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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.
General Appearance
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
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.
PHYSICAL EXAMINATION
INVESTIGATION DONE:
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:
Surgery: NO
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
CLINICAL FEATURES
The clinical features depend more on the degree of anaemia.
Symptoms:
Signs :
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.
IRON THERAPY
PERENTERAL THERAPY
ORAL THERAPY
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.
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
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.
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.
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.
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.
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.
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.