings
Condition of the newborn :Good , posture-flexed ,well cried , alert
Vital signs:
Colour of skin :Pink texture - soft smooth .Dryness over hands and feet .Good turgor .Vernix
present.
Heart rate (Apex bit):138 beats/ min Respiration : 40 breaths/ min
Physical measurement:
Weight: 2.8 kg Length : 49 cm Head circumference : 34 cm
Chest circumference : 31 cm
Head to foot examination:
Examination of head:
Frontanelles/sutures/caput: Anterior frontanelle dimond shaped , 2.5X3cm. No overriding of
suture, no moulding.
Face: Normal
Eyes: Clean and healthy Sclera –White, Iris – Dark gray
Ears: Top of the pinna of ears is in a horizontal plane to the outer cantus .
Pinna is firm ,cartilage felt along with edge .Instant recoil .
Nose: Nasal passage is patent
Mouth:No precocious teeth , no epstain pearl , uvula in midline .No cleft lip or cleft palate .
Neck: Short .No gland is palpable .
Limbs and digits : 10 fingers of hands and toes each .Palmer creases present over 1/3rd portion.
Chests :Clear .
Breast: Breast tissue is more than 10 mm. Areola raised .
Abdomen: Soft , No palpable mass .
Umbilical cord: Umbilical cord is clean and no bleeding .2 arteries and 1 vein present .
Genitalia : Labia majora well developed and completely cover the labia minora .No discharge
.Urethral meatus is located above the vaginal orifice .
Anus: Patent.
Spine/back: Normal .
Hips(ortoloni’s test): No hip dislocation .
Legs: 10 fingers of toes and sole creases present over a 1/3rd portion .
Reflexes:

529
Grasp: Present . Moro: Present . Glabellar: Present . Rooting: Present .
Sucking: Present . Planter and Babinski : Present . Muscle activity: Normal .
Urine: Passed. Meconium: Passed .
General impression : Baby is normal .
(Specify if any abnormalities found)

Nursing care process for mother

Nursing diagnosis Expected Nursing interventions Evaluation
outcomes (Implementations)
1.Alteration of body Normal body Checked vital signs . BP: 110/80 mm
system due to labour system. Checked dehydration level. of hg.
process. Vital signs within Checked fundal height and P-82 b/m
R- 22 b/m
normal range . consistency .
Fundal height- 15
Fundus firm . Checked lochia – amount , cm.
Lochia scanty to colour. Uterus- Hard ,
moderate rubra . globular .
Lochia rubra
present in normal
amount .
2.Pain related to Mother verbalizes Assess for pain relief in mother Suture area is
episiotomy suturing after relief with and administered pain normal .
. interventions . medication . Wound is clean
Pain at the level of Discussed reasons of pain and and healthy .
toleration . it’s expected duration . No unbearable
Assess perineum Inspected the suture area for pain present .
swelling, redness, edema , bleeding .
bleeding . Perineal care provided.
3.Alteration in Mother Provided comfortable position Expressed better
comfort related to experiences and advised early ambulation. feelings.
uterine cramping minimum For uterine cramps Baby is put to
and heaviness of discomfort. administered pain medication. breast.
breast . Promoted perineal exercise.
Assess breast for engorgement.
Instruct to prevent breast
engorgement.
Encouraged proper emptying
by giving colostrums and
continue exclusive breast
feeding.

4.Altered nutrition Receive enough Provided normal diet with She had taken diet
and fatigue due to rest. plenty of water Provided rest. and rest.

530
Nursing diagnosis Expected Nursing interventions Evaluation
outcomes (Implementations)
labour process and Ensured nutrition Advised to adjust sleep timings
sleep pattern with the baby’s sleep timings.
disturbances . Provided support system for
help .
5.Potential alteration Early identification Postnatal assessment done – Normal findings .
in physiological of any deviation . head to foot examination done
process due to
labour process .
6.Altered No bladder Encouraged to empty the No bladder
elimination pattern distension. bladder and bowel. distension.
due to physiological No full rectum. Measured the first
process of labour . void .
Mother asked for
frequency and
amount of void .
She did not pass
stool.
7.Risk for infection . No signs of post- Provided antibiotic as ordered . No phlebitis , no
partum Checked for Homan’s sign . Homan’s sign .
complication . Episiotomy
No phlebitis , wound normal .
Homan’s sign .
Episiotomy wound
infection .
8.Knowledge deficit Mother verbalizes Taught postnatal exercises – Verbalizes
on self care as understanding of abdominal and breathing , foot understanding of
mother states to written and verbal and leg , pelvic floor, bending verbal
whom to consult for instructions on self and straightening alternate instructions on
post partum checkup care activities and knee. Provided verbal self care activities
and care . breast feeding . instructions about balanced and breast feeding
nutritious diet in increased .
amount and rich in high
protein, vitamin and roughage .
Plenty of water to drink .
Personal hygiene , daily bath ,
clean , loose cotton garments.
Sexual activity.
Return of menstruation .
FP methods for spacing .
Signs of complication.
Baby care especially regarding

531
Nursing diagnosis Expected Nursing interventions Evaluation
outcomes (Implementations)
hypothermia , cord infection ,
meconium , urine and
immunization .
Provided information about
postpartum check up.

9. Alteration of Patient will Established mutual trust and Demonstrate

family process demonstrate good respect . positive parenting
coping skills . Taught parenting , baby behaviour .
Acceptance of role holding , baby care .
of parent . Provided support system .
Demonstrate
positive parenting
behaviour .
Adequate bonding.
Nursing care process for baby
Nursing Expected Nursing interventions Evaluation
diagnosis outcomes (Implementations)
Ineffective Adequate body Kept infant warm with mother. Baby’s body
thermoregulation temperature . Wrapped the baby in a baby temperature is
related to heat sheet covering the head and normal.
loss from extremities.
exposure in Baby is kept clean and dry after
postnatal ward . urination and passing after
meconium.

Potential risk for Establish Mother is advised regarding the Baby is

ineffective airway breathing risk . crying.
due to pressure of effectively. Support person is informed. Respiration is
mother’s breast Baby is kept under close normal.
and baby’s observation. .
blanket .

Potential risk for No sign of Strict aseptic technique is No sign of

infection related infection maintained while handling the infection
to newly clamped baby .
umbilical cord Eyes are cleaned with sterile
and exposure to swabs.
eyes to vaginal Cord is checked for dry
secretions . gangrene.

532
Nursing Expected Nursing interventions Evaluation
diagnosis outcomes (Implementations)
Altered nutrition Unaltered Breastfeeding :Initiated with Baby is active
less than body nutritional colostrum . and passed
requirement status . Baby is sucking breast milk urine .
related to properly . .
newborn’s Checked passage of urine .
transition to Checked baby’s body weight .
extrauterine life.
Altered Normal Checked passage of urine . Baby has
elimination elimination Checked passage of meconium . passed urine
pattern related to pattern . and
newborn’s meconium.
transition to
extrauterine life.
Potential risk for Early diagnosis A thorough physical Nothing
congenital of any examination done . abnormalities
anomalies or any abnormality or All physical parameters checked found
abnormality anomalies .
All reflexes checked
Potential risk for Parents will Helped to allay anxiety related Demonstrates
ineffective accept the role to sex . positive
parenting related of parent . Taught parenting , parenting
to sex of baby . behaviour.
Health seeking Demonstrate Advice given focusing on Parents asked
behaviour related positive normal newborn's problems more
to needs of a parenting regarding : newborn's normal questions and
normal newborn behaviour. behaviour and abnormal one, clarifies their
during hospital Adequate e.g. sleep pattern, condition and doughts
and after bonding. colour of skin, crying, regarding
discharge form elimination, stabilization. baby care.
the hospital. Exclusive breast feeding for 6
months.
Activity / hygiene / clothing /
saftery / security / bonding.
Immunization schedule : Inj.
BCG, Hep B and '0' dose polio
given at hospital.
Advice to continue rest of the
schedule in time.
Attendance at well baby clinic.

Signature of student Signature of supervisor

533
534