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SUBMITTED TO - Ms. Ashin M Jacob

Submitted by - Ms. Sneha Sehtrawat
MSc Nursing (OBG)
Rufaida College of Nursing


NAME Suman Rani
AGE 27yrs
SEX Female
WARD NO. Gynae Ward
MRD NO. IP0947723
INCOME Rs. 25000/- per month
LANGUAGE KNOWN Hindi and english
ADDRESS 12/9, Sangam Vihar, ND
DIAGNOSIS G2P1L1A0 with Severe Anemia
DATE OF DISCHARGE not discharged yet
INFORMANT Self and mother-in-law

My patient Suman Rani , a 27 yrs old female with POG with G2P1L1A0 with Severe
Anemia POG 35+2 wks & came to gynae OPD on 22.08.2016 with the complaints of
deranged hematology profile, severe pallor, fatigue, activity intolerance, lassitude, anorexia,
indigestion, giddiness, swelling in lower extremities.

No C/o B.P.V, L.P.V, epigastric pain

C/o fainting spells(occasional),lathargy, restlessness, weakness, oedema(ankles).

Her general condition was poor. She looked not adequately hydrated.

On examination- T- 37.2C
P- 88/ min
BP- 130/80 mm/Hg
R- 20/min
RBS stat- 136mg/dl

On Fundal examination- Soft

NTNT ( non-tender, non-tensed)
Liquor adequate
FHS / R/ 144/min

A series of diagnostic tests were carried out and patient was diagnosed & admitted in Gynae
ward under Unit IV.

Mrs Suman Rani W/O Ramesh Kumar lives in a city in her rented house. Water and
electricity facility is adequate and her house is well ventilated. Her house has toilet
constructed. Her husband is the one of earning member the family she live in a joint family.
No pet animals are there in her house.


a) Family composition

S. Name Relations Age Sex Education Occupa-tion Health status

No -hip with

1. Ramesh Husband 33 M Graduated In service Good

Kumar yrs
2. Suman Self 27 F Graduated Tailor Poor
Rani yrs

4. Sakshi Daughter 3 yrs F Preschooler - Healthy&


There are two members in the family except the patient.

b) Family medical history

There is a history of anemia in her sister and maternal grandmother during their
There is so no other significant history of medical illness in the family.


a) Present Obstetric History

My patient Suman Rani , a 27 yrs old female with POG with G2P1L1A0 with Severe
Anemia POG 35+2 wks & came to gynae OPD on 22.08.2016 with the complaints of
deranged hematology profile, severe pallor, fatigue, activity intolerance, lassitude, anorexia,
indigestion, giddiness, swelling in lower extremities.
1st Trimester

The mother had bouts of nausea and vomiting and food craving for fried foods and aversion
for milk and milk products. She had increased urination and fatigue. She also had
unexplained , unanticipated and significant weight loss despite pregnant state but she

2nd Trimester

During the second trimester her nausea subsided but she started feeling pain in the lower
extremities and cramps too. She observed changes in urination pattern, leg cramps and
occasional dizziness. Quickening start at 5th month.

3rd Trimester

During the third trimester she is having increased fatigue, constipation, increased frequency
of micturation and vomiting.She experienced excessive thirst, increased frequency and
volume of urine.

Present Surgical History:

No significant present surgical history.
Menstrual history:

She has regular cycles with duration of 4-5 days. She experiences dysmenorrhea quite
regularly and take over the counter NSAID for it .


Mrs. Suman Rani is a multigravida mother. Admitted with the complains 35wks+2days of

G1 - FTNVD, Female child, Active and healthy

G2 - Present pregnancy, spontaneous conception.

According to her it was her 1st time to be hospitalized even thought she had given birth to
one daughter previously.

b)History of Past Medical Illness

No any significant history of past medical history.
She also has no known allergy of any kind. She never had a serious illness like this before to
be brought to the hospital. She said that she had occasional influenza, dysmenorrheal cramps,
stomachache and headache but worse than those, none.

c) History of Past Surgical Illness

No past surgical history

Personal history
Personal Habits - She is a non-smoker, non-alcoholic female.

Dietary Habits -She is a non-vegetarian.

Sleep and rest -She usually sleeps 8 hours a day which

demonstrates a normal sleeping pattern.

Activities of daily living -She faces difficulty in performing activities of

daily living because of increasing fetal weight,
POG and fatigue.

Elimination -Bowel evacuation once a day which is normal.

Bladder habits -She demonstrates abnormal bladder emptying


Sexual History -No H/O any sexual assualt, sexually

Transmitted disease and sexually transmitted

Drug History -No H/O any previous ongoing treatment expect

History of allergy - No significant previous known H/O any

Hypersensitivity reaction from any drug or

Menstrual history - Regular menstrual cycle of 29 days with 4-5

Days of bleeding, which is normal.
No H/O dysmenorrhea.

Psychiatry history -She is oriented to person, place and time.

Insight and thinking present. No
Significant H/O psychiatric illness given by the
Patient or informant.

Nutritional Status -Breakfast: Banana shake, apple , brown bread

Lunch:2 chapatti, Dal, salad and a bowl of curd
Snacks: Tea and poha.
Dinner:One bowl porridge with milk and
an egg.

Head to toe examination

General Appearance
Nourishment Moderately nourished
Body built Thin
Hygiene & grooming Poor personal hygiene
Activity Partially active
Posture Lethargic and curved posture
Movement Subnormal activity level

Mental status Examination

Consciousness Conscious but confused
Look Anxious and worried,appears to be pale, weak and
Attitude Cooperative but hesitating
Affect and mood Sad
Speech Appropriate, no stammering
Orientation oriented to person,place and time

Vitals signs
Temperature 98.9F
Pulse 98/min
Respiration 22/min
Blood pressure 110/66mm/Hg

Weight & Height

Height 53
Weight 61kgs
BMI 23.91kg/cm2(Normal)

Shape Normal, cephalic
Scalp Dandruff flakes present
Face Acne & chloasma present
Subjective symptoms She is very conscious about acne
marks on her face;dry skin and poor skin turgor.

Texture Dry hairs yet straight
Colour Dark brown
Grooming Clean & plaited
Subjective feelings Patient has no complaints but hair texture is dry.

Eyebrows Normal, symmetrical
Eyelids Normal but dry
Eyelashes Normal
Pupil colour Hazel green
Size 3mm
Reaction to light Reactive pupils to light
Corneal reflex Present
Conjunctiva clear and pink
Lens normal and transparent
Pupil vision Bilaterally symetrical
Extraocculor muscles Normal
Subjective symptoms No subjective complaints

Position Normal
Cerumen cerumen present
Otorrhoea Absent
Subjective complaints No c/o hearing

Response to normal voice tone Normal
Watch tick test Bilaterally ears responding to
Watch tick test
Subjective complaints No subjective complaints
External Symmetrical
Nasal septum Midline; no deviation
Patency of nasal cavity Air passes freely through both
Nostrils as the client was
Frontal and maxillary sinuses Normal
Olfaction Present

Mouth and larynx

Outer lips dry and crackled
Inner lips Pale, moist and smooth
Teeth All present with 2 molar

gums Brown colored and healthy

Tongue Not-hydrated and coated
Palate Normal
Uvula Normal, no inflammation.
Odour of mouth No foul smell
Subjective data No complaints
Movement Range of motion present
Trachea Midline
Lymph nodes Not palpable
Jugular vein Non-distended
Carotid pulse Palpable
Thyroid gland Normal

Transverse diameter It is twice the anterior posterior
Diameter and symmetrical.
Expansion of chest Symmetrical & palpable
Auscultation No crackles
Apical pulse Normal vascular sounds
Breath sounds Normal
Cough Absent
Sputum Absent
Heart S1 , S2 present
Subjective symptoms No subjective symptoms of chest.

Breast & axilla

Symmetry Bilaterally symmetrical.
Areola amd nipples Montogomentory tubercles
Hair distribution Uniform
Discharge Scanty and viscous.
Lesions and masses Absent
Axillary nodes Not palpable.
Condition of breast Normal and healthy.

Appetite Normal
Per-abdomen palpation All findings normal.
Subjective symptoms No subjective symptoms

Colour Pale in colour
Texture Normal
Temperature Warm to touch
Lesions No skin lesions present
Turgor Skin turgor normal
Discoloration Striae gravidarum and linea nigra

Upper extremities
Symmetry Bilaterally symmetrical
Range of motion Range of motion normal
Peripheral pulse Palpable and normal
Reflexes Normal
Edema/swelling Pedal edema present.
Cyanosis Absent
Joints Normal and flexible
Deformity No deformity present.

Lower extremities
Symmetry Bilaterally symmetrical
Range of motion Range of motion normal
Peripheral pulse Palpable and normal
Reflexes Normal
Edema/swelling Pedal edema present.
Cyanosis Absent
Joints Normal and flexible
Deformity No deformity present.

Shape Normal
Texture Normal and smooth
Nail bed colour Pink
Tissue surrounding nails Healthy, no abrasions.
Capillary refill time 3 secs( normal)

Genitals and rectum

Hemorrhoids Absent
Vaginal discharge No abnormal discharge.
Labia majora and minora Healthy and normal.
Diagnostic evaluation and

1. Haemoglobin 7.7gm/dl 13-18gm/dl
2. Total leukocyte count 10800/cumm 4000-11000
3. Neutrophils 69% 45-70
4. Lymphocytes 30% 20-45
5. Eosinophils 01% Upto 6
6. Monocytes 02% 2-10
7. RBC 3.4mill/cumm 4.5-5.4
8. Haematocrit 21.9% 40-54
9. Platelet count 2.66lacs/cumm 1.5-4

2) LFT

10. S. Bil(/total) 0.7mg/dl 0.2-1.0

11. S. Bil (Direct) 0.3mg/dl 0.0-0.2
12. S. Bil(Indirect) 0.4mg/dl 0.2-0.8
13. SGOT 20 IU/L 5-40
14. SGPT 26 IU/L 5-40
15. S. Alk Phosphatase 110 IU/L 25-90
16. AST 32 IU/L 11-30(IU/L)
17. ALT 34 IU/L 6-32(IU/L)
3) KFT

18 Blood urea 48mg/dl 15-45

19. S. Creatinine 1.8mg/dl 0.5-1.4
20. S. Protein 7mg/dl 6-8
21. S. Albumin 2.9mg/dl 3.7-5
22. S. Globulin 3.5mg/dl 1.5-3.0
23. S. Na 148meq/L 136-145
24. S. K 4.1meq/L 3.5-5.4
25. S. C 114meq/L 98-108
26. TSH 1.2Miu/l 0.3-3.04 mIU/L
27. VDRL negative negative
28. HIV negative negative
29. Hbs Ag negative negative

color: yellowish light yellow
ph 5.6 4.5-7.2
reaction acidic acidic
pus cells 6-7 pus cells nil
RBCs 2-3 0-3
epithelial cells trace 0-trace
75-76 >80
urine protein
trace negative
urine ketone
+1 negative

A single live intrauterine pregnancy,

The internal os is closed. The cervical length is normal. Liquor is adequate.

Cardiac activity and fetal movement are present. The FHR is 148 bpm.
The placenta is posteriorly placed. 3.4 cms away from the internal os, Gr 3 maturity. No
incidence of retro/ intra placental bleed is seen. Placental blood flow is reduced and weighs
approx 560gms.

No ROC. Fetal ascities absent.

Impression: Mild placental insufficiency present.


Transfusion of packed red blood cells (RBCs) should be reserved for patients who are
actively bleeding and for patients with a severe and symptomatic anemia. Transfusion is
palliative and should not be used as a substitute for specific therapy. In chronic diseases
associated with anemia of chronic disorders, erythropoietin may be helpful in averting or
reducing transfusions of packed RBCs.
Hemolytic transfusion reactions and transmission of infectious disease are risks of blood
product transfusions. Patients with autoimmune antibodies against RBCs are at greater risk
of a hemolytic transfusion reaction because of difficulty in cross-matching the blood.
Occasionally, the blood of patients with autoimmune hemolytic anemia cannot be
cross-matched in vitro. In these cases, the patients require in vivo cross-matching, in which
incompatible blood is transfused slowly and periodic determinations are made to ensure that
the patient is not developing hemoglobinemia. This method should be used only in patients
with either significant hypoxia from the anemia or evidence of coronary insufficiency.

Iron Supplementation
The appropriate treatment of anemia due to blood loss is correction of the underlying
condition and oral administration of ferrous sulfate until the anemia is corrected and for
several months afterward to ensure that body stores are replete with iron. Relatively few
indications exist for the use of parenteral iron therapy, and blood transfusions should be
reserved for the treatment of shock or hypoxia.
Although the traditional dosage of ferrous sulfate is 325 mg (65 mg of elemental iron) orally
three times a day, lower doses (eg, 15-20 mg of elemental iron daily) may be as effective and
cause fewer side effects. To promote absorption, patients should avoid tea and coffee and
may take vitamin C (500 units) with the iron pill once daily. If ferrous sulfate has
unacceptable side effects, ferrous gluconate, 325 mg daily (35 mg of elemental iron) is a
possible alternative for patients who cannot tolerate ferrous sulfate.

Nutritional Therapy and Dietary Considerations

Nutritional therapy is used to treat deficiencies of iron, vitamin B-12, and folic acid.
Pyridoxine may be useful in the treatment of certain patients with sideroblastic anemia, even
though this is not a deficiency disorder. A strict vegetarian diet requires iron and vitamin
B-12 supplementation.
Iron deficiency anemia is prevalent in geographic locations where little meat is in the diet.
Many of these locations have sufficient dietary inorganic iron to equal the iron content in
persons residing in countries in which meat is eaten. However, heme iron is more efficiently
absorbed than inorganic food iron. Folic acid deficiency occurs among people who consume
few leafy vegetables.
Management of Aplastic Disorders
Treatment of aplastic disorders includes removal of the offending agent whenever it can be
identified, supportive therapy for the anemia and thrombocytopenia, and prompt treatment of
infection. Avoid transfusion in patients with a potential bone marrow donor, because
transfusion worsens the probability of cure from transplantation.
As part of supportive therapy, British Committee for Standards in Haematology guidelines
recommend immunosuppression with antithymocyte globulin and cyclosporine as first-line
therapy in the following adult patients.
Patients with severe or very severe aplastic anemia who lack a matched sibling donor (MSD)
Patients with severe or very severe aplastic anemia aged >35-50 years

Activity Restriction
Patients with severe anemia should curtail their activity until the anemia is partially
corrected. Transfusion can often be avoided by ordering bed rest while therapy is initiated
for a patient with correctable anemia (eg, pernicious anemia).

Treatment of anemia in Pregnancy:

- Prophylactic
- Curative Prophylaxis includes
- Avoidance of frequent child birth by proper family planning method.
Dietary prescription: Realistic balanced diet rich in iron and portion like liver, meat, eggs,
green vegetable etc. Adequate treatment should be instituted to eradicate hook worm
infestation, control of dysentery, malaria, nephropathies & excision of bleeding piles. Hb
level should be estimated at the 1st and 30thand finally at 36thweek.

Curative treatment:
- Hospitalisation, if Hb level is below 7.5 gram percent.

General treatment:
- Diet balanced diet rich in protein, vitamins and iron
- Antibiotic for infective focuses,
Specific Therapy as needed:
- Oral,
- Parental,
- Blood transfusion.
Depending on
- Severity of anemia,
- Duration of pregnancy,
- Associate complicating factors

Iron Therapy:
1. Intravenous,
a. Total dose infusion,
b. Multidose infusion,
2. Intramuscular:
- Iron dexran,
- Iron sorbital.

Estimation of total requirement:

0.3 X w ( 100-Hb%) gm of elemental iron + addition of 50%.
Improvement is expected withon 3-4 weeks
In 3rdstage-
- Active management.
Prophylactic antibiotic to prevent infection
- Iron therapy for at least 3 months following delivery.
Risk periods:
- At 30-32 weeks of pregnancy,
- During labor,
- Immediately following delivery

Maternal aspect-
1. If detected early & proper treatment is instituted, anemia improves promptly;
2. Substantial chances of recurrence in next pregnancy,
3. Contributes to about 2-% maternal death in developing countries.
Fetal aspects-
- Baby born at term from severely anemic mother will not be anemic at birth. But there is
little or no reserved iron. So anemia develops at neonatal period Preterm labour,
- lBw(low Birth weight),
- IUD (Intra-Uterine death)

he most common anemia in pregnancy is called Iron deficiency anemia, which can be simply
described as a condition which is presented with a decrease in hemoglobin and oxygen
transport. Its etiology may vary but may be sometimes due to an anemic state, heavy
menstrual periods and poor nutritional intake prior to pregnancy. It can be suspected when
the hemoglobin level is below 11 mg/dl. Furthermore, it is characterized with a small-sized
RBC and a reduced hemoglobin level than the average cell count. The mean corpuscular
volume and the mean corpuscular hemoglobin are both observed to be low in this type of
anemia. Thus, it is associated with low birth weight and premature delivery.
Megaloblastic anemia or folic acid deficiency is defined as a disorder in the RBC production
in which the red cells fails to divide and become enlarged. Folic acid is very important in the
synthesis of nucleic acid which is also required for the production of red blood cells. During
pregnancy, a woman needed more folic acid than ever before.Its complications may
correspond to adverse defects in fetal development and also for early abortion and abruption

Proper timing, dosage, and knowledge on counteractions of its over-reaction are vital
concepts to be incorporated in the health education.
Along with this, health promotion and disease prevention activities like diet, exercise, and
fetal monitoring are of great importance.
Nursing considerations in general for pregnant clients with
anemia include:

1) Assessment of nutritional intake and status

2) Assess for fatigue, pallor, sore tongue, anorexia, nausea and vomiting, stomatitis, some
signs of infection, and severe pain (due to veno- occlusive crisis )
3) Observe and monitor hematologic laboratory results
4) Encourage client to eat foods high in iron and folic acid like green leafy vegetables, fish,
meat, poultry, eggs, and legumes.
5) Teach how to prepare food in order to minimize the loss of iron and folic acid (steaming
with small amount of water)
6) Encourage to take foods high in Vitamin C for iron absorption
7) Emphasize diet high in fiber and fluids to avoid constipation (side effect of iron intake)
8) Emphasize also good hygiene to avoid urinary tract infection
9) Also instruct client to avoid people with infection, as they may be prone to acquire
infection, too.
10) Teach client to watch out for signs of preterm labor
11) Observe and monitor fetal well being
12)Allow client to rest as much as possible and provide emotional support


History taking on:

a.First presentation of the manifestations of diabetes (3 Ps)

b.First diagnosis of DM
c.Family members with DM

Review of systems:

1.Weight gain, increasing fatigue/weakness/tiredness

2.Skin lesions, infections, hydration, signs of poor wound healing
3.Changes in visionfloaters, halos, blurred vision, dry/burning eyes, cataract, glaucoma
4.Gingivitis, periodontal disease
5.Orthostatic hypotension, cold extremities, weak pedal pulses
6.Diarrhea, constipation, early satiety, bloating, flatulence, hunger and thirst
7.Frequent urination, nocturia, vaginal discharge
8.Numbness and tingling of the extremities, decrease pain and temperature sensation

1. Nutrition
Assess timing and content of meals
Instruct on importance of a well-balanced diet

Explain the importance of exercise

Plan for a weight reduction course

2. Insulin use
Encourage verbalization of feelings
Demonstrate and explain insulin therapy
Allow client to do self-administration
Review mastery of the whole process

3. Injury from hypoglycaemia

Monitor maternal blood glucose level
Instruct on insulin-activity-diet interaction
Teach on the signs and symptoms of hypoglycaemia
Teach/present list of things/foods that need to be available at all times (in cases of
hypoglycaemic attacks)
Have identification band indicating the health condition (DM) for fainting instances

4. Activity tolerance
Plan for regular exercise
Increase carbohydrate intake before exercise
Instruct to avoid exercise if blood glucose level exceeds 250 mg/dL and urine ketones are
Advise to use abdomen for insulin injection if arms and legs are used for exercise

5. Skin integrity
Avoid alcohol use, instead, lotion
Teach on proper foot care
Advise to stop smoking and alcohol use

6. Fetal well-being
Continuous monitoring of fetal activities and fetal heart tone
Monitor fetal activities during maternal activities
Monitor early signs of labor
Advice to report of any discharge coming from the vagina
Monitor daily weight and advice to report on rapid weight gain.

7. Educative
Teach on lifestyle modifications
Advice to see psychologists with other family members for therapy on the possibilities
of fetal abnormalities
Advice to call emergency response team in cases of emergency
Advise to religiously follow health instructions


1.Body weight is within the normal range for the age of gestation.
2.Demonstrates proper technique in self-administration of insulin
3.No episodes of hypoglycemia as claimed by the client
4.No skin problems/lesions
5.Verbalizes readiness on the possible fetal defects.
6. Stable fetal heart rate

Nursing Care Plan for Anemia

Nursing Diagnosis for Anemia

Ineffective Cerebral Tissue Perfusion related to changes in the oxygen bond

with hemoglobin, decrease in hemoglobin concentration in the blood.
Imbalance nutrition less than body requirements related to inadequate food
intake .
Self-care deficit related to weakness
Risk for infection related to inadequate secondary defenses (decreased
hemoglobin )
Activity intolerance related to imbalance between supply and demand of
oxygen .
Impaired gas exchange related to ventilation perfusion .
Ineffectivene breathing pattern related to fatigue .
Fatigue related to anemia .

Nursing Diagnosis for CVA - Stroke: Ineffective Cerebral Tissue Perfusion related to
inadequate cerebral blood supply, occlusive disorder, hemorrhage, cerebral vasospasm,
cerebral edema

Goal: Maintain adequate cerebral tissue perfusion

Evaluation Criteria:
a) Maintain the level of awareness
b) stable vital signs
c) No increase in ICT

a) Monitor / record neurological status
b) Monitor vital signs
c) Evaluation of the pupil, record the size, shape, equality and reaction to light
d) Put the head with a slightly elevated position
e) Maintain a state of bedrest.

Most women who have gestational diabetes deliver healthy babies. However, gestational
diabetes that's not carefully managed can lead to uncontrolled blood sugar levels and cause
problems for you and your baby, including an increased likelihood of needing a C-section to

Complications that may affect your baby

If you have gestational diabetes, your baby may be at increased risk of:

Excessive birth weight. Extra glucose in your bloodstream crosses the placenta,
which triggers your baby's pancreas to make extra insulin. This can cause your baby to
grow too large (macrosomia). Very large babies those that weigh 9 pounds or more
are more likely to become wedged in the birth canal, sustain birth injuries or require a
C-section birth.

Early (preterm) birth and respiratory distress syndrome. A mother's high blood
sugar may increase her risk of early labor and delivering her baby before its due date. Or
her doctor may recommend early delivery because the baby is large.

Babies born early may experience respiratory distress syndrome- A condition that
makes breathing difficult. Babies with this syndrome may need help breathing until their
lungs mature and become stronger. Babies of mothers with gestational diabetes may
experience respiratory distress syndrome even if they're not born early.
Low blood sugar (hypoglycemia). Sometimes babies of mothers with gestational
diabetes develop low blood sugar (hypoglycemia) shortly after birth because their own
insulin production is high. Severe episodes of hypoglycemia may provoke seizures in the
baby. Prompt feedings and sometimes an intravenous glucose solution can return the
baby's blood sugar level to normal.

Type 2 diabetes later in life. Babies of mothers who have gestational diabetes have a
higher risk of developing obesity and type 2 diabetes later in life.
Untreated gestational diabetes can result in a baby's death either before or shortly after

Gestational diabetes may also increase the mother's risk of:

High blood pressure and preeclampsia. Gestational diabetes raises your risk of high
blood pressure, as well as, preeclampsia a serious complication of pregnancy that
causes high blood pressure and other symptoms that can threaten the lives of both mother
and baby.

Future diabetes. If you have gestational diabetes, you're more likely to get it again
during a future pregnancy. You're also more likely to develop type 2 diabetes as you get
older. However, making healthy lifestyle choices such as eating healthy foods and
exercising can help reduce the risk of future type 2 diabetes.

Of those women with a history of gestational diabetes who reach their ideal body
weight after delivery, fewer than 1 in 4 eventually develops type 2 diabetes

1.Dutta .D.C. Textbook of Obstetrics. Sixth edition. 2004. Pg no221-230

2.Marie Elizabeth ,Midwifery for nurses ,2nd edition no. 206-215
3.Diagnosis and management of GDM: an update Judi A Turner Published online 2010 Sep
30. doi: 10.2147/IJWH.S8550 PMCID: PMC2990902.

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