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CASE STUDY ON ANEMIA

Date care started : 18.8.15

Date care ended : 28.8.15

Name of the student : Mr…………………

Submitted to : Mr. Manish Sharma

Submitted on : 12/09/2015

I. 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 JK loan hospital, I got a chance to give
nursing care to a patient with severe anemia with IUGR.

II. Nursing history and assessment:

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 striae gravidarum 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.

Patient Profile:
Name of the patient : Mrs. Sudha w/o Mr. Sudhir
Hospital number :
Age : 30years
Sex : Female
Date & Time of Admission : 18.8.15
Diagnosis : G4P1 A2L1 with 38WKS with severe anemia
Date of surgery (if any) : No
Informant : Husband
Chief complaints:
History:
SOCIO-ECONOMIC & CULTURAL DATA

 Housing: My patient Mrs. Sudha lives in a rented house of single room set. There is no
adequate ventilation.
 Occupation & monthly income: Mrs. Sudha is a house wife, but her husband is a driver
working in a private firm. Their monthly income comes about Rs.5000/-
 Literacy: My patient Mrs. is illiterate. Her husband has studied till 10th class.
 Social life & recreational facilities: They are maintaining good communication with
their neighbours and others. There are 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

 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: In their 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: spontaneous abortion at 2 1/2 month 5 yrs back. D & C done.
G2: full term normal vaginal delivery at home. Baby girl 4 yrs old. Active and healthy.
G3: Spontaneous abortion at 3 months 3 years back. D & C done in private clinic.
G4: 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. On 18.05.14 breathlessness was
increased and she came to Ummaid hospital and gets admitted there.

Mile stones& New born reflexes

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

V. MEDICAL PLAN OF TREATMENT (MEDICAL & SURGICAL)

INVESTIGATION DONE:

INVESTIGATION VALUE NORMAL VALUE INFERENCE


INPATIENT
27.03.15
Maternal blood group B+ve
5.08.15 Single live fetus,
USG vertex presentation,
placenta is fundo
posterior grade II,
FHS- 156/min. &
regular, expected
foetal weight= 2.9 kg.
18.8.15
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
20.8.15
Urine routine & Pus cells & RBCs – Within normal
microscopy nil limits
Epithelial cells- 2-3
Nil
Urine albumin Nil
Urine sugar
22.8.15
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

25.8.15
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.

Medications:

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


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.

Surgery: NO

VI. DESCRIPTION OF THE DISEASE:

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.

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
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.
 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.
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.
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.
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 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.

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 on 19.05.14,
20.05.14, and 22.05.14.

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

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.

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.

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.
DATE TREATMENT
18..15 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.

19.8.15 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.

20.8.15 Inj. Monocef 1gm I/V BD


Non stress test.
Transfuse 1 unit blood.

21.8.15 Inj. Lasix 20 mg I/V BD


Inj. Monocef 1 gm I/V BD
Inj. R B Tone 1 amp(50mg) I/V stat.
Watch for fetal movement and fetal heart sound.
Adequate rest.

Same treatment was continued.


22.8.15
23.8.15 Transfuse 1 unit of blood.
USG colour Doppler.
Non stress test.
Watch for uterine contractions.
24.8.15 Induced with cervigel
Watch for uterine contractions.
I/V antibiotics to be continued.
Watch for bleeding p/v
Sterile perineal pad
Inj. Synto 2 u I/V @ 8 drops /mt
Full term normal vaginal delivery with right medio lateral episiotomy.
25.8.15 Post natal management
Cap. Ampclox 500 mg QID
Tab. Brufen 400mg TDS x 3 days
Tab. FS/ BC/ OC 1 tab OD x 6 wks
Exclusive breast feeding to babies till 6 months.
Perineal care
Sterile vulval pad
Watch for bleeding p/v
Take good, adequate nutritious diet
26.8.15 Patient went LAMA as there was nobody in her house to look after her
elder daughter.

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 on
25.02.10 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

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 hospitalisation
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 hospitalisation
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 SUBJECTIVE OBJECTIVE GOAL & IMPLIMENTATION RATIONALE EVALUATION
DIAGNOSIS DATA DATA PLANNING
1 Impaired gas Patient Patient is GOAL: To 22.8.15 22.08.15
exchange complaining of having Air improve the Given oxygen by The gas
related to breathing hunger, gas exchange mask. Immediate exchange
decreased difficulty, taking deep PLANNING: Maintained propped administration improved with
haemoglobin irritability. breaths, not -Give oxygen up position. of oxygen oxygen
level able to talk. by mask. Administered Tab. improves the administration.
-Giving FS BD as prescribed. gas exchange.
propped up Reminded patient to
position. take iron rich diet. To know the 24.08.15
Administering Reminded to avoid patient status.
3 units of tea and calcium tab. Gas exchange is
blood. Along with Tab.FS To increase improved.
Monitor the 23.08.15 the
haemoglobin Assessed the haemoglobin
levels respiratory status. level.
Monitor the Monitor the vital
vital signs. signs. 25.08.15
- comfortable Administered 2 units Deep breathing
position of blood. To improve exercises
- left lateral 24.08.15 the fetal removed the gas
position while Assessed the circulation. exchange
taking rest. haemoglobin level. difficulty.
Reviewed the vital
signs and record it. 26.08.15
Left lateral position Gas exchanging
while taking rest. Gas exchange takes place
25.08.15 become more normally with
Oxygen efficient. out any
administration was difficulty.
given when
necessary.
Taught deep
breathing exercises.
26.08.15
Given comfortable
position.
Propped up position
maintained.
2 Altered Patient is Not taking GOAL: to 21.08.15 21.08.15
nutrition less complaining of food properly improve the Assess the nutritional To know the Nutritional
than body anorexia, nutritional status of mother. pattern of food status is
requirement status of Asked about the likes she used to maintained by
related to mother and dislikes of the take. serving small
anorexia and PLANNING: mother. and frequent
anaemic give iron rich Given iron rich diet. meals.
condition of diet. 22.08.15
mother Small and Served small and 23.08.15
frequent frequent meals. Taking iron rich
meals. Reviewed the likes To increase diet.
Education of the mother. the interest in
about the 23.08.15 food.
intake of Taught importance of
nutritious diet diet in pregnancy.
in pregnancy. Different iron rich
diets are given. To increase 25.08.15
24.08.15 the knowledge Taking normal
Given I/V fluids. diet rich in iron.
25.08.15
Taking normal diet
3 Ineffective Patient is Tachypnoea, GOAL: To 22.08.15 22.08.15
breathing craving for tachycardia, improve the Assessed the To know the Breathing
pattern related oxygen, not breathing respiratory status. patien’s actual difficulty
to dyspnoea able to breath pattern. Monitor the vital condition. relieved with
properly. PLANNING: signs. oxygen
-Checking Administer oxygen administration.
vital signs. via mask.
-Giving 23.08.15
oxygen. Maintained propped To improve 23.08.15
- propped up up position. the gas Breathing
position to Reassessed the vital exchange. difficulty
mother. signs. reduced.
Deep 24.08.15
breathing Maintained left
exercises. lateral position while
taking rest. To improve
Taught deep the
breathing exercises. uteroplacental
25.08.15 circulation.
Assessed heart sound
and lung sounds. 25.08.15
Breathing
normally
without any
difficulty.
4 Anxiety related Asking about Looking very GOAL: To 22.08.15 22.08.15
to outcome of the fetal tensed by the remove the Assessed her level of To know the Anxiety
the pregnancy outcome. facial anxiety. anxiety. level of reduced little
expression, PLANNING: Talk to the patient. anxiety. extent.
biting lips To talk with Given psychological
etc. the patient. support. Talking
Giving 23.08.15 removes some
psychological Clarify her doubts anxiety. 23.08.15
support. about the fetal
Teaching outcome. Clarification of
relaxation Taught relaxation Clearing doubts relieved
techniques. techniques. doubts her anxiety to a
Giving 24.05.14 relieves little extent.
information Educate the mother anxiety.
about the fetal about her condition.
outcome. Practised her
Educating the relaxation 24.08.15
mother about techniques. Anxiety is
her condition 25.08.15 Relaxation decreased.
and its Make her support therapy is the
prognosis. person to include in best method to
her care. reduce 25.08.15
anxiety. Patient fully
relieved out of
Support her anxiety.
persons are
very necessary
to relieve
anxiety of
patient
5 Alteration in Enquiring Patient is GOAL: to 22.08.15 22.08.15
family process about her crying make her Talked with patient Relieving her Patient
related to daughter with thinking family about her family anxiety. understands
hospitalization her husband. about her adjusted to her condition. about her
Asking about elder disease Given psychological family coping.
her condition daughter. condition. support.
of house with PLANNING: 23.08.15
him. Talking with Told her husband to
patient. show her daughter To reduce her 23.08.15
Making once to her. tension about Family cop up
alternate 24.08.15 her child. with her disease
arrangements Talked with support condition.
to look after person to arrange
her child and some alternative Making them 24.08.15
house. person to look after understand Family
her child. how to give members
Reassessed her psychological adjusted with
anxiety level. support to her. her
hospitalisation.

6 knowledge Patient asked Mother is not GOAL: To 24.08.15 Early 16.08.15


deficit related help for take care of increase the Encouraged the attachment of Knowledge
to self care and feeding baby. her baby knowledge mother to feed the baby to breast. increased as
baby care Her facial properly level of the baby in side lying evidenced by
expressions mother position. Maintaining correctly
reveals she regarding Done the breast care. hygiene of the holding the
don’t know parenting, Taught different breast. baby.
how to take baby care and positions to mother To give Knowledge of
care of her self care. for feeding the baby. comfortable the mother
baby. PLANNING: Make the mother position to the increased as she
Teaching aware about the mother. started to take
about importance of giving care of the
Perineal care. colostrum to baby. baby.
Breast care. 25.08.15 Make the baby
Kangaroo Taught the kangaroo warm.
care. mother care Prevent any 25.08.15
Baby care. technique. infection. Baby care was
Importance of To remove the done properly
maintaining good air, which by mother
breast hygiene. went inside indicating of
26.08.15 while feeding. knowledge
Burping of the baby To prevent improvement.
after each feed. breast 26.08.15
Baby should be fed engorgement Mother’s
from both breast. knowledge
increased

7 Risk for Goal: To 23.08.15 To check any 23.08.15


infection prevent Monitor vital signs. signs of There is no
related to infection Assessed the I/V site infection. signs of
anaemia Planning: vital for any signs of Redness, infection .
signs infection. edema or
monitoring. Administer increased 25.08.15
Catheter care. antibiotics. temperature Normal vital
Checking 25.08.15 may indicates sign suggestive
wound/ Maintained strict infection. of infection
surgical aseptic techniques. To prevent control.
incision daily 26.08.15 any ascending
Perineal care given. infection. 27. 08.15
Monitor episiotomy No signs of
wound site for any infection.
signs of infection.
Removed I/V
cannula
27.08.15

FOR BABY
S.NO NURSING SUBJECTIVE OBJECTIVE GOAL & IMPLIMENTATIO RATIONALE EVALUATION
DIAGNOSIS DATA DATA PLANNING N
1 Ineffective Hands and Goal: To make 25.08.15 To prevent heat
thermoregulation feet of the the baby warm. Covered the baby loss. Thermoregulation
R/T minimal baby are cold Planning: properly. Will help the was maintained
clothing mummifying the Keep baby clean baby to
baby. and dry. maintain normal
Keeping baby Put off the fan. body
away from door, 26.08.15 temperature.
window,etc. Checked the vital Vital signs are stable.
Advices on signs of the baby. To know the No signs of
importance of Keep the baby near temperature of hypothermia.
thermoregulation to the mother. baby.
Breast feeding was To provide
given to the baby. warm to baby.
27.08.15
Kangaroo mother
care given to baby. To provide
Regular change of warm as well as 27.08.15
wet nappies. bonding Hands and feet of
Provide appropriate between the baby is warm.
seasonal clothings. mother and
baby.
Reviewed mother’s To keep baby
understanding warm.
about the baby care. No signs of
Encouraged To ensure the hypothermia.
continuation of teachings have Mother keeping the
these practices at been correctly baby warm.
home also perceived.
2 Altered nutrition Baby is Goal: To 25.08.15 25.08.15
less than body crying maintain the Encourage the Breast feeding Breast feeding to
requirement frequently, good nutritional patient to start improves the baby is initiated.
related to poor sucking level. feeding as early as immunity.
sucking. hands. Planning: early possible.
breast feeding to Taught the Colostrum is a
baby. importance of good source of 26.08.15
Education of giving colostrum to immunity. Baby is feeding
importance of baby. Need of the regularly.
breast feeding 26.08.15 baby should be
Feed the baby met. 27.08.15
regularly at Baby is getting breast
frequent intervals. milk.
Exclusive breast
feeding till 6 To give
months. comfortable
27.08.15 position to
Taught different baby.
breast feeding
techniques.
Not to give any
other things to baby
other than breast
milk.
3 Risk for hygiene of Goal: Baby will 25.08.15 25.08.15 25.08.15
infection related the not have any Checked the vital To know the No signs of infection
to decreased surrounding infection. signs of the baby. early signs of
immunity is not Planning: Always wash hands infection.
maintained, monitoring the before touching the To prevent 26.08.15
baby is in vital signs of baby. infection. Baby is warm and
hospital baby. 26.08.15 clean. Infection
Restricting the Keep baby clean 26.08.15 signs are not found.
visitor’s entry. and dry. To prevent
Increasing the Dot mix the baby’s cross infection.
knowledge of clothes with anyone
mother. else’s.
Keep the
surroundings also
clean. 27.08.15
27.08.15 Baby is breast
Breast feed the 27.08.15 feeding properly.
baby. Breast feeding
Limit the number of gives immunity
visitors. to the baby. Infection to baby
is prevented.
Do not hold the
baby in bare hands. As baby’s
Avoid the visit of immunity is
anyone having any less.
infection.
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.

PROGRESS NOTED & PREPARATION FOR DISCHARGE

22.8.15
General condition of the patient is good. Dyspnoea relieved. Haemoglobin level improved with 2
units of blood. Fetal movements are present. Fetal heart sounds are present and regular.
23.8.15
Patient’s condition is fair. Vital signs are stable. No signs of onset of labour. USG colour Doppler
done. Taught relaxation techniques.Taking normal diet.Due medications given. Fetal heart sound
checked and it was regular.
24.8.15
Patient’s general condition is good. Vital signs are stable. Due medications are given. Haemoglobin
levels increased. 1 unit blood was again transfused, so total 3 units of blood already given. No
reactions to blood transfusion found. Patient withstand the procedure well. Health teachings given.
25.8.15
Cervigel was instilled at 9am. Uterine contractions started. Advised to do deep breathing exercises.I /
V fluids on flow. Personal hygiene maintained. Patient getting good uterine contractions and shifted
to labour room.Delivered a baby girl weighing 1.900gm on 25.5.14 at 3.10 pm.
26.8.15
General condition is good. But looking very tired. Vital signs are normal. Perineal care given.
Stitches are healthy. Bleeding per vagina is normal. Breasts are soft and secretory. Feeding is given to
baby. Uterus is well contracted. Personal hygiene is maintained. Bladder functions retained. No
special complaints.
27.8.15
General condition was good. Vital signs are normal. Perineal care given. Stitches are healthy.
Bleeding per vagina is normal.Maintain good personal hygiene. Bowel and bladder functions
retained. Breasts are soft and secretory.Feeding well to the baby. Planning to go on discharge.
Discharge advises given.

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.

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SUMMARY
My patient Mrs. Sudha w/o Mr. Sudhir 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 on 25.8.15 at 3.30 pm a baby girl weighing 1.9 kg by normal vaginal
delivery with right mediolateral episiotomy. Both mother and baby were comfortable and got
discharged on 28.8.15.

CONCLUSION
Anemia 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 iron
supplementation is certainly most important for those pregnant women who develop anemia.

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House Corporation, 1999, page no. 2, 167-169, and 107.

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