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IDENTIFICATION DATA OF PATIENT

NAME OF THE PATIENT- Daljit Kaur


AGE- 25 yrs
SEX- Female
EDUCATION- B.A.
OCCUPATION- Housewife
RELIGION- Sikh
MARITAL STATUS- Married
ADDRESS- chandu
NAME OF THE WARD- Postnatal-I
DATE OF ADMISSION- 04/3/19
DATE OF DISCHARGE- 14/3/2019
DATE OF OPERATION- 05/3/2019
TYPE OF OPERATION- Lower Segment Caesarean Section
DOCTOR INCHARGE- Dr. Rashmi
DIAGNOSIS- Breast engorgement

CHIEF COMPLAINTS

 Heaviness in both the breast since 2 days


 Tenderness in both breast since 2 days
 Pain in both the breast since 2 days

PRESENT HISTORY

 Patient Daljit Kaur is admitted in SGT Hospital with the diagnosis of full term pregnancy
but after delivery she is having present chief complaints of heaviness in both the breast,
tenderness in both breast, pain in both the breast and having difficulty to feed her baby.

PAST MEDICAL HISTORY

 Patient having no any significant past medical history

PAST SURGICAL HISTORY

 Patient having no any significant past surgical history.

FAMILY HISTORY

Name of Relationship Age/sex Marital status Occupation Health Educational


the family with patient status background
member
Prabhjot Husband 27yrs/M Married Pvt. job Healthy +2
Daljit Patient 25yrs/F Married Housewife Unhealthy B.A.
Newborn Newborn 03 days Unmarried Nil Healthy Newborn

FAMILY TREE

Prabhjot Daljit

HEALTH FACILITY NEAR HOME:-


Dispensary near the sector, and transport facility is by car, bus

SOCIO ECNOMIC STATUS:-


Housing-Pucca house, 3 room set, 1 bathroom, 1 toilet, 1 kitchen.
Water supply- Tap water and they drink filter water
Sanitation- Environmental hygiene is maintained
Income-Rs1, 70, 000 per annum

PERSONAL HISTORY
Hobbies- Watching T.V. and cooking.
Dietary Habits- Vegetarian
Addiction- Not present

PERSONAL HYGIENE
Oral hygiene- Maintains oral hygiene with toothpaste and brush 1 times a day
Bath- Takes bath daily
Diet- Non-vegetarian
No. of meals per day- 3 times per day.
Food preference- Homemade food
Fluid- 10-12 glasses/day
Tea & coffee- 2 cups/day
Sleep & rest- 2 hours in afternoon and 6 hours in night

ELIMINATION
Bowel per day- Regular, frequency, 1-2 times.
Urine frequency day- 3-4 times, night- 1 times, light yellow colour.

MOBILITY AND EXERCISE


Exercise / Activity- No special or postnatal exercise is done by patient but patient having some
activities after operation.
Joints- No pain in joints and having normal mobility.
MENSTURAL HISTORY
Regular, 5 days duration, 28 days cycle, moderate dysmenorrhea present.

MARITAL HISTORY
Spouse Health- Good
Spouse occupation- Pvt. Job
Substance use- No history of any substance use
Addiction- No

OBSTETRIC HISTORY
P1L1A0

SEXUAL HISTORY
Frequency of sexual activity- 1-2 times/week
Method of contraception- Condom
Dyspareunia- Present
Relationship- Satisfactory

PHYSICAL ASSESSMENT
General appearance and behaviour
Build- Normal
Nutrition- Good nutrition

Anthropometric Measurement
Weight- 62 kg
Height- 5’5’’

Physical Assessment

Subjective data Objective data


HEAD TO TOE EXAMINATION:
Head The condition of the scalp is normal; hairs are
clean, dry and black in colour.
Eyes Colour of the eyes is black and vision is
normal.
Nose Smell perception is normal, no nasal
congestion and any type of abnormal
discharge.
Ears Hearing is normal and no any type of abnormal
discharge from ears.
Throat No enlargement of any lymph nodes and
tonsils.
Chest There is no any chest pain, chest congestion.
Breast Breast size is increased, nipple and areola is
also enlarged and pigmented. Both breasts are
heavy, tender, firm and painful for patient.
Patient has pain in lower abdomen due to
Abdomen stitches and having dressing over the abdomen
on stitches.
Lower and upper extremities are normal. But
Extremities having difficulty in walking due operation and
stitches.

SYSTEMIC EXAMINATION: On inspection- normal symmetry


Respiratory system On percussion- no fluid present
On auscultation- normal breath sounds
Pulse –82/min
Circulatory system Blood pressure-120/70mm Hg
Recent-intact
Neurological system Remote –intact
Well oriented
Insight and judgment present
Normal speech
On inspection-normal shape and symmetry
Gastrointestinal system On percussion- no taped fluid present
On auscultation-normal bowel sounds
Urinary output is normal.
Renal system

VITAL SIGNS

DATE TEMPERATURE PULSE RESPIRATION B.P. REMARKS


4/3/19 99 F 88/min 20/min 110/80 Increase in
mmHg temperature and
pulse rate
5/3/19 98.6 F 82/min 20/min 110/70 Normal
6/3/19 98.6 F 82/min 20/min 120/70 Normal
ROUTINE INVESTIGATIONS

S.No. TEST PATIENT’S NORMAL REMARKS


VALUE VALUES
1. Hemoglobin 10 gm/dl 12-15 gm/dl Decreased
2. TLC 7700/cumm 4000-11000/cumm Normal
3. DLC; N 55% 40-70% Normal
4. L 32% 20-40% Normal
5. M 02% 1-6% Normal
6. E 06% 2-10% Normal
7. BT 4.2 min. 3-7 min. Normal
8. CT 6.8 min. 4-10 min. Normal
9. Blood Sugar 102 mg/dl 70-110 mg/dl Normal
10. HIV -ve --------- Normal
11. VDRL -ve --------- Normal
12. Blood Group O +ve --------- ----------

MEDICATIONS

S.No. Drug Salt Dose Route Frequency Action


1. Inj. Ciplox Ciprofloxacin 100 ml I/V BD Antibiotic
2. Inj. Metrogyl Metronidazole 100 ml I/V TDS Antibacterial
3. Inj. Monocef Cefotaxime Sodium 1 gm I/V BD Antibiotic
4. Inj. Genta Gentamycin Sulphate 80 mg I/V BD Antibiotic
5. Inj. Voveran Diclofenac sodium 25 mg I/M BD Analgesic
SHORT TERM GOALS

 To relieve pain.
 To prevent infection.
 To prevent further complication.
 To maintain the normal temperature of the newborn.
 To feed the newborn at regular interval.
 To maintain personal hygiene.
 To provide comfort.
 To enhance the physical mobility of the patient.
 To enhance the knowledge of the patient the patient regarding breastfeeding technique.

LONG TERM GOALS

 To rehabilitate the patient after surgery.


 Teach the patient family about medication, their frequency, dose, action and adverse
effect.
 Teach the patient about active and passive exercises.
 Teach the patient about the dietary pattern i.e. high protein diet and low cholesterol diet.

NURSING DIAGNOSIS

 Pain related to tenderness in the breast.

 Ineffective breastfeeding related to pain or difficulty with breastfeeding process.

 Risk for infection related to complication of the breast engorgement.

 Anxiety related to pain and tenderness.

 Knowledge deficit related to breastfeeding process.


NURSING CARE PLAN

S. Nursing Goals Planning Implementation Evaluation


No diagnosis
1. Pain related To relieve -Assess the level of the -Level of pain is Pain of the
to tenderness the pain of pain with the help of assessed with the help patient is
in the breast. the patient. pain scale. of pain scale. relieved.
-Provide diversional -Diversional therapy is
therapy to the patient, provided to the patient
e.g. T.V and e.g. T.V and
newspaper. newspaper.
-Advice the patient to -Patient is advised to
apply hot or cold apply hot or cold
compressions on the compressions on the
breast that helps to breast that helps to
reduce the tenderness. reduce the tenderness.
-Advice the patient for -Patient is advised for
manual expression of manual expression of
remaining milk after remaining milk after
each feed. each feed.
-Administer analgesics -Analgesics such as
to the patient as injection voveran are
prescribed by the administered to the
physician such as patient as prescribed by
Injection voveran. the physician.

2. Ineffective To establish -Assess the -Breastfeeding pattern Effective


breastfeeding an effective breastfeeding pattern and mother’s breast
related to breast and mother’s knowledge regarding feeding is
pain or feeding. knowledge regarding breastfeeding are established.
difficulty breastfeeding. assessed.
with -Educate the mother -Mother is educated
breastfeeding regarding breast care regarding breast care
process. and breastfeeding and breastfeeding
techniques. techniques.
-Educate the mother to -Mother is educated to
feed her baby every one feed her baby every one
hourly or demand feed hourly or demand feed
also. also.
-Stay with mother -Stay with mother
during feeding and during feeding and
evaluate the position of position of the mother
the mother and baby and baby is evaluated
during feeding. during feeding.
-Ensues that the -Ensued that the
neonate is awake and neonate is awake and
alert during feeding. alert during feeding.
-Provide positive -Positive reinforcement
reinforcement to the is provided to the
mother in order to mother in order to
increase her confidence increase her confidence
and self-esteem. and self-esteem.

3. Risk for To reduce Assess the breast for -Breast of the patient is Risk of
infection the risk of tenderness, redness and assessed for tenderness, infection is
related to infection. pain. redness and pain. reduced.
complication -Check the vital signs -Vital signs of the
of the breast of the patient especially patient are checked.
engorgement. temperature.
-Educate the patient to -Patient is advised to
clean her breast before clean her breast before
and after each and after each
breastfeeding. breastfeeding.
- Educate the patient to -Patient is advised to
maintain her personal maintain her personal
hygiene. hygiene.
-Educate the mother to -Mother is educated to
feed her baby every one feed her baby every one
hourly or demand feed hourly or demand feed
also. also.
-Advice the patient to -Patient is advised to
apply hot or cold apply hot or cold
compressions on the compressions on the
breast that helps to breast that helps to
reduce the tenderness. reduce the tenderness.
-Advice the patient for -Patient is advised for
manual expression of manual expression of
remaining milk after remaining milk after
each feed. each feed.
-Educate the patient for -Patient is advised for
use of breast pump use of breast pump
helps to reduce the helps to reduce the
tension in the breast. tension in the breast.
-Administer antibiotics -Antibiotics are
to the patient as administered to the
prescribed by the patient as prescribed by
physician such as the physician such as
Gentamycin. Gentamycin.

4. Anxiety To reduce -Assess the anxiety -Anxiety level of the Anxiety


related to the anxiety level of the patient with patient is assessed with level of the
pain and level of the the help of anxiety the help of anxiety patient is
tenderness. patient. scale. scale. reduced.
-Explain the procedures -Procedures are
to the patient. explained to the patient.
-Provide the -Psychological support
psychological support is provided to the
to the patient. patient.
-Explore the feelings of -Feelings of the patient
the patient. are explored.
-Clear all the doubts of -All the doubts of the
the patient. patient are cleared.
-Provide the -Counselling is
counselling to the provided to the patient
patient regarding regarding complications
complications of breast. of breast.

5. Knowledge To enhance -Assess the knowledge -Knowledge of the Knowledge


deficit related the of the patient regarding patient regarding of the
to knowledge disease condition. disease condition is patient is
breastfeeding of the assessed. enhanced.
process patient. -Advice the patient to -Patient is advised to
support her breast with support her breast with
binders. binders.
-Advice the patient to -Patient is advised to
put her baby on the put her baby on the
breast regularly. breast regularly.
-Advice the patient for -Patient is advised for
manual expression of manual expression of
remaining milk after remaining milk after
each feed. each feed.
-Advice the patient for -Patient is advised for
the use of breast pump the use of breast pump
may help to reduce the may help to reduce the
tension in the breast. tension in the breast.
-Educate the patient for -Patient is advised for
regular follow-up visits. regular follow-up visits.

PROGRESS NOTES

Patient is stable, breast pain and tenderness is relieved. Now, patient is breastfeed her baby
normally. Vital signs are normal but she is having mild pain in stitches. Proper medication and
complete bed rest is taken by patient.
HEALTH EDUCATION

Diet
 Advice regarding fat free diet.
 Advice patient to take protein rich diet.
 Advice to take 3 meals a day and in between snacks.
 Advice patient to take more fluids per orally.
 Advice regarding intake of haematinic and calcium supplement
Exercise

 Avoid heavy exercises after taking meal.


 Educate the patient for postnatal exercises.
Hygiene

 Teach the patient about maintaining proper personal hygiene.


 Educate the patient to clean her perineal area properly after each urination and defecation.
 Educate the patient to change her pad every 8 hourly.
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.
Immunization

 Educate the parents of the newborn about immunization according to the age.

Breast feeding

 Educate the mother about proper breastfeeding technique and its importance.
 Educate the mother to breastfeed her baby every one hourly.
 Ensues that the neonate is awake and alert during feeding.

Follow-up care
Advise the patient for regular medical check-up so that if any complication occurs can be
detected at right time.
 Advise the family that follow-up care is very important and necessary to prevent
complication.
BIBLIOGRAPHY

 Dutta DC. Textbook of obstetrics; Central publisher, 6th ed. 2004.


 Jacob annamma. A comprehensive textbook of midwifery and gynaecological nursing;
Jaypee publisher, 3rd ed. 2012.