PROFILE OF THE CLIENT

Name of the mother : Mrs.Jency

Age : 28years

Educational status : 8th std

Occupation : Housewife

Nationality : Christian
Religion : W/o, Stalin
Jonespuram,
Pasumalai, Madurai.

Name of the Husband : Mr. Stalin

Age : 30 years

Educational status : +2

Occupation : Labour in private company

Name of the hospital : Govt.Rajaji Hospital, Madurai

Ward : Antenatal ward

IP No : 0078

LMP : Not known

EDD USG : 30.01.2012

Weeks of gestation : 36weeks

Obstetrical Score : G2 A1

Informant : client

Date of admission : 15.01.2012 at 11.50am

DIAGNOSIS : Pregnancy with Rh-Incompactibility

SOCIOECONOMIC STATUS:

Client is living nuclear family. Her husband is the breadwinner of

the family her monthly income is Rs.6000/- she is living in the rented house,
water supply and electricity facility is adequately present. There is a RCA
latrine facility available. There is no kitchen garden, House is well ventilated.

FAMILY HISTORY:
Name of
S.N The Educational Relationship With Health
Age Sex Occupation
o Family Status Client Status
Members
1. Jency 28 F 8th std housewife client healthy
2. Stalin 30 M +2 husband husband healthy

FAMILY PEDIGREE:

48yrs 52yrs 45yrs

25yrs 28yrs 30yrs 28yrs

Key notes:

- Abortion PP - Male

- Present pregnancy - Female

- Death
Family Medical History:

There is no history of any hereditary diseases like hypertension, asthma

and communicable disease like measles and tuberculosis.

Personal History:

She is moderately built, non vegetarian not having any allergies to any
food, she takes 3 meals per day. She is sleeping 7 hours at night one hour in the
day time. She is practicing good hygiene.

Menstrual History:

She attained menarche at the age of 13years. Her menstrual cycle is 3/28
days

Marital history:

She married one year back Her sexual history is normal and she is not
using any contraceptives. No consanguineous marriage.

Past medical /Surgical History:

There is a nil significance of past medical and surgical illness.

Post obstetrical history:

Mother Baby
Month Abortion
S. Complication Complication
& preterm Type of Se Birth condition Health
No during during
Year / full delivery x wt at birth status
pregnancy puerperium
term
1. 2010 - Abortion - - - - - -

Present medical History:

Admitted for safe confinement

Present obstetrical History

I trimester:

No H/O fever, drug exposure, radiation, H/O vomiting present, No

history of spotting PV, pain abdomen.
II trimester

Quickening felt at 16 weeks of gestation had regular antenatal checkup.

Mild muscle cramps, low back pain

III trimester: Frequency of micturition present.

Lightening: Yes

Fetal movement: Normal and felt

VITAL SIGNS
S.No Vital signs Clients value Normal value Remarks

1. Temperature 98.4o F 98.4o F Normal

2. Pulse rate 88/mt 72-80beats /mt Normal

216 -20 16-20breath Slightly

3. Respiration rate
breath /minute /minute raised

4. Blood pressure 110/80mm/ hg 120/80mm/Hg Normal

 PHYSICAL EXAMINATION

Ht : 148cm Wt : 56kg Gait : Normal

Posture: Lordosis present

General appearance:
Body built - moderate built
Health status - Healthy
Activity - Limited movement

Mental status:

Orientation - Well oriented

Facial expression - Looks anxious.

Head:

Hair - Black in colour, no dandruff

Clean - Clean

Face: Pallor - Not present Oedema - Not present

Chlosma - Not present

Eyes:

Vision - Normal vision Sclera - Normal Conjunctiva - Pallor

Eye lids – Normal. Per orbital oedema - Nil

Ears: Hearing - Normal

Nose: No septal deviation

Mouth

Lips - Normal Tongue - Not coated Palate - Normal Teeth -No dental
carries, Gums - bleeding, Mucosa - Intact
Chest:

Shape - Cylindrical Movement - Symmetry in expansion

Respiration - 22/minute Breath sounds - Hard

Heart beats S1 S2 heard

Extremities upper and lower

Pulsation - Felt both upper and lower limbs, Symmetry -

Oedema - Not present Axilla - No palpable mass or lymph

ROM - Normal

Back

Deformity - Not present, Lordosis - present

OBSTETRICAL EXAMINATION

Breast

Size - enlarged consistency - soft symmetry - yes

Veins - Normal

Areola - Primary, Secondary areola present

Montgomery’s Tubercles - Present, Nipple - protractility

Nodules/ lumps -Not palpable modules or lumps

Axillary nodes -Not present Discoloration - Not present

Perineum

Hygiene - adequately maintaining

Discharge - No discharge, Bleeding - No bleeding

Oedema - Nil Pruritis - Nil Infection - Nil

Abdomen
Inspection
Shape - Over distended or unduely distended abdomen

Size - Pendulous abdomen

Contour - Flunks full present

Skin changes - Linea nigra - present, Striae gravidarum - present

Fetal movements - Present

Palpation

Height of the fundus - 38cm

Abdominal girth - 110cm

Fundal palpation: Soft broad mass felt in upper pole of uterus indicate
fetal buttocks.

Lateral palpation

Left → Irregular nodules felt

Right → Firm resistant continuous mass felt indicates fetal spine

Pelvic palpation

Grip I Hard round mass felt - it denotes vertex presentation.

Converging present

Grip II Head mobile, not engaged

Summary findings
Lie Longitudinal
Attitude Universal flexion
Presentation Vertex
Position Right Occipito Anterior
Engagement Not engaged
Auscultation
FHR 142/mt,
Rhythm regular,
INVESTIGATION:
Name of the
S.No patient value Normal value Remarks
Investigation
Blood glucose
1. 95mgm 80-120mgm Normal
(r)

2. Blood urea 16mg 20-40mgm Normal

Serum
3. 1.0mg <1mg Normal
Creatinine
urine Alb Nil Nil
4. Normal
sug Nil Nil
belong
5. Blood Hb 8.6gm 12-14gm Normal

6. USG Abdomen Dichorionic

Twin both fetus
in longitudinal
presentation
cephatics breech
presentation
concordance
twince 35 weeks
7 Blood grouping B negative
and Rh typing
Subjective data : Mother said that she can’t eat properly aversion to eat
Objective data : As evidenced by refusing the food with was given by the care giver.
Nsg. Diagnosis :Nutrition less than body requirement related in adequate intake of food.
Goal :Maintain adequate intake of balanced diet
PLANNING IMPLEMENTATION RATIONALE EXPECTED OUTCOME
Assess the level of Assessed the nutritional status by Helps to know the
nutritional status. 24hrs recall nutritional demand
and further plan.
Explain the importance Explained need for the growing fetus
of nutrition’s diet & demand To understanding the
need. reason helps to take
Advice the caregiver to Adviced to given in a look warm serve diet adequately.
Maintain adequate intake of a
give frequent and small and frequent
balanced diet after
attractive manner It stimulates appetite
intervention.
Teach to eat high To take green leaf vegetables and dates Provide adequate
calorie, protein, rich and pulses and nuts. calories for mother
high carbohydrate ward fetus to aid in
foods. healing and prevent
wasting (or) los of
fetus well being.
BIBLIOGRAPHY:
1. Annamma Jacob (2008) “A comprehensive textbook of midwifery”
Jiterdar Pvt. Jaypee, 2nd edition.
2. B.T.Basavanthappa, 2006 “Textbook of midwifery and reproduction
health nursing” Jaypee brothers 1st edition
3. Dawn.C.S “Textbook of obstetrics and neonatology” Dawn Books
Calcutta
4. Lowder Milk Permy 008, “Maternity and women’s health care” , 8th
edition.
5. Sadar. A. Orshan, 2008 “Maternity Newborn women’s health nursing”,
Lippincott 1st edition.
6. Adele pillitteri 2003, “Maternal and child health nursing” Lippincott, 4th
edition.
7. J.E.Park 2010, “Preventive and Social medicine” 20th edition,
8. Dutta 2006 “Textbook of obstetrics” 6th edition

NET REFERENCE:
www.google.com
www.wikipedia.com
www.pubmed.com
 College of nursing
Madurai medical college,
Madurai.

Guide & Evaluator

Mrs. R. AMIRTHA GOWRI, M.Sc (N),
Mrs.V.VIJAYALAKSHMI M.Sc (N).,
Faculty in Nursing
College of Nursing
Madurai Medical College
Madurai.
Submitted by
P.REVATHI
M.Sc., (N) II Yr.
INDEX
S.No Page
Contents
. No.
1. Introduction
2. Demographical Data
3. Biological Environmental History
4. Physical Assessment
5. Investigations
6. Treatment
7. Disease condition
8. Time plan
9. Nursing Theories
10. Nursing Diagnoses
12. Conclusion
13. Bibliography
 TIME PLAN

DAILY CARE FOR ANTENATAL MOTHER

From 15.01.2012 to 21.01.2012

DATE TIME CARE PARTICULARS

17.01.201 7am to Introduced myself to the mother and family members

2 8am looking after ward cleanliness doing basic nursing,
Bed making, Vital signs temperature 98.4o F, 86/mt,
24/mt
8am to Carrying out instruction given by the doctor to the
10am mother.
Administering drugs. FST 1od, BCT od, Calcium od
Explaining the reason for hospitalization
10 am to Antenatal assessment done. Health education given
1pm regarding need of rest.
18.01.201 7am to Greeting to the mother
2 8am Ward supervision - cleanliness
Bed making done, vital signs checked Vital signs
temperature 98.4o F, 80/mt, 22/mt
8am to Accompanying with the mother for investigation
10am (USG) Administration of drugs FST 1od, BCT od,
Calcium od
10am to Breast care ginerm and explained the need.
1pm Health education given regarding importance
nutrition’s diet (iron and protein rich)
19.01.201 7am to Bed making done.
2 8am Vital signs temperature 98.4o F, 80/mt, 22/mt
8am to Antenatal assessment done.
10am Explained about DFMC care of newborn
10am to New born
1pm Importance of high calorie intake.
20.01.201 7am to Bed making done Vital signs temperature 98.4o F,
2 8am 86/mt, 22/mt
Administration of drugs.
Caring out order
8 am to Explaining the availability of scientifically advanced
 DATE TIME CARE PARTICULARS

1pm equipments and experts giving psychological support

to the family members.
21.01.201 7am to Bed making done.
2 8am Vital signs temperature 98.4o F, 80/mt, 22/mt
8am to Antenatal assessment done.
10am Explained about DFMC care of newborn
10am to New born (Twin)
1pm Importance of high calorie intake.

NURSING DIAGNOSES
1. Anemia related to hemodilution.
2. Fear and anxiety related to delivery process
3. Ineffective breathing pattern related to compression of grand
uterus along the diaphragm.
4. Nutrition imbalanced less than body requirement related to

inadequate intake of food.

5. Constipation related to decrease bowl mobility.

6. Pain-chronic (back) related to Lordosis
7. Tissue perfusion ineffective related to positioning during sleep.
8. Knowledge deficit regarding postnatal follow up care
9. Risk for transmission of infection related to invasive procedure.

10.Sexuality pattern ineffective related to fear of sexual act.

11.Health seeking behaviour related to interest in maintaining

optimal health during pregnancy.

Subjective Data : Mother said that she feels fear, asking about time of delivery.
Objective Data : Anxious, dull, starring look, repeatedly asking about labour process.
Nursing Diagnosis: Anxiety related to labour process
Goal : To alleviate the fear

Planning Implementation Rationale Evaluation

Assess the level of anxiety level Assesses the level of anxiety by Base line about intervention Mother said
talking to her that she feels
better and
Explained the process of labour Explained the process of delivery Alleviate the fear had confident
Educate the mother reaction during Educate her how to react during Creates awareness to cope up
labour. labour. the situation.

Show her recently delivered Showed her recently delivered For Moral support
mother. mother
INTRODUCTION:

“Prevention is better than cure”, from this proverb, Timely care

is saves the life of both mother and baby.

From that, early care and detection of blood grouping, tying

during pregnancy period it will help to prevent complication and

saves the life of mother and fetus.

So far I have choose this topic and select the patient with Rh

incompatibility for my care study to give comprehensive nursing care.

OBJECTIVES:

 To understand detail about the disease condition.

 To educate the client regarding the care of child.

 To detect complication and take preventive measures.

 To reduce anxiety and fear associated with pregnancy.

 To reduce the maternal and infant mortality and mobility

rate.

 To sensitize the mother to the need of family planning.

 DISEASE CONDITION

Nomenclature:

Land Steiner and weiner in the year 1940, discovered specific unknown
antigen in human red cells. As it was also present in the Rhesus monkey, the
antigen van named Rh. The individual having the antigen is called Rh- positive
and in whom it is not present, it is called Rh-negative.

Meaning:

Rh negative cell group is inherited as a recessive trait a child must inherit

+ve same gene from both parents + 0 show Rh-negativity.

Incidence:

15% of the white population has the Rh-ve factors.

Genotype:

The complete genetic makeup of the Rh blood group of an individual is

its genotype antigen D is the more potent and account for almost all damages.

An individual carrying D on both sets of antigen (DD) is called

homozygous and when carrying only (Dd) in onset, it called heterozygous. The
heterozygous persons are always classified as Rh (-ve)

When the genotype is homozygous half the genes will be incomplete with
the Rh-negative mother and such all the children will be Rh(+ve) and may be
affected by hemocytic disease.

Etiology:

Rh negative mothers

Rh positive father

Rh positive fetus
 Mechanism of antibody formation in the mother (or) Rhesus ISO –
immunization and its presentation

Placental barrier

Rh –negative mother Rh –Postive

fetus

normal placental with no communication between material and fetal flood.

Placenta
Rh –negative mother Rh –Postive

fetus

Fetul cell enter maternal circulation through break in placenta barrier and at
placental separation
Placenta barri
Rh –negative mother Rh –Positive

fetus

Maternal production of Rh antibodies following introduction of Rh +ve blood.

Clinical manifestation:

 Maternal syndrome – The salient feature are generalized edema,

proteinuria, pruritis due to cholestasis.
  Icterus gravis neonatrum
 Congenital anemia
 PPH

Effects on fetus:

Erythroblastosis fetalis

Hydrops fetalis

Kericterus

Investigation:

Book picture Patient picture

Blood grouping Done
Blood typing Done
History collection Done
OSG scan Done
Straight x-ray abdomen -
Antibody detection (Coomb’s test) done
Management:
Antenatal:
During pregnancy all woman have their blood grouped for ABO and Rh
type.

Woman who are Rh –ve are screened for Rh antibodies with an indirect
coomb’s test. In the absence of antibodies the blood is restored at 28 and 34 wks
of pregnancy.

Antenatal prophylaxis at 28 and 34 wks is now being advocated for Rh (-

ve) women with no living children.

If antibodies are found at any stage antibody titres are measured

regularly.
 In addition the fetus is monitored closely by ultrasound for any edema
and hepatomegaly.

The pregnancy may be allowed to continue with ongoing monitoring of

bilirubin and antibody level and fetal status.

Postnatal:

At birth the following tests are performed on the cord flow.

 ABO blood group and Rh type.

 A direct coomb’s test to detect the present of maternal antibodies
on fetal red cells.
 Hemoglobin estimation and serum bilirubin level.
 Infant with Rh is immunized are usually cared for in ICU.
 Aim is to reduce bilirubin level and remove maternal Rh
antibodies from the baby’s circulation.

Complication:

To the mother:

Maternal mortality

Abortion

Anemia

Jaundice

To the fetus:

Erythro blastosis fetalis

Kernicterus
Hemolytic disease
Nursing management:

After admitting the patient reassurance the patient.

 Immediately do the all investigation like blood grouping and Rh typing.

Putting a venflan immediately and regularly adminstered the injection as

prescribed.

To treat anemia, educate the client about iron rich foods and high
nutrition diet.

Administer the B complex and FST and calcium tablets as prescribed to

treat anemia.
SUBJECTIVE DATA: The patient verbalizes that she OBJECTIVE DATA: The patient looks tired, pallor,
has tiredness and fatigue. coated tongue.
NURSING DIAGNOSIS: Anemia related to hemodilution.

GOAL : Improve the Hb level

S.No Plan of action Implementation Rationale Evaluation

1. Establish rapport with the Established rapport Gain co-operation
client client Hb level is
2. Assess the general condition Assessed the head to toe Provide bone line data
improved as
examination
evidenced by
3. Monitor blood Hb% level Monitored Hb% level Know about Hb level
increased Hb
Hb: 9.6 gms
4. Administer vitamin Administered BCT, FST, Maintain/improve Hb count
supplementation with iron Folic acid
5. Instruct to the mother to take Health education given
iron rich food about PN diet
6. Reassess the client Reassessed the client For further plan

SUBJECTIVE DATA: The mother verbalizes that she OBJECTIVE DATA: The mother looks fear,
has fever chill restlessness
NURSING DIAGNOSIS: Risk for infection related to invasive procedure

GOAL : Prevent the trasmitting infection

S.No Plan of action Implementation Rationale Evaluation

1. Assess the general condition Assessed the general Know about patient
condition condition Reduced the
2. Administer anti-D infection as Administered anti-D, Prevent immunoglobulin
risk for
prescribed Inj-Rholine 300mgIn
infection as
3. Provide clean environment Provided clean Prevent infection
evidenced by
environment
4. Provide perineal care Provided perineal care Prevent infection effective
5. Administered antibiotics as Administered antibiotics Provide infection control nursing care.
prescribed as prescribed
6. Reassess the client Reassessed the client For further plan faction
 HEALTH EDUCATION

Regarding diet:

Instruct to the mother, to take highly nutritious food, to drink more fluids.

Regarding exercise:

Educate to the mother about pelvic floor exercise.

Regarding care of baby:

Immunization schedule

Breast feeding

Follow up care

Regarding personal hygiene:

Instruct to the mother, to maintain personal hygiene, perineal hygiene,

breast care.

Regarding medication:

Instruct the mother to take medicine regularly.

Regarding follow-up care:

Educate to the mother to follow up care of both mother and baby.

Conclusion:

By this care study, I came to know about the condition, Rh

incompatibility and gained knowledge regarding the management. I hope that
the client may also gained some knowledge about her condition.

I thanked our madam Mrs. Amritha Gowri M.Sc(N) Tutor ,

Mrs.V.Vijajalakshmi M.Sc(N) Tutor, who guided me throughout my care study.

My sincere thanks goes to my client and her family for their kind co-
operation and support for the completion of my care study successfully.
 DRUG CHART
S.No Dos- Contra Nurse’s
Name of drug Route Frequency Indication Side effect
. age indication responsibility
1. F.S.T 100 Oral 1-2 times a Prophylaxis Haemo Constipatio Client use of
Iron absorbed mg. 1 day and of iron siderosis peptic n gastric antacid and any
in the GI tract od deficiency ulcer enteritis irritation other drugs
through the anemia and ulcerative nausea may interact
mucosal cell colitis abdominal. with their
where it Hemolytic Cramps preparation.
combines with anemia vomiting.
the protein
transferrin.
This complex
is transported
to bone
marrow to
produce Hb.
2. T. Calcium is 500 mg Oral BD/ od Pregnancy, Cancer with GI irritation Monitor for
necessary for per day Acute hypo metastasis constipation calcium level
activation of calcaemia hyperglycaemi watch for
much enzyme tetancy, a ventricular fatigue nausea
reaction and is premature fibrillation vomiting CNS
required for delivery renal disease Depression
rene impulses maternal D.M.
contraction of
cardiac and
skeletal
S.No Dos- Contra Nurse’s
Name of drug Route Frequency Indication Side effect
. age indication responsibility
muscles.
3. Cap. Amoxycillin 500mg. Oral Tds Prophylaxis and GI tract problem GI irritation Watch for
Antibiotic antibiotic constipation fatigue nausea
vomiting CNS
Depression
4. T.Aldomed 250mg. Oral 1 od Hypotension - Hypotension Watch for
Antihypertensive fatigue nausea
vomiting CNS
Depression
5. T.Metronidazole 400mg Oral tds Antimicrobial Nausea vomiting Hypotension Advised to take
Antimicrobial
JEAN BALL – THE DECK – CHAIR THEORY OF MATERNAL
EMOTIONAL WELL BEING:

SUPPORT SYSTEMS FOR MATERNAL WELL BEING

This theory addresses following concepts

1. Women: The focus of ball‘s work concern for individual women and for
their successful emotional, social and psychological development during the
child birth process.

2. Health: Health is central to this model, being seen in the definition of the aim
of postnatal care ‘to enable a woman to be successful in becoming a mother.

3. Environment: The social and organizational environments in the form of

support systems and postnatal care services are importance elements of this
model, support having been shown to be crucial for the well being of the
woman.

4. Midwifery:

In the part the research on postnatal care was motivated by a concern

about the lack of information about the effects of midwifery care on emotional
well being. The model provides guidance on many areas of intervention by
midwives which including patterns of care, support in decisions on feeding
methods, help with feeding and individual care planning.

5. Self:

The theory clearly starts from the stand point that the role of the midwife
is to support and assist the woman to become confident in the role of mother.
 THEORY APPLICATION

RAMONA.T. MERCER THEORY OF ANTEPARTUM STRESS AND

MATERNAL ROLE ATTAINMENT:

The effect of ante partum stress on the family functioning.

On antenatal care there is a concern to provide support during pregnancy

to reduce the effects of poor social circumstances, lack of social support and
poor self esteem among women. Mercer and her colleagues have been seeking
to understand the effects of antenatal stress on family functioning as a whole, on
functioning of pairs of individuals in a family, and on health status.

Mercer et al (1986) identify six variables from research and other

literature which are related to health status, dyadic relationships and family
functioning.

1. Ante partum stress

2. Social support
3. Self esteem
4. Sense of mastery
5. Anxiety and
6. Depression
HEALTH STATUS:
The mothers and fathers perception their prior, health, current health,
health outlooks, resistance - susceptibility to illness health worry concerns,
sickness orientation and rejection of sick role.

Infant health status is defined as the extent of any pathology combined

with the parental rating of the infants overall health.
ANTEPARTUM STRESS:

Resulting from a combination of negative life events and the level of risk
associated with the pregnancy.

The family:

A dynamic system which includes subsystems - individuals (mother,

father, fetus/ infant) and dyads (mother - father, mother - fetus / infant and

father - fetus / infant) within the overall family system.

Within the model it is suggested that variables have either negative or

positive effects on family functioning as indicated in this description of the

model.

Stress from negative life events and pregnancy risk were predicted to

have either direct negative effects on self esteem and health status, self esteem,

health status, and social support were predicted to have direct positive effects on

sense of mastery, sense of mastery was predicted to have direct negative effects

on anxiety and depression which in turn have direct negative effects on family

functioning.
MERCERS MODEL OF RELATIONSHIP BETWEEN ANTEPARTUM STRESS AND FAMILY FUNCTIONING

Self esteem

Negative life events sense of mastery

Anxiety

Pregnancy risk Health status

Family functioning

Child birth risk Parental depression

Competence

Social support