GOVT.

COLLEGE OF NURSING
JODHPUR

CASE STUDY ON
FULL TERM VAGINAL DELIVERY( FTVD )

SUBMITTED TO: SUBMITTED BY:

Mrs. JYOTI BALA JANGID PRIYANKA GEHLOT

LECTURER M.Sc. (N) FINAL YEAR

GCON BATCH-2019
 CASE STUDY
INTRODUCTION
Anemia is a major problem which is facing by most of the pregnant women in India. This problem
has to be detected in its early stage and to be treated to prevent any complications to mother as well
as to baby. During our clinical posting in Ummaidhospital, I got a chance to give nursing care to a
patient with severe anemia with IUGR.

IDENTIFICATION DATA
 Name : Mrs. Kiran w/o Mr. kartik
 Age : 25 yrs
 Ward :2
 Unit : III
 Bed no :12
 Date of admission : 25.8.2021
 Date of discharge :27.8.2021
 Religion : Hindu
 Diagnosis : G2P1A0L1 with 38WKS with severe anemia
 Date of selection of care : 25.8.2021
 High risk factors : Bad obstetric history- no
Severe Anemia -3
Uterine size less than period of gestation- 2

 Total score :5

SOCIO-ECONOMIC & CULTURAL DATA

 Housing: My patient Mrs. kiran lives in a rented house of single room set. There is no
adequate ventilation.
 Occupation & monthly income: Mrs. kiran is a house wife, but her husband is a driver
working in a private firm. Their monthly income comes about Rs.5000/-
 Literacy: My patientMrs. is illiterate. Her husband has studied till 10th class.
 Social life & recreational facilities: They are maintaining good communication with their
neighbours and others. Thereare no such recreational facilities in their home as well as they
are not interested in recreations.
 Religion: my patient belongs to Hindu religion. There are so many restrictions in their
house during pregnancy due to some religious beliefs.
 Health habits: she is maintaining health habits like washing the hands before and after
eating, preparing food, toileting etc.
 Dietary regime: She is an egg vegetarian. She used to take food only two times in a day.
Early morning she had tea/ milk. No extra things are added into their diet during pregnancy
also.
Breakfast/ Brunch: Milk/Tea + roti + Sabji
Dinner: rice + roti + dal + sabji
1
  Attitude towards present pregnancy by:
SELF: she had a positive attitude towards pregnancy. Her elder child is 4 yrs old and she is
eagerly waiting for her coming child. Though she is more anxious towards her present
pregnancy but she is not maintaining no more extra concerning towards her health in
pregnancy.
OTHERS: she is living along with her husband. Her in laws are not alive. Only she is having
distant relatives in their husband side. They used to come and visit her very rarely. But her
parents and sisters used to come and visit her during her pregnancy and they all have a
positive attitude to pregnancy.
 Cultural data: Intheir culture during pregnancy they are not allowed to go out alone. After
delivery also they have to remain inside the house for 7 days and after that only they will
come outside and face the other people. After delivery they have to eat only hot foods and
hot boiled water for 2 months.
 Position of mother in the family & society: She is living in a nuclear family along with her
husband. In her house she had a good position.

HISTORIES
 Personal history: She is egg-vegetarian, no addictions and not allergic to any medicines
and foods.
 Family history: there is no significant family history in her family like Diabetes,
hypertension, cardiac diseases etc.
 Past history of mother: There is no significant history of medical and surgical illness in my
patient.
 Menstrual history: Menarche at the age of 13 yrs. She had regular 3-4/28 day cycle.
Having Normal blood flow.
 Marital history: she is married since 6 yrs. She is having a good marital relationship with
her husband.

 Obstetrical history:G1- normal pregnancy

G2: present pregnancy.
 History of present condition
Trimester I: uneventful, had normal minor ailments of pregnancy.
Trimester II: had stomach pain in 5th month, shown to nearby clinic where she has given
some medicines and Inj. TT was also taken. Advised for blood test and other investigations
but it was not done by them.
Trimester III: weakness started, breathlessness, tiredness etc. When it becomes severe she
was again shown to nearby clinic where she was advised to do the USG and it was done
shows oligohydramnios with low birth weight baby. breathlessness was increased and she
came to Ummaid hospital and gets admitted there.

2
FINDINGS ON EXAMINATION
Head to toe examination
Skin: Not clean & healthy. Well hydrated.
Nails: Not Clean. Pale in colour.Capillary refill time > 3 sec.
Head: Symmetrical shape, hairs are soft. Scalp is clean and healthy. No dandruff.
Face: clean. Cholasma present.
Eyes: clear. Severely pale.Normal vision.
Ears: clean, no discharge, hearing normal.
Nose: clean, no discharge. No sepal deviations.
Mouth: pink in color. No ulcerations, dental caries, normal movement of tongue and pharynx.
Neck: normal movement. No rigidity.
Chest: symmetrical shape.
Lungs: bilaterally clear.
Heart: Soft systolic soft murmer heard.
Breast: soft and secretary. Colostrum present.
Abdomen: Linea nigra and striaegravidarum are present.
Abdominal girth is 75 cm. Size of uterus is small for the gestational age.
Fundal height: 31cm, 32 weeks.
Genitalia: clean and healthy, no leaking per vaginally.
Upper extremity: normal range of motion.
Lower extremity: normal range of motion. Edema present.

General Appearance
General condition of the patient is good. Having weakness.

INVESTIGATIONS DONE

INVESTIGATION VALUE NORMAL VALUE INFERENCE

INPATIENT
25.8.2021
Maternal blood group B+ve
Single live fetus,
USG vertex presentation,
placenta is fundo
posterior grade II,
FHS- 156/min. &
regular, expected
foetal weight= 2.9 kg.

Haemoglobin 3.7gm% 12-16 gm % Abnormal

Urine – albumin Nil Nil Normal
Urine – sugar Nil Nil Normal
TLC 9400mm3 6000-11000mm3 Normal
DLC P=68%, L=26%, P=40-75%, L=30-50%,
M=02%, N=04% M=1-10%, E=01-3%
Platelet count 2,30000mm3 150000-450000mm3 Normal
10-40mg/dl
Blood urea 26 mg/dl Normal
3
Urine routine & Pus cells & RBCs – Within normal
microscopy nil limits
Epithelial cells- 2-3
Nil
Urine albumin Nil
Urine sugar

Haemoglobin 6.9gm% 12-16gm% Less

TLC 7900mm3 6000- 11000mm3 Normal
DLC P=68%, L=26, P=40-75%, L=30-50%,
M=02, E=04 M=1-10%, E=01-3% Normal
Platelet count 2,20000mm3 150000-450000mm3 Normal
Blood urea 28 10-40mg/dl Normal
Serum creatinine 0.4
S. Bilirubin(total) 0.5
SGOT 36
SGPT 35
Alkaline phosphatase
841

25.5.10
Haemoglobin 7.7gm% 12-16gm% Less
TLC 6400mm3 6000- 11000mm3 Normal
DLC P=65%, L=29%, M= P=40-75%, L=30-50%, L & E are
01%, E=05% M=1-10%, E=01-3% abnormal
Platelet count 197000mm3 150000-450000mm3 Normal

Colour Doppler USG Placenta anterior

grade III. Liquor less.
AFI=3. Single live
fetus in cephalic
position. Expected
fetal weight=
1549gm. Both uterine
arteries are normal in
flow velocity.

4
 DETAILS OF CONDITION
ANAEMIA IN PREGNANCY

It is the commonest disorder that may occur in pregnancy. According to the standard laid
down by the WHO, anaemia in pregnancy is present when the haemoglobin concentration in the
peripheral blood is 11gm% or less. During pregnancy plasma volume expands resulting in
haemoglobin dilution. For this reason, haemoglobin level below 10gm% at any time in pregnancy is
considered anaemia.

INCIDENCE

The incidence of anaemia in pregnancy ranges widely from 40-80% in the tropics compared
to 10-20% in the developed countries. Anaemia is responsible for 20% of maternal death in the
third world countries.

CAUSES OF PREVALANCE OF ANAEMIA

Iron deficiency anaemia is very much prevalent in the tropics particularly amongst women
of child bearing age, specially in the under privileged sector. The main causes are

Faulty dietetic habit: high phosphate and phytic acid help in formation of insoluble iron phosphate
and phytates in the gut, thereby reducing the absorption of iron.

Faulty absorption mechanism: because of high prevalence of intestinal infestation, there is

intestinal hurry which reduces the iron absorption. Hypochlorhydria, often associated with
malnutrition also hinders absorption.

Iron loss: more iron is lost through sweat. Repeated pregnancies at short intervals along with a
prolonged period of lactation puts a serious strain on the iron store.Excessive blood loss during
menstruation which is left untreated and uncared for. Hook worm infestation with consequent blood
depletion. Chronic malaria, chronic blood loss due to bleeding piles and dysentery.

CLASSIFICATION

 Physiological anaemia of pregnancy

 Pathological anaemia
1. Deficiency anaemia – iron deficiency, folic acid deficiency, vitamin B12 deficiency,
protein deficiency.
2. Haemorrhagic- acute ( following bleeding in early months or APH), chronic( hook
worm infestation, bleeding piles etc.)
3. Hereditary- thalassemia, sickle cell haemoglobinopathies, hereditary
haemolyticanaemia, other haemoglobinopathies.
4. Bone marrow insufficiency
5. Anaemia of infection- malaria, tuberculosis
6. Chronic disease (renal) or neoplasm.

5
PHYSIOLOGICAL ANAEMIA

There is disproportionate increase in plasma volume, RBC volume and haemoglobin mass
during pregnancy. In addition there is marked demand of extra iron during pregnancy specially in
the second half. Even an adequate diet provide the extra demand of iron. As a result there will be
low serum iron, increased iron binding capacity, and increased rate of iron absorption. Thus the fall
in haemoglobin concentration during pregnancy is due to combined effect of haemodilution and
negative iron balance. The anaemia is normocytic and normochromic in type.

Criteria for physiological anaemia: the lower limit of physiological anaemia during the second half
of pregnancy should fulfil the following haematological values.

a) Hb – 10gm%
b) RBC – 3.2 million/mm3
c) PCV – 30%
d) Peripheral smear showing normal morphology of the RBC with central pallor

PATHOLOGICAL ANAEMIA- IRON DEFICIENCY ANAEMIA

The women who has got sufficient iron reserve and is on a balanced diet, is unlikely to develop
anaemia during pregnancy inspite of an increased demand of iron. But if the iron reserve is
inadequate or absent, the factors which lead to the development of anaemia during pregnancy are:

i. Increased demand of iron: an adequate balanced diet contains not more than 18-20 mg of
iron and assuming that the absorption rate is increased by two folds, the demand is hardly
fulfilled.
ii. Diminished intake of iron: apart from socio-economic factors, faulty dietetic habits, loss of
appetite and vomiting in pregnancy are responsible factors.
iii. Disturbed metabolism: pregnancy depresses the erythropoietic function of the bone
marrow. Presence of infection markedly interferes with the erythropoiesis. One should not
even ignore the presence of assymptomaticbacteriuria.
iv. Pre-pregnant health status: majority of the women in the tropics usually starts pregnancy
on a pre existinganaemic state or atleast with inadequate iron reserve. It is the state of the
stored iron which largely determines whether or not and how soon a pregnant woman will
become anaemic.
v. Excess demand: Multiple pregnancy, women with rapidly recurring pregnancy, the
demand of iron which accompanies the natural growth before the age of 21.

CLINICAL FEATURES

The clinical features depend more on the degree of anaemia.

Symptoms:

Features in book In patient

Lassitude & a feeling of exhaustion or weakness Present
Anorexia Present
Indigestion Absent
Palpitation Present
Dyspnoea Present

6
 Giddiness Present
Swelling of legs Absent

Signs :

Features in book In patient

Pallor Present
Glossitis Absent
Stomatitis Absent
Oedema of the legs Absent
A soft systolic murmur Present
Crepitations may be heard at the base of the Present
lungs

INVESTIGATIONS

The patient having haemoglobin level 9gm% or less should be subjected to a full haematological
investigations to ascertain the type of anaemia, degree of anaemia, cause of anaemia.

Degree of anaemia: this requires haematological examinations which includes the estimation of
haemoglobin, total red cell count, determination of packed cell volume.

Haemoglobin level 8-10gm% ----Mild anaemia

7-8gm%-------moderate anaemia

Less than 7gm% ----severe anaemia

Type of anaemia:

 Peripheral blood smear: abundant presence of small pale

staining cells with variation in size and shape suggest
microcytic hypochromic anaemia. Reticulocyte count may be
slightly raised.
Fig.1
Type of anaemia
 Haematological indices: calculation of MCHC, MCV and MCH are based on the values of
Hb estimation, red cell count and PCV.
 Other blood values: serum iron is usually below 30µg/100ml., Total iron binding capacity is
elevated to beyond 400µg/100ml, percentage saturation is10% or less, serum ferritin below
15µg/L, serum bilirubin is not raised.

A typical iron deficiency anaemia shows the following blood values. Haemoglobin- less than 10gm
%, red blood cells –less than 4million/mm3, PCV- less than 30%, MCHC- less than 30%, MCv-
less than 75µm3 and MCH- less than 25pg.

Cause of anaemia

Appropriate investigations should be taken as per the history and clinical examination to find out
the cause of anaemia.
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  Examination of stool: to detect helminthic infestation
 Urine examination; microscopic and culture examination should be done to rule out any
infections.

DIFFERENTIAL DIAGNOSIS

1. Infection
2. Nephritis
3. Pre eclampsia
4. Haemoglobinopathies

TREATMENT

PROPHYLACTIC

It includes avoidance of frequent child births, a minimum interval between pregnancies should be at
least 2 years.

Supplementary iron therapy: daily administration of 200mg of ferrous sulphate along with 1mg
folic acid is a effective prophylactic treatment. Tea should be avoided within 1 hour of taking tablet.

Dietary prescription: a realistic balanced diet rich in iron and protein should be prescribed which
should be within the reach of the patient and should be easily digestable. The foods rich in iron are
liver, meat, egg, green vegetables, green peas, beans, whole wheat, jiggery etc. Iron utensils should
preferably be used for cooking and the water used in rice and vegetable cooking should not be
discarded.

Adequate treatment: It should be started to eradicate to eradicate hookworm infestation, dysentery,

malaria, bleeding piles and urinary tract infection.

Early detection of falling haemoglobin level is to be made. Haemoglobin level should be estimated
at the earliest in the first antenatal visit, at the 30thwk and at 36th week.

THERAPUETIC

Anaemia is not a disease but a sign of an underlying disorder. Treatment must be preceded
by an accurate diagnosis of the cause of anaemia and type of
anaemia.

Hospitalisation : patients having less than 7.5gm%should be

hospitalised.

General treatment

Diet: A realistic balanced diet rich in proteins, iron, vitamins and

which is easily digestable are prescribed.

Fig. 2 showing iron rich fruits

To improve the appetite and facilitate digestion, preparation containing acid pepsin may be given
thrice daily after meals.

8
Antibiotic therapy: to reduce sepsis

Choice of therapy: Depends on the severity of anaemia, duration of pregnancy, associated

complicating factors.

IRON THERAPY

 PERENTERAL THERAPY
 ORAL THERAPY

ORAL ROUTE Fig.3 Iron tablets

Iron is best absorbed in the ferrous form and as such

any of the ferrous preparations available either in the tablets
and capsules may be prescribed. Fersolate tablets contains 200mg

ferrous sulphate which contains 60mg of elemental iron, trace of copper and manganese. The
treatment should be continued till the blood picture becomes normal, there after maintenance of
tablet daily is to be continued for at least 100 days following delivery to replenish the iron stores.

Response of therapy is evidenced by: sense of well being, increased appetite, improved outlook of
the patient, haematological examination (rise in Hb level, normal haematocrit level)

Rate of improvement: the improvement should be evident within 3 weeks of the therapy.

Contra indications of oral therapy:

 Intolerance to oral iron

 Severe in anaemia in advanced pregnancy

PARENTERAL THERAPY

Indications

 Contraindications of oral therapy as previously

mentioned.
 Patient is not co-operative to take oral iron.
 Cases seen for the first time during the last 8-10
weeks with severe anaemia.

Intravenous route- repeated injections, total dose infusion

Intramuscular route

Intravenous route fig.4 Iron injection

Total dose infusion: the deficit of iron is calculated and the total amount of iron required to correct
is administered by a single sitting I/V infusion. The compound used is iron dextran compound.

9
Advantages: 1. It eliminates repeated and painful I/M injections. 2. Treatment is completed in a day
and the patient may be discharged much earlier from the hospital. 3. It is less costly compared to the
repeated I/M injection.

Estimation of total; requirement: 0.3 x W (100- Hb%)mg of elemental iron. W= patient’s weight in
pounds. Hb%= observed haemoglobin concentration in percentage. Additional 50% is to be added
for partial replenishment of the body store iron.

Intramuscular therapy

Iron dextran (imferon)

Iron sorbitol citric acid complex in dextrin

Oral iron should be suspended at least 24 hours prior to therapy to avoid reaction. Test dose should
be given before starting the therapy. Dose should be given by Z-track technique.

Blood transfusion

Indications

 Correct anaemia due to blood loss and to combat postpartum haemorrhage.

 Patient with severe anaemia.
 Refractory anaemia- Anaemia not responding to either oral or parenteral therapy in spite
of correct typing.

 Associated infection fig 5 Blood

transfusion

Advantages

 Increases oxygen carrying capacity of the blood

 Haemoglobin from the haemolysed red cells may be utilised for the formation of new red
cells.
 Stimulates erythropoiesis
 Supplies the natural constituents of blood like proteins, antibodies etc.
 Improvement is expected after 3 days.

10
TREATMENT

S.NO IN BOOK IN PATIENT

1 Prophylactic treatment
Iron supplement Tab.Ferroussulphate 1 bd

Diet Iron rich diet.

2 Therapeutic treatment Since this patient was admitted in
Iron supplement- parenteral route hospital after 38 wks of preganancy, she
was given Inj. Orofer 100mg IV.
3 Blood transfusion 3 unit PRBC was given

MANAGEMENT

During labour

First stage: the patient should be in bed and should lie in a position comfortable to her.
Arrangements for oxygen inhalation is to be kept ready to increase the oxygenation for the maternal
blood and thus diminish the risk of fetal hypoxia. Strict asepsis is to be maintained to minimise
puerperal sepsis.

Second stage: asepsis is maintained. Prophylactic low forceps or vaccum delivery may be done to
shorten the duration of second stage. I/V methergin 0.2mg should be given following the delivery of
anterior shoulder.

Third stage: one should be vigilant during the third stage. Significant loss of blood loss should be
replenished by fresh packed cell transfusion after taking the usual precautions. The danger of post
partum over loading of the heart should be avoided.

Puerperium : Prophylatioc antibiotics are given to prevent infection. Pre delivery anti anaemic
therapy should be continued till the patient restores her normal clinical and haematological status.
Iron therapy should be continued for at least 3 months following delivery. Patient should be warned
about the danger of recurrence in the subsequent pregnancy.

COMPLICATIONS

During pregnancy:

1. Pre eclampsia may be related to malnutrition and hypoproteinemia.

2. Inter current infection- it impairs erythropoeisis by bone marrow depression.
3. Heart failure at 30-32 wks of pregnancy
4. Pre termlabour

During labour:

1. Post partumhaemorrhage- patient can’t tolerate a minimal amount of blood loss.

2. Cardiac failure-due to accelerated cardiac outputwhich occurs during labour or immediately
following the delivery. As the blood in the uterine circulation is squeezed in the general
circulation, it puts undue strain on the weak heart already compromised by hypoxia.
3. Shock

11
During puerparium:

1. Puerperal sepsis
2. Subinvolution
3. Failing ;lactation
4. Pulmonary embolism

Effects on baby

Amount of iron transferred to the fetus is unaffected even if the mother suffers from iron
deficiency anaemia. So the neonate does not suffer from anaemia at birth. There is increased
incidence of:

1. IUGR
2. Intra uterine death- due to severe maternal anoxemia

PROGNOSIS

Maternal: If detected early and proper treatment is started, anaemia improves promptly. On rare, it
may remain refractory till pregnancy is over, when rapid improvement occurs. Anaemia either
directly or indirectly contributes to 20 % of maternal deaths in third world countries.

Foetal: If detected early and responsive to treatment, the fetal prognosis is not too bad. In severe
and neglected cases, the fetal prognosis is adversely affected by prematurity with its hazards. Baby
born at term, to severely anaemic mother will not be anaemic at birth, but as there is little or no
reserve iron anaemia develops in neonatal period.

12
MANAGEMENT OF MOTHER& BABY-SUMMARY OF SPECIFIC NURSING CARE
AND MANAGEMENT DATE WISE

Important issues regarding the case-

What happened: My patient was belonging to a low socio-economic family. During this pregnancy
she was not maintaining her health properly as well as she was not availing any health facility
during her antenatal period. Because of her less nutritious intake, she prone to anaemia and she got
admitted with severe dyspnoea and weakness on 19.05.14 in Ummaid hospital.

Predisposing factors: the predisposing factor in my case which leads to the severe high risk
condition in my patient are

1. knowledge deficit: my patient is an illiterate. She had no knowledge about the care which
she has to take care during pregnancy. Also she don’t know the importance of availing
health facility for maintaining her health.
2. low socio-economic factor which contributes her to anaemia, as she was not able to afford
any high nutritious diet.
3. Lack of family support: She has no family members who can guide her and help her in
maintaining her health. Her husband is also not supportive as he had to work from 6.30 am
till 10 pm night.

 The antenatal, intra-natal and postnatal management are discussed as follows:

DATE TREATMENT
25.8.2021 Antenatal management
Oxygen by mask administration.
Propped up position
Routine blood & urine investigations.
Arrange 2 units of blood and to be transfused as early as possible.
Daily fetal movement count.
Watch for vitals and foetal heart sound.
USG for colour Doppler.
Compltehaemogram and P/S for type of anaemia.

26.8.2021 Daily fetal movement count.

Oxygen SOS
T. Albendazole 1 tab HS
Inj. Lasix 20 mg I/V BD
Transfuse 1 unit blood.
Propped up position.
High protein and iron rich diet.

27.8.2021 Inj. Monocef 1gm I/V BD

Non stress test.
Transfuse 1 unit blood.

13
The main points of obstetric care:

This case is managed properly by giving oxygen by mask whenever necessary, propped up position,
3 unit blood transfusion, I/V infusion therapy with iron sucrose ie. R B Tone 50mg in 100 ml
solution. Cut short the second stage of delivery by giving episiotomy. Prevention of PPH.

Management of baby
 Baby girl delivered by normal vaginal delivery with right mediolateral episiotomy at 3.30 pm
with a birth weight of 1.9 kg.
 The baby cried immediately after birth and respiration was regular.
 Oral and nasal suctioning done.
 Kept under warmer.
 Immunisations given.( BCG, Hep-B, OPV, Vit.k)
 Apgar score at 1 minute and 5 minute are:
1 minute 5 minute
Heart rate 2 2
Respiratory rate 2 2
Muscle tone 1 1
Reflex irritability 2 2
Colour 1 2
Total 8 9

 Baby transferred to mother.

Physical examination
 Skin - warm and pink
 Respiration - regular
 Cyanosis - acrocynosis
 Oedema - negative
 Fotannel (A/P)- palpable
 Sutures - palpable
 Moulding - present
 Head and neck - normal
 Eyes - well-formed
 ENT - bilateral pinna formed, no pre-auricular tags formed
 Thorax - symmetrical
 Abdomen - normal
 External genitalia - labia majora and minora seen
 Congenital anomalies - TOF ruled out, no Anal atresia- baby passed meconium
 Reflexes - present
 Grasp - good
 Respiration - normal, 40/mt
 CVS - S1S2 normal
 GIT - normal

DRUG STUDY

S.N Name of the Pharmacol Action Side-effects Nursing

14
o drug ogical responsibilities
name
1 Tab. Ampicillin Broad-spectrum Rash, bone Assess I& O, report
Ampicillin anti-infectant marrow haematuria, bowel
500mg suppression, patterns before
nausea, vomiting, treatment,
diarrhoea, respiratory rate, and
vaginitis, allergies.
glomerulonephriti
s, lethargy, coma
convulsions.
2 Tab. Rantac Ranitidine Histamine (H2) headache, Assess allergy to
150 mg hydrochlori antagonist constipation, ranitidine, impaired
de diarrhoea, nausea, renal or hepatic
vomiting, function, CBC, liver
abdominal pain, and renal function
local burning or tests, orientation,
itching at IV site affect etc. Monitor
leukopenia, for side effects.
granulucytopenia,
thrombocytopenia
, pancytopenia
3 Tab. Ferrous Ferrous Haematinic Nausea, Assess HB level
sulphate sulphate constipation, before and after
200mg epigastric pain, treatment.
black and tarry Observe for signs of
red stools, toxicity—nausea,
temporarily vomiting, diarrhoea,
discoloured tooth, haematemesis, pallor,
enamel and eyes cyanosis, shock.
Increase water intake
if constipation
occurs.
4 Tab. Voveran Diclofenac Analgesic and Nausea, anorexia, Assess blood count,
sodium anti pyretic vomiting, LFT and uric acid,
dysrhymias, evaluate therapeutic
dysuria, responses.
bronchospasm.
5 Tab. Alendronate Calcium Rash, oedema of Assess for history of
Osteocalcin sodium regulator— feet, headache, allergy.
500mg increases flushing, tetany, Observe for side-
absorption of chills, weakness, effects.
calcium in dieresis, nausea, Assess BUN,
bones. diarrhoea, creatinine, uric acid,
vomiting, chloride, electrolytes
anorexia,
abdominal pain,
salty taste,
swelling and
tingling of hands.

15
NURSING PROCESS
NURSING CARE PLAN- PROBLEM LISTS

FOR MOTHER

S.NO ACTUAL PROBLEM POTENTIAL PROBLEM

1 Impaired gas exchange related to 9. Potential for foetal injury related to
decreased haemoglobin level anaemia and oligohydramnios
2 Altered nutrition less than body 10. Risk for impaired home maintenance
requirement related to anorexia and related to hospitalization
anaemic condition of mother
3 Ineffective breathing pattern related 11. Risk for infection related to anaemia
to dyspnoea
4 Anxiety related to outcome of the
pregnancy
5 Alteration in family process related
to hospitalization
6 Alteration in comfort related to pain
on the episiotomy wound
7 Altered skin integrity related to
episiotomy wound
8 knowledge deficit related to self care
and baby care

FOR BABY

S.NO ACTUAL PROBLEM POTENTIAL PROBLEM

1 Ineffective thermoregulation R/T Risk for infection related to decreased
minimal clothing immunity
2 Altered nutrition less than body
requirement related to poor sucking.

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S.NO NURSING DIAGNOSIS SUBJECTIVE OBJECTIVE GOAL & IMPLIMENTATIO RATIONALE EVALUATION
DATA DATA PLANNING N
1 Impaired gas exchange Patient Patient is having GOAL: To Given oxygen by Immediate The gas exchange
related to decreased complaining of Air hunger, taking improve the gas mask. administration of improved with
haemoglobin level breathing deep breaths, not exchange Maintained propped oxygen improves oxygen
difficulty, able to talk. PLANNING: up position. the gas exchange. administration.
irritability. -Give oxygen Administered Tab.
by mask. FS BD as prescribed. To know the
-Giving propped Reminded patient to patient status. Gas exchange is
up position. take iron rich diet. improved.
Administering 3 Reminded to avoid To increase the
units of blood. tea and calcium tab. haemoglobin
Monitor the Along with Tab.FS level.
haemoglobin
levels Assessed the
Monitor the respiratory status. Deep breathing
vital signs. Monitor the vital To improve the exercises
- comfortable signs. fetal circulation. removed the gas
position Administered 2 units exchange
- left lateral of blood. difficulty.
position while
taking rest. Assessed the
haemoglobin level. Gas exchange Gas exchanging
Reviewed the vital become more takes place
signs and record it. efficient. normally with out
Left lateral position any difficulty.
while taking rest.

Oxygen
administration was
given when
necessary.
Taught deep
breathing exercises.

17
 Given comfortable
position.
Propped up position
maintained.
2 Altered nutrition less Patient is Not taking food GOAL: to
than body requirement complaining of properly improve the Assess the nutritional To know the Nutritional status
related to anorexia and anorexia, nutritional status of mother. pattern of food is maintained by
anaemic condition of status of mother Asked about the likes she used to take. serving small and
mother PLANNING: and dislikes of the frequent meals.
give iron rich mother.
diet. Given iron rich diet.
Small and Taking iron rich
frequent meals. Served small and diet.
Education about frequent meals. To increase the
the intake of Reviewed the likes interest in food.
nutritious diet in of the mother.
pregnancy.
Taught importance
of diet in pregnancy. To increase the
Different iron rich knowledge Taking normal
diets are given. diet rich in iron.

Given I/V fluids.

Taking normal diet

3 Ineffective breathing Patient is craving Tachypnoea, GOAL: To
pattern related to for oxygen, not tachycardia, improve the Assessed the To know the Breathing
dyspnoea able to breath breathing respiratory status. patien’s actual difficulty
properly. pattern. Monitor the vital condition. relieved with
PLANNING: signs. oxygen
-Checking vital Administer oxygen administration.
signs. via mask.
-Giving oxygen.
- propped up Maintained propped To improve the Breathing
position to up position. gas exchange. difficulty

18
 mother. Reassessed the vital reduced.
Deep breathing signs.
exercises.
Maintained left
lateral position while To improve the
taking rest. uteroplacental
Taught deep circulation.
breathing exercises.

Assessed heart sound

and lung sounds. Breathing
normally without
any difficulty.
4 Anxiety related to Asking about the Looking very GOAL: To
outcome of the fetal outcome. tensed by the remove the Assessed her level of To know the Anxiety reduced
pregnancy facial expression, anxiety. anxiety. level of anxiety. little extent.
biting lips etc. PLANNING: Talk to the patient.
To talk with the Given psychological Talking removes
patient. support. some anxiety.
Giving
psychological Clarify her doubts Clarification of
support. about the fetal Clearing doubts doubts relieved
Teaching outcome. relieves anxiety. her anxiety to a
relaxation Taught relaxation little extent.
techniques. techniques.
Giving
information Educate the mother
about the fetal about her condition. Relaxation Anxiety is
outcome. Practised her therapy is the decreased.
Educating the relaxation best method to
mother about techniques. reduce anxiety.
her condition
and its Make her support Support persons Patient fully
prognosis. person to include in are very relieved out of
her care. necessary to her anxiety.

19
 relieve anxiety of
patient
5 Alteration in family Enquiring about Patient is crying GOAL: to make
process related to her daughter with thinking about her her family Talked with patient Relieving her Patient
hospitalization her husband. elder daughter. adjusted to her about her family anxiety. understands
Asking about her disease condition. about her family
condition of house condition. Given psychological coping.
with him. PLANNING: support.
Talking with
patient. Told her husband to
Making show her daughter To reduce her Family cop up
alternate once to her. tension about her with her disease
arrangements to child. condition.
look after her Talked with support
child and house. person to arrange
some alternative Making them Family members
person to look after understand how adjusted with her
her child. to give hospitalisation.
Reassessed her psychological
anxiety level. support to her.

6 knowledge deficit related Patient asked help Mother is not take GOAL: To Early attachment
to self care and baby care for feeding baby. care of her baby increase the Encouraged the of baby to breast. Knowledge
Her facial properly knowledge level mother to feed the increased as
expressions reveals of the mother baby in side lying Maintaining evidenced by
she don’t know regarding position. hygiene of the correctly holding
how to take care of parenting, baby Done the breast care. breast. the baby.
her baby. care and self Taught different To give Knowledge of the
care. positions to mother comfortable mother increased
PLANNING: for feeding the baby. position to the as she started to

20
 Teaching about Make the mother mother. take care of the
Perineal care. aware about the baby.
Breast care. importance of giving
Kangaroo care. colostrum to baby. Make the baby
Baby care. warm.
Taught the kangaroo Prevent any Baby care was
mother care infection. done properly by
technique. To remove the mother indicating
Importance of air, which went of knowledge
maintaining good inside while improvement.
breast hygiene. feeding.
To prevent breast Mother’s
Burping of the baby engorgement knowledge
after each feed. increased
Baby should be fed
from both breast.
7 Risk for infection related Goal: To Monitor vital signs. To check any There is no signs
to anaemia prevent Assessed the I/V site signs of of infection .
infection for any signs of infection.
Planning: vital infection. Redness, edema Normal vital sign
signs Administer or increased suggestive of
monitoring. antibiotics. temperature may infection control.
Catheter care. indicates
Checking Maintained strict infection.
wound/ surgical aseptic techniques. To prevent any No signs of
incision daily ascending infection.
Perineal care given. infection.
Monitor episiotomy
wound site for any
signs of infection.
Removed I/V
cannula

FOR BABY
21
S.NO NURSING DIAGNOSIS SUBJECTIVE OBJECTIVE GOAL & IMPLIMENTATIO RATIONALE EVALUATION
DATA DATA PLANNING N
1 Ineffective Hands and feet of Goal: To make Covered the baby To prevent heat
thermoregulation R/T the baby are cold the baby warm. properly. loss. Thermoregulation
minimal clothing Planning: Keep baby clean and Will help the was maintained
mummifying the dry. baby to maintain
baby. normal body
Keeping baby Put off the fan. temperature.
away from door, Checked the vital
window,etc. signs of the baby. To know the Vital signs are
Advices on Keep the baby near temperature of stable.
importance of to the mother. baby. No signs of
thermoregulation Breast feeding was To provide warm hypothermia.
given to the baby. to baby.

Kangaroo mother
care given to baby. To provide warm
Regular change of as well as
wet nappies. bonding between
Provide appropriate the mother and Hands and feet of
seasonal clothings. baby. baby is warm.
To keep baby
Reviewed mother’s warm.
understanding about
the baby care. To ensure the
Encouraged teachings have No signs of
continuation of these been correctly hypothermia.
practices at home perceived. Mother keeping
also the baby warm.
2 Altered nutrition less Baby is crying Goal: To Encourage the Breast feeding to
than body requirement frequently, maintain the patient to start Breast feeding baby is initiated.
related to poor sucking. sucking hands. good nutritional feeding as early as improves the
level. possible. immunity.
Planning: early Taught the
breast feeding to importance of giving Colostrum is a Baby is feeding

22
 baby. colostrum to baby. good source of regularly.
Education of immunity.
importance of Feed the baby Need of the baby
breast feeding regularly at frequent should be met. Baby is getting
intervals. breast milk.
Exclusive breast
feeding till 6 months.
To give
Taught different comfortable
breast feeding position to baby.
techniques.
Not to give any other
things to baby other
than breast milk.
3 Risk for infection related hygiene of the Goal: Baby will
to decreased immunity surrounding is not have any Checked the vital To know the No signs of
not maintained, infection. signs of the baby. early signs of infection
baby is in Planning: Always wash hands infection.
hospital monitoring the before touching the To prevent
vital signs of baby. infection.
baby. Baby is warm and
Restricting the Keep baby clean and clean. Infection
visitor’s entry. dry. To prevent cross signs are not
Increasing the Dot mix the baby’s infection. found.
knowledge of clothes with anyone
mother. else’s.
Keep the
surroundings also
clean.

Breast feed the baby.

Limit the number of Breast feeding Baby is breast
visitors. gives immunity feeding properly.
to the baby.
Do not hold the baby

23
 in bare hands. Infection to baby
Avoid the visit of As baby’s is prevented.
anyone having any immunity is less.
infection.

24
HEALTH EDUCATION
In ward:
 Propped up position
 Left lateral position while lying.
 Count daily fetal movements.
 Take deep breaths in between.
 Take iron rich diet.
 Maintain hygiene to prevent any infections.
 Inform any bleeding occurs.
After discharge
Cap.Ampicillin 500mg QID X 5 days
Tab. Voveran 1 TDS x 3 days
Exclusive breast feeding to babies till 6 months.
Perineal care
Take good, adequate nutritious diet.
Follow up visit
Need for taking medications
Need for personal hygiene.
Spacing of children.
Use of temporary family planning methods.
For baby
Exclusive breast feeding.
Keep baby dry,clean and warm.
Maintain the hygiene of the baby.
Timely Immunisation of the baby.

PROBLEM FACED
a) By patient: Since my patient is an unbooked case, no blood investigations were done earlier.
Also she is living in a nuclear family, so there was nobody in her house to look after her elder
daughter who is 4 yrs old as her husband is with her in hospital. Another problem they faced
in hospital is that difficulty in arranging blood for transfusing it to her, as no donor was
available for them.
 By the student: To convince the mother for family planning.

0
SUMMARY

My patient Mrs. kiran w/o Mr. kartik was admitted in safdarjung hospital with a complaint of severe
dyspnoea. Routine blood investigations revealed that she is severe anaemic. Iron injections were
started and 3 units of blood were transfused. Injectable antibiotics also started for prophylactically.
She delivered baby girl weighing 1.9 kg by normal vaginal delivery with right mediolateral
episiotomy. Both mother and baby were comfortable and got discharged on 27.8.2021

CONCLUSION

Anaemia in pregnancy is a condition with effects that may be deleterious to mother and foetus. About
4-16% of maternal death is due to anaemia. It also increases the maternal morbidity, fetal mortality
and morbidity. Practice of routine iron supplementation during pregnancy is necessary, although
ironsupplementation is certainly most important for those pregnant women who develop anemia.

1
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