Professional Documents
Culture Documents
FOR
POST-NATAL MOTHER
PATIENT PROFILE:
Age : 28 years
Religion : Hindu
Education : 12th
L.M.P. : 21/9/18
E.D.D. : 28/6/19
ADMISSION HISTORY:
1. On admission complain :
Personal History:
She is vegetarian, non alcoholic, no smoker, have no drug allergy.
Medical History:
Surgical History:
Family History:
Obstetrical History:
Primi gravida
Patient has received three antenatal visits and received both doses of T.T. vaccine.
Primi gravida
Menstrual History: Regular normal flow 3-5 days cycles 26-28 days
2. CONDITION ON ADMISSION;
General examination:
Personal history:
Patient is vegetarian. No history of drug allergy or drug addiction. Absence of any type of substances abuse like smoking, drug and alcohol
etc.
Functional history:
Contraceptive history:
General:-
Weight: 65 kg.
Temperature: 37.4degree C
Pulse: 78/ min.
Respiration: 22/min.
Hydration: Adequate
Anemia: no
Pallor: no
Heart: NAD
Lungs: NAD
4. EXAMINATION:
Lateral Grip : in left lateral Grip felt like a continuous hard, flat surface and irregular small knobs opposite side.
Pelvic Grip : hard round part felt it means presenting part is head and station is 3/5.
On auscultation
Vaginal examination:
Vulva : normal
Vagina : normal
Effacement of Cx : 80%
Membrane : intact
Moulding : ++
Pelvis : adequate
Hb : 10.6gm%
Albumin :Nil
Delivery notes:
Under all aseptic condition patient normally vaginal delivered an alive Fch on 27/6/19 at 11a.m. placenta and membrane complete and intact
delivered. Episiotomy is repaired in back stitches.
Baby notes :
Wt. of 2.8 kg, baby delivered vertex. Cry after suctioning of mouth
posture – flexed.
NEED ASSESSMENT
NEED PROBLEM
Physical need :
psychological need
Main objective :- To bring back the physiological and psychological health of pre pregnant state.
Contributory objectives: -
i. Pain r/t physiological changes and epsiotomy
ii. Anxiety r/t care of baby and breast feeding
iii. Insufficient breast feeding r/t breast problems
iv. Less nutrition then body requirement
v. Knowledge deficit r/t lack of exposure.
vi. Risk of infection r/t inadequate primary defences and invasive procedure
1. Pain r/t physiological To reduce the pain -rest and comfortable positioning. - provide comfortable position – Pain is reduced
changes and left lateral position. some extent.
epsiotomy
-hot water fomentation on wound site - Rest is given 8-10 hours in a
day.
-encourage sitz bath
- Encouraged for sitz bath after
-encourage administer analgesic as reqired.
second day.
2. Anxiety r/t care of To reduce the -encourage variety of position -position like- side lying, semi-fowler, Anxiety is
baby and breast anxiety vary position for each feeding is reduced.
feeding - baby is put on his breast for close bonding. explained.
- family member participation . - encourage the family member to help
-explain how neonates feeding is differ from in baby care.
older infants. - explained about reflexes of neonate.
-discuss about the positioning of breast e.g. rooting, suckling reflex.
feeding. -adequate rest is provided to mother.
3. Insufficient breast To provide effective -to assess the breast feeding . -explain exercise of retracted nipple. Breast feeding
feeding r/t breast breast feeding. will be
problems -to examine the breast for retracted nipple, -prepare a breast pump of syringe. effectively.
breast engorgement and breast abscess.
-empty the breast with breast pump
-to examine the reflexes of the baby.
-checked the rooting and suckling
-examine the temp., colour and consistency of reflex.
breast for breast abscess.
-teach the nipple care –avoid use of
-assess the frequency of breast feeding, soap, use breast cream.
4. Less nutrition then To provide sufficient -teach about extra caloric (450cal.) -give the small and frequent diet in Nutritional
body requirement nutrition. requirement. form of milk, dal, cheese, leafy requirement is
vegetable and fruits. fulfilled.
-explain the importance of nutrition in infant
growth. -liquid diet milk and juices intake
quantity is increased.
-to increase fluid intake to 2500-3000ml.
-calcium and iron is given as
-advice to take one more cup milk or eat supplement diet.
equivalent amount dairy product.
5. Knowledge deficit r/t Her family will -assist parents to meet infant’s basic physical -infant is rooming-in. Infant care is
lack of exposure. accept and needs: accepted by
incorporate infant -infant holding of head and back family.
into family. -encourage rooming in. support is demonstrated.
-holding demonstrate techniques (football, -avoided the tub bath until chord
cradle upright hold) and provision of head and stump is off.
back support. -avoided the wet wiper.
-discuss avoiding of tub bath until umbilical -separately washing infant cloth and
stump is off. linen in practice.
-advice to change diapers before and after -to wear appropriate cloths to infant
feeding . in winter 3-4 layers and in summer 1-
2layers .
-encourage washing infant cloth and linen
separately.
6. Risk of infection r/t Protect from -assess the temperature every 4 hourl y first -temperature is taken with in normal Protected from
inadequate primary infection. day then 6 hrly. limit. infection.
defences and invasive
procedure -assess odour of lochia. -lochia colour is light red and no
odour.
- inspect episiotomy every 8 hourly
-maintained perineal hygiene with
-teach about perineal hygiene. antiseptic solution after every void.
Baby care
7. Hypothermia r/t Protect from -rooming– in. -skin to skin contact maintained with Baby is
immature hypothermia mother. protected from
thermoregulation -keep dry and warm baby. hypothermia.
centre. -wet diaper changed frequently.
-do not wet the baby.
-baby head is covered with cap and
-maintain room temperature.
-proper cover with cloths. hand and feet covered shocks.
8. Risk of infection r/t Protect from -maintain personal hygiene. -use of neat and clean cloths for child. Risk of
poor developed infection. infection is
primary defences. -breast feeding regularly. -change wet and soiled diaper minimised.
frequently.
-assess changes in vital signs.
-wash hands pre and post feeding,
-use universal precaution for prevention of
infection.
HEALTH EDUCATION:
For healthy mother and healthy child mother should be able to:-
1. Educate the mother about importance of colostrum feeding and exclusive breast feeding up to 4-6 moths.
2. Keep the baby clean, dry and warm to avoiding the hypothermia.
3. Educate the mother about rest and sleep to promote psychological support.
4. Explain about the requirement of the additional food supplement and fluid to ensure adequate breast milk.
5. Explain about the danger signs –excessive bleeding, fever, pain abdomen and headache. Danger signs of newborn- child have
fever, child is not suckling well, and the child has difficulty in breathing. If any symptom occurs then come soon to hospital.
6. Regular antenatal visit for evaluation of health of mother and growth –development of infant.
8. Explain about the appropriate position of baby at the time of breast feeding.