INTRODUCTION
As per my clinical posting I was posted in the Antenatal ward in IGM Hospital.
During my clinical posting I found a patient who was suffering from pain at lower
abdomen ,headache, high blood pressure and doctor diagnosed her as Pre-eclampsia. I had
taken this diagnosis for my care plan.
DATA COLLECTION-
Name of the mother :-Mrs. Piyali Datta
Age of the mother :-29 years
Registration no. :- 14569
Ward :- Antenatal ward
Admission date :- 22/10/24
Education :- 10th pass
Occupation :- House wife
Address :- Udaipur
L.M.P :- 20/9/23
E.D.D :- 27/6/24
Obstetrical Score :- G1P0A0L0S0
Gestational Age :- 37 weeks 6 days
Diagnosis :- Pre-eclampsia
Chief complain :-
Leaking per vagina since 12 hrs.
Lower abdominal pain since 6 hrs
Restlessness due to increase in blood pressure
Obstetrical History:-
Past obstetrical history:-
Sl Date of For term Pre- Abortion Nature of Nature of Child
delivery term pregnancy puerperium
1. She is a Primigravida Mother
Present obstetrical history;-
1st Trimester:- In 1st trimester she feels very restless. She had confirmed her pregnancy at 5
weeks by urine test and takes 2 doses of T.T.
2nd Trimester:- In 2nd trimester she felt quickening of fetus at 18th week and she took iron,
calcium and folic acid tablets.
3rd Trimester:- In 3rd trimester she had done ultrasound and findings were normal. But she
was having nausea and vomiting.
Medical Surgical History:-
Present Medical History:- My patient Mrs. Piyali Datta has leaking per vagina and lower
abdominal pain.
Past Medical History:- My patient Mrs. Piyali Datta doesn’t have any past medical history.
Present Surgical History:- My patient doesn’t have any present surgical history.
Past Surgical History:- My patient doesn’t have any past surgical history.
Menstrual History:-
Age of menarche:- 13 years
Duration:- 4-5 days
Flow:- Moderate
L.M.P:- 20/01/24
Marital History:-
Duration of Marriage:- 1 years
Age Duration Marriage:- 28 years
Consanguinous Marriage:- No
Relationship with husband:- Satisfactory
Family History:-
Type of family:- Nuclear family
Number of members:- 3 members
Hereditary illness:- Absent
Family Tree:-
Lt. Santanu datta Mrs. Ela datta
Mr. Arav datta Mrs. Piyali datta
Index:-
Male dead
Male
Female
Female patient
Family flowchart:-
Sl Name of Age/ Relationshi Educatio Occupatio Marital Health
no the gender p with n n status status
. family patient
member
s
1. Mrs. Ela 50yrs/ (F) Mother-in- Class 5 Housewife Widowe Healthy
datta law passed r
2. Mr. 34yrs/ Husband B.A Business Married Healthy
Arav (M) passed
data
3. Mrs. 29yrs(F) Patient Class 10 Housewife Married Unhealth
Piyali passed y
datta
PERSONAL HISTORY—
Diet:- She takes small and frequent diet
Appetite:- Loss of appetite present
Rest and sleep- Adequate
Activity- Well Active
Bladder:- Passes 6-7times
Bowel :- Passes 1-2times
Habits and hobbies- She don’t have any bad habits.
Hygiene- Well Maintained
SOCIO ECONOMIC HISTORY—
Head of the family: Mr. Arnab Datta
Income: Approximately Rs. 40000/- per month
House Type:Pucca
Location:Urban
Water supply: Tap water
Electricity:Available
Ventilation:Good
Sanitation:Pucca
Drainage System:Pucca
PHYSICAL EXAMINATION—
VITAL SIGNS-
Temperature - 98.60F
Pulse - 72 bpm
Respiration - 24 bpm
B.P - 158/80 mmHg
ANTHROPOMETRIC MEASUREMENTS—
Weight -68 kg
Height -5’1’’
GENERAL HEAD TO TOE EXAMINATION—
General appearance-
Body built :- Normal
Activity :- Dull
Posture :- Normal
Pallor :- Absent
Head-
Hair :- Hair color is black, equally distributed.
Scalp:- Dandruff and other infections are absent.
Face:
Chloasma – Present
Colour- Pale
Scar- Absent
Eyes-
Symmetry:-Eyes are symmetrical
Eyebrows :-Black in color, equally distributed.
Eyelids-No inflammation present.
Eyelashes-No infection present, equally distributed
Sclera-White in color
Conjunctiva-Pinkish in color
Cornea-No discharge present
Vision-Normal
Pupilary reaction-Normally reacted.
Nose-
Nasal septum-not deviated
Nostrils-no discharge present, no infection present
Ears-
Symmetry-symmetrical
External ears- no infection present
Gross hearing-adequate
Pinna-normal
Discharge-there is no discharge is present
Mouth-
Lips-Moist, brownish in color
Gum- no gingivitis, scurvy present
Teeth- Discolouration of teeth & dental carries is present
Tongue- normal, moist, no infection present.
Throat- There is no redness, enlarge tonsils
Neck-
Range of motion- performed
Lymph nodes- There is no enlarged lymph node
Chest-
Inspection
Shape & Symmetry: Normal
Palpation-No abnormal mass or lumps like structure is absent.
Auscultation: S1 and S2 sound heard.
Breast:-
Montegumeris tubercle- Present
Areola- Primary and secondary areola is present
Discharge- Absent
Nipple- Cracked nipple absent
Abdomen-
Inspection
Size-enlarged
Shape- oval
Linea niagra- present
Striae gravidanum- present
Umbilicus- potruded
Other scar mark- absent
Palpation
Abdominal girth- 92 cm
Fundal height- 37 cm
Fundal palpation:
1. Fundal grip- Cephalic presentation
2. Lateral grip- on right side of knob like structure present and on left regular continuity
structure which suggests back or spine of the fetus.
3. Pawlik grip/pelvic grip1- the presenting part is not fixed.
4. Pelvic grip 2- the presenting part is not engaged as I found convergent during palpation.
Auscultation
FHS-140 beats/min
Genitalia-
Discharge – Fluid discharge absent
Bleeding- Absent
Vulva – Normal
Chadwick sign- Present
Extremities-
Range of motion- Flexion, Extension, Rotation present
Homan’s sign- Absent
Muscle strength edema – present
MEDICATIONS:
SL NO. MEDICATION DOSE ROUTE FREQUENCY
1. Inj. Taxim 1gm IV BD
2. Inj. 4mg IV TDS
Ondensterone
3. Inj. 80mg IV BD
Gentamiacin
4. Inj. Diclofenac 3 ml IM TDS
5. I/U fluids
RL 5% I/U 24hrs
INVESTIGATION-
Date Investigation Mother’s value Normal value Remarks
BLOOD
20/5/24 Rh grouping B+ Normal
Hb 10.2 gm% 12- 14gm%
Decreased
RBS 83mg/dl 80- 100gm/dl
TSH 4.65 mIU/L 0.1-2.5 mIU/L Increased
HIV/HBSAG Non-reactive
URINE
Albumin&Sugar 13 mg 12- 19mg Normal Non
HIV reactive
HbAg
Non reactive
HCV
Non reactive
Nursing Management
Nursing theorists and their work have a significant impact on nurse education and clinical practice.
They can be applied both in theoretical research and used practically in diverse interventions
aimed at the improvement of patient care quality and patient outcomes. One of the theories most
commonly employed in practice is Paplau’s Theory of Nursing. Peplau's theory is one of the
early Nursing theories, published in 1952. The nurse-patient relationship consists of four
steps (orientation, identification, development and conclusion). In these steps nurse could
have the role of foreign, reliable person, teacher, and guide in nursing care, substitute and
consultant.
Theory application
Rimi Sarkar was admitted in the hospital. She was having normal term pregnancy with pre-
eclampsia, and felt dizziness and weakness and adviced to be on bedrest. She needs support
from others to perform daily living activities.
So, I applied Paplau’s Theory for my patient while caring her to improve his health status by
setting the goals with both the nurse and the patient’s mutual understanding.
The model focuses on four phases –
1) Orientation phase
2) Identification phase
3) Exploitation phase
4) Resolution phase
Metaparadigm :
Here according to this theory,
Nurse : Myself, I am giving to the client.
Person : Person indicates the family member who is suffering from health problem.
Environment :IGM hospital
Health :The health refers to the health problem of the family member.
Here I am applying the paplau’s theory of interpersonal relation.
Application of this theory to the care of the client –
In the care of the clients with Polyhydroamnios. So I need to maintain a good
interaction with the family members to achieve the goal by working together so that both
become mature and knowledge in the process.
Paplau Interpersonal Relationship Theory Model –
Nurse orientation :
Meet with the client, Client orientation :
identification of the The client greet me
client, asking the need and gave self
of problems the family introduction.
members are facing. Identification :
Identification : The client explains that
The client is suffering There is a
she is suffering from
from pain, and good
pain and restlessness
restlesness due to interpersonal
relationship Exploitation :
increase in amniotic
fluid. between me The client has followed
and the family my instruction and i
Exploitation : members. have check the persons
Advice the client to pain level
check the persons pain Resolution phase :
level
The client is followed.
Resolution phase :
Provide health
education to the client.
NURSING DIAGNOSIS
Ineffective tissue perfusion related to decrease in RBC, hemoglobin and hematocrit as
evidenced by weak and pale in appearance
Activity intolerance related to body weakness secondary to low RBC level as
evidenced by intolerance for long standing.
Anxiety related to pain and tenderness as evidence by frequent question
Knowledge deficit related to pre-eclampsia, treatment and self-care as evidenced by
asking statement of concern
Assessment Nursing Goal Planning Implementatio Rationale Evaluation
Diagnosis n
Subjective Ineffective To -Monitor -The vital signs - The
data : tissue maintain the vital are monitored, It provides adequate
Client saysperfusion adequate signs, urinary output baseline tissue
that she
related to perfusion. assess and weight of information perfusion is
feels decrease in urine the client is maintained.
dizziness RBC, output and checked daily
hemoglobi weigh -This avoid
n and client. uterine
hematocrit pressure on
Objective as vena cava
data : evidenced -Place the -The patient is and prevent
Face looks by weak client on placed in left supine
pale and pale in left recumbent hypotension
appearance recumbent position and
position maternal well
being is checked -This
periodically promotes
-Maintain -Adequate oxygenation
adequate ventilation is and good
ventilation maintained blood
circulation.
-
Replacement
- -I/V fluids are of fluid
Administer administered as maintains
fluid as prescribed by circulatory
prescribed. doctor volume and
tissue
perfusion.
Assessment Nursing Goal Planning Implementa Rationale Evaluatio
Diagnosis tion n
Subjective data:- Activity To able -Assist the -To -It ensures The
Patient complains intolerance patient patient assistance is safety and patient is
of weakness related to to during provided to additional able to
body perform moving and the client support to perform
Objective data:- weakness activity on going in whenever the patient activity
Patient is feeling secondary to with the room she needs it with
worried low RBC minimu minimum
level as m assistance
evidenced assistan -Assist the -The client
by less ce patient in is assisted in -It improves
tolerance for comfortable a comfort
long position comfortable
standing position.
-
-let the Opportunity -It increases
patient do is provided self-reliance
much to patient so
activities that she can
do activities
Assessment Nursing Goal Planning Rationale Implementation Evaluation
Diagnosis
Subjective Anxiety To -Assess the -To know -Anxiety level of -Anxiety
data:- related to reduce anxiety level The anxiety the patient is level of the
Patient pain and anxiety of the patient level of assessed with patient is
complains tenderness level with the help patient the help of reduced
that she is as of the of anxiety anxiety scales
feeling evidence patient scale
scared of by
pain and frequent - Provide the - To feel -Feelings of the
tenderness question psychological the comfort patient are
support to the to the explored
Objective patient patient
data:-
On - Provide the -To help in -Counselling is
observation counseling to knowing provided to the
patient is the patient about the patient regarding
asking regarding pre- complications of
frequent complication eclampsia pre-eclampsia
question of pre-
eclampsia
HEALTH EDUCATION:
Diet-
Advice regarding fat free diet.
Advice patient to take protein rich diet.
Advice to take 3 meals a day and in afternoon snacks
Advice patient to take more fluids per orally.
Exercise-
Avoid heavy exercises after taking meal.
Educate the patient for antenatal exercises
Hygiene:-
Teach the patient about maintaining proper personal hygiene.
Educate the mother for hand washing before eating food
Defecation:-
Educate the patient to clean her perineal area properly after each urination
Medication-
Educate the patient about medication regimen, route, dose, frequency and adverse effects
Rest and sleep:-
Advice the patient to take proper rest and sleep at least 6 hours in night and 2 hours in a day
Follow-up care:-
Advise the patient for regular medical check-up so that if any complication occurs can be
detected at right time.
Advice the family for follow-up care and its importance and to report immediately if there is
any sign of complication
CONCLUSION:-
As per my clinical posting I have posted in the antenatal ward and I got a patient Pre-
eclampsia. I gave care as per her need of the patient and it will help me to deal with same
kind of patient in future.
