BIODATA OF THE CLIENT:

 Name : Mrs. Shabnam Ishaqkhan pathan

 Age : 21 years
 Sex : Female
 Register no. : 398765
 Ward : Postnatal ward
 Cot no :3
 Doctor’s unit : Dr. AUM
 Admission date : 20/05/24 at 9:20 am
 Education : 12th passed
 Occupation : Housewife
 Income : 10,000/ month
 Address : Chandana,ta-dist kheda.
 Nationality : Indian
 Marital status : Married
 Obstetrics score : G1P0A0L0 D1
 Diagnosis : Intra Uterine Death.
 Surgery : No any surgery

Present Obstetrical History:

 My client is primi gravida and 21 year old, on the date of admission at morning time
came hospital with complain of abdominal pain and vaginal bleeding.
 She was admitted on 20/05/24 in civil Hospital.
 At present, she having bright red colour and in varying amount bleeding and anemic.
 On examination per abdomen 32 wk gestation, vertex presentation,uterus become
contracted and FHS not located with stethoscope.
 Per vaginally examination show present.

Chief Complain with duration:

 Patienthaving complained of bleeding since 20/05/24 at 1:00 am

Past History:
Medical and Surgical History: She had no history of TB, , diabetes mellitus, other medical
complains or surgical history in past.. She had no history of any surgery in her life.
Past obstetrical History: She is primi gravida and no history of abortion.

Family History:

Name Age Sex Relationship Education Occupation Income Remark

with patient

Mr.ishaq 26 yrs M Husband 12th std Job 10,000/ -

khan pathan -

Mrs.shabnam 21 yrs F Self 12th std Housewife - -

banu pathan.

 Expect patient, her husband not having disease like T.B, diabetes, hypertension, heart
disease, and asthma. There is no history of any blood or psychiatric disorder.

Socioeconomic history:

 Client lives in Nuclear family. She is a housewife and her husband is earning person
in her family. Monthly income is 10,000/ month so their economic condition is not
very good.
 Her husband is supportive to her. In the hospital, he always remains with client. Her
social relations with family members, friends and neighbors are good and healthy.
 Her social status in her community is good. She participates in all social & family
functions.

Menstrual history:

 The age of the menarche started is 12 years.

 Interval is 28 days. Duration is 4-5 days.
 Before pregnancy, she is having regular menstrual cycle and normal flow.

Marital history

 Age of marriage: She married when she was 20 years old and consanguineous
marriage.

Present pregnancy:-
  Admitted on : 20/4/24…at 9:20 am
 Height of fund : 29 cm
 Presentation : Vertex presentation
 Position : LOA
 Engaged/not engaged/free : Free
 FHR : FHS not audible

General Condition
 B.P. :150/100 mmHg
 TPR T: 98.8 ‘F P: 90/ min R: 20 b/min
 Urine: Sp. Gravity : 1.016
 Reaction : Acidic
 Protein : Absent
 Glucose : Absent

HEAD TO TOE EXAMINATION:

 Head: No dandruff was present but hairs become rough. No skull injury or scalp
infection.

 FACE: Face looking anxious by facial expression.

 EYES: Eyes were clean, conjunctiva appeared light pink colour and sclera appeared
whitish in color. Sclera is pale color. Eyesight of patient was normal. No discharge
was present in the patient’s eye.

 EAR: Ears were normal in size in shape, hearing was normal, no any discharge was
present in the ear, and both ears were clean.

 NOSE: No septal deviation was there. Curvature of nose appeared normal. No

complication was seen in the patient.

 MOUTH: No cracked lips were present, tongue was appeared pale in color, and
ulcer was not present in the patient’s mouth. Slight yellow discoloration was seen in
the teeth.

 NECK: No enlargement of the lymph node.

 CHEST: Shape and size of the chest was normal. There was symmetrical movement
of both chests.

 BREAST: Primary and secondary areolas are Present. Montego marries tubercles are
prominent. No palpable mass in both breasts. Nipple is retracted.

 ABDOMEN:
AG: 55 cm
 FH: 15.5 cm
No tenderness, no any scar.
 BACK: back pain due to Infection and long time supine position.

 EXTRIMITIES: Not any abnormality in Extremities. Normal range of motion.

 GENITAL ORGAN: episiotomy done. redness present.

Vital signs of patient :-

Vital signs Patient value Normal value

Temperature 97. 8F 96.8- 97.2 F

Pulse 90 beats / min 80-86 beats/ min

Respiration 20breath/ min 20 breaths/ min

Blood pressure 130/84 mmHg 120/ 80 mm of Hg

INVESTIGATION:

Name of investigation Patient value Normal value

Complete blood count

- Hb 9.8 gm %
- RBC 4.6 million/cumm 13 – 15 gm %
- Platelet count 2.6 lakh/ cumm 4.5 -5.0 million/cumm
1.5-4.5 lakh/cumm

Differential count:-
Neutrophils 52% 50- 70%
Lymphocytes 24 % 22-40%
Monocytes 3% 2-6%
Eosinophils 1% 1-6%
Basophils 0 0-2.5%
 Blood group B Positive -

HbS Ag Negative Negative

VDRL test Non reactive Non reactive

HIV test Non reactive Non reactive

Urine report

Colour Dark yellow Pale yellow

Odour Aromatic Aromatic

Reaction Acidic (5.5) Slight acidic

Specific gravity 1.025 1.o16-1.026

Urine Albumine Negative Negative

Urine sugar Negative Negative

Sonography:
Sonography reveals no Fetal heart activity

 have follow-up, bereavement counseling and, where appropriate, genetic counseling.

Management in my client :-( Medical management)

Treatment:

Drug Dose Route Time

Tab.Tafixime 200 mg Orally 1-0-1

Tab. Rantac 150 mg Orally 1-0-1

Tab.Diclofenac Orally 1-0-1

Tab. Calcium 500 mg Orally o.d(1-0-0)

Tab.fe Orally
Sr Name of Dosage Action Indication Side effect Nurses responsibility
no the /Route/Freque and
medicati ncy contraindicati
on on

1. Tab. Dosage neutralises Acidity, constipation,  Assess ECG

Calcium :500mg gastric hypocalcaemia, anorexia, for QT and T
acidity osteoporosis, nausea, wave
Frequency: OD hyperphosphate vomiting,
amia, RIH diarrhoea, Calcium level during
Route :oral treatment.
rebound
hyperacidity. -Assess cardiac status

Evaluate –therapeutic
response

Action : Assess – fatigue, Hb

Tab. needed for
Folic %, reticulocyte count
Dosage erythropois anaemia Side effects: and nutritional status
2. acid is,
: 200mg flushing,
increases bronchospasm, Teach family and
Frequency: RBC, patient – to take drug
hypersensitivit
OD WBC, as prescribed
y
platelet
Route : oral - To alter nutrition to
formation
include high folic acid
food

fast, slow, or
3. prevent nau uneven
Inj.ondas 8 mg sea and heartbeats;
tron. vomiting c
intravenous feeling like
aused
by cancer c you might pass
hemotherap out; or
y. It works headache with
by
chest pain and
blocking
one of the severe
body's dizziness,
natural fainting, fast or
substances
pounding
(serotonin)
heartbeat.
 APPLICATION OF NURSING THEORY
THEORY OF INTERPERSONAL RELATIONS
Introduction
 Born in Reading, Pennsylvania [1909]
 Graduated from a diploma program in Pottstown, Pennsylvania in 1931.
 Published Interpersonal Relations in Nursing in 1952
 1968 :interpersonal techniques-the crux of psychiatric nursing
Roles of nurse
 Stranger: receives the client in the same way one meets a stranger in other life situations
provides an accepting climate that builds trust.
 Teacher: who imparts knowledge in reference to a need or interest
 Resource Person : one who provides a specific needed information that aids in the
understanding of a problem or new situation
 Counselors : helps to understand and integrate the meaning of current life
circumstances ,provides guidance and encouragement to make changes
Theory of interpersonal relations
 Middle range descriptive classification theory
 Influenced by Harry Stack Sullivan's theory of inter personal relations (1953)
 Also influenced by Percival Symonds , Abraham Maslow's and Neal Elger Miller

Identified four sequential phases in the interpersonal relationship:

1. Orientation
2. Identification
3. Exploitation
4. Resolution
Orientation phase
 Problem defining phase
 Starts when client meets nurse as stranger
 Client seeks assistance ,conveys needs ,asks questions, shares preconceptions and
expectations of past experiences
 Nurse responds, explains roles to client, helps to identify problems and to use available
resources and services

Factors influencing orientation phase

Identification phase
 Selection of appropriate professional assistance
 Patient begins to have a feeling of belonging and a capability of dealing with the problem
which decreases the feeling of helplessness and hopelessness
Exploitation phase
 Use of professional assistance for problem solving alternatives
 Advantages of services are used is based on the needs and interests of the patients
 Individual feels as an integral part of the helping environment
 They may make minor requests or attention getting techniques
  Patient may fluctuates on independence
 Nurse must be aware about the various phases of communication
 Nurse aids the patient in exploiting all avenues of help and progress is made towards the
final step

Resolution phase
 Termination of professional relationship
 The patients needs have already been met by the collaborative effect of patient and nurse
 Now they need to terminate their therapeutic relationship and dissolve the links
 between them.
 Sometimes may be difficult for both as psychological dependence persists

LIST OF NURSING DIGNOSIS:

1. Deficient fluid volume related to bleeding

2. Ineffective Tissue perfusion peripheral related to Bleeding
3. Acute pain related to condition as evidence by facial expression
4. Anticipatory grieving related to loss of previous pregnancy, cause of abortion, future
childbearing.
5. Knowledge deficit related to signs and symptoms of possible complications.
6. Knowledge deficit regarding condition, prognosis, self care and treatment needs
related to lack of exposure evidenced by inaccurate follow- through of instructions
Assement Nursing diagnosis Goal Planning Implementation Evaluation
Subjective data: 1.Deficient fluid The patient will  Record onset and  Record onset and Maintain the optimal
volume related to experience amount of vaginal amount of vaginal tissue perfusion.
Weakness bleeding minimal bleeding before bleeding before
bleeding, remain admission. admission.
Vertigo
normovolemic,  Assess bleeding  Assess bleeding
Objective data: and maintain every 30 minutes every 30 minutes or
optimal tissue or as the patient's as the patient's
Pale condition condition warrants.
perfusion.
lethargic
warrants.  Note color of blood
 Note color of and number of
blood and number perineal pads used
of perineal pads and their degree of
used and their saturation and
degree of weight
saturation and  Monitor vital signs
weight and compare with
 Monitor vital signs baseline
and compare with  Measure fundal
baseline height from the
 Measure fundal superior aspect of
height from the the symphysis pubis
superior aspect of to the top of the
the symphysis uterine fundus
pubis to the top of every 30 minutes.
the uterine fundus  Monitor for frank
every 30 minutes. bleeding,
 Monitor for frank ecchymoses,
bleeding, petechiae,
ecchymoses, hematomas, and
petechiae, bleeding from
hematomas, and mucous membranes
bleeding from or sites of invasive
mucous procedures.
membranes or  Obtain and monitor
sites of invasive Hb level and HCT,
procedures. as ordered.
 Obtain and  Start an I.V. infusion
Assement Nursing diagnosis Goal Planning Implementation Evaluation

Objective data: 2. Ineffective Tissue 1. Demonstrate the  Perform a  Perform a Maintain the fluid balance
perfusion (peripheralre circulation status comprehensive comprehensive
Pale lated to bleeding which is assessment of assessment of
characterized by :
lethargy peripheral peripheral circulation.
Systolic and
diastolic pressure circulation.  Monitor fluid status
in the normal  Monitor fluid status  Monitor vital signs
range.  Monitor vital signs  Monitor cerebral
 Monitor cerebral perfusion pressure
2. Fluid balance
can be maintained,
perfusion pressure  Monitor fluid intake
as evidenced by :  Monitor fluid intake and output
normal blood and output  record the patient
pressure  record the patient response to stimuli
skin turgor ; not response to stimuli  Position the patient in
dry
 Position the patient semi fowler position
in semi fowler  Encourage oral input
position 
 Encourage oral input
Assement Nursing diagnosis Goal Planning Implementation Evaluation
Subjective Data 3. Acute pain related Reduce the level
 Conduct a  Conduct a  The patient did not
to bleeding and as of pain,
Verbalize or report evidence by facial comprehensive comprehensive show facial expressions
pain with cues. assessment of pain assessment of pain include of pain .
expression.
Objective Data include the location, the location,  The patient did not look
1.Position to avoid characteristics, onset characteristics, onset and nervous.
pain.
and duration, frequency duration, frequency of  The patient will report
2.Expressive behavior of quality, intensity or quality, intensity or pain and duration of
(eg, restlessness,
moaning, crying, severity of pain. severity of pain. pain episodes .
excessive vigilance,  Observation of  Observation of  The patient did not
sensitive to stimuli
non-verbal cues of non-verbal cues of moan and cry .
and took a deep
breath). discomfort, especially discomfort, especially
there are those who are there are those who are
3.Face mask (pain).
unable to communicate unable to communicate
4.Behavior maintain effectively.. effectively..
or condescension.
 Adjust the  Adjust the
5.Evidence that pain frequency of the dose as frequency of the dose as
can be observed.
indicated by assessment indicated by assessment of
6.Sleep disorders. of pain include the pain include the location,
location, characteristics, characteristics, onset and
onset and duration, duration, frequency of
frequency of quality, quality, intensity or
intensity or severity of severity of pain and the
pain and the precipitation factor.
precipitation factor.  Manage pain with
 Manage pain opioid administration
with opioid scheduled.
administration  Providing
scheduled. analgesic before
HEALTH TEACHING:

Given health education regarding:

 Dietary Instruction
 Postnatal care
 Maintaining personal hygiene ,
 Postnatal exercise
 Regular check up and follow up
 Family planning methods

1. Postnatal advise :-
- Advise her to do not left heavy things and take adequate rest.
- Advise her to drink more water and nutritious diet.
- Advised her to take 8 hrs rest in night and 2 hrs in afternoon.
2. Dietary Instruction:-
- Advised to eat food containing more iron like drum stick, juggery and green leafy
vegetable.
- Explained for diet like high calorie and high protein and vitamin reach diet.
- Eat food at regular interval.
3. Maintaining personal hygiene:-
- Advise for daily bath, mouth care hair care.
- Advice her to clean perineal area with soap and water after each urination and
defecation.
4. Regular check up and follow up: - according to doctors orders.
5. Postnatal Exercise: Explained and taught about deep breathing and, pelvic floor exercise,
tailor sitting.
6. Advised her to take all medicine regularly and come for routine checkup according
doctor’s order.
7. Family planning methods :-
- Advised her to use temporary family planning methods like copper T use after
delivery.
- Advise her conceive pregnancy after 2-3 year it help full for improvement of their
health status.
- Maintain calm and warm environment

Discharge Plan:
Medication

 Tab.cefixime(200) 1-0-1
 Tab.rantac (150) 1-0-1
 Tab.diclofenac
 Tab.folic acid
 Tab.calcium