INDEX

S.NO CONTENT PAGE NO

STUDENT PROFILE

NAME

COURSE

SUBJECT

NAME OF THE INSTITUTION

PATIENT SELECTED FROM

INTRODUCTION

Mrs……….. got admitted in the era hospital, lucknow on ……………with the complaints of
HISTORY OF PATIENT

IDENTIFICATION DATA

Name

Age

Sex

Bed no

Ipd no

Address

Nationality

Religion

Education

Occupation

Marital status

Family members

Addiction

Diagnosis

Doctor incharge

Source of information

Date of admission

Time of admission

Obstetric score

CHIEF COMPLAINTS

PRESENT HISTORY OF ILLNESS

PAST MEDICAL HISTORY

CHILDHOOD ILLNESS

IMMUNIZATION

MEDICAL HISTORY

PAST SURGICAL HISTORY

PERSONAL HISTORY

Drug addiction

Dietary habits

Sleeping pattern

Nutritional pattern

Exercise pattern

Work pattern

Hygiene

Bowel pattern

Allergies

Hobbies

MENSTRUAL HISTORY

Age of menarche-

Duration of menstruation

Amount of menstruation

Menstrual irregularities

Dysmenorrheal

LMP

EDD

MARITAL HISTORY
 Age of marriage

Type of marriage

Consanguineous marriage

Relationship with husband

No. of children

Any sexual disorder

PAST OBSTETRICAL HISTORY

s.no date and year pregnancy event labor methods of nvd puerperium baby status

HEALTH OF PARENTS/SIBLINGS/SPOUSE/CHILDREN

Parents-

Siblings

Spouse

Children

FAMILY MEMBERS

S.no. Name age Sex Education Health Relationship Death if any

status

FAMILY MEDICAL HISTORY

FAMILY SURGICAL HISTORY

FAMILY TREE

PSYCHOSOCIAL HISTORY

Primary language

Secondary language
House

Type of family

Relationship of patient with family

Mood of patient

Social group of patient

Position of patient in society

Position of patient in family

Socioeconomic status of patient

ENVIRONMENTAL HISTORY

Cleanliness of house

Type of residence area

Village/city/town

Hazards

Pollutant

Water supply

Sanitation

Drainage system

Method of waste disposal

Method of cooking practice

Any epidemic disease

Mode of transportation

Miscellaneous

VITAL SIGN

S.no Vital sign Patient value Normal value Evaluation

1 Temperature 98.60F
2 Pulse 70-80 beats/min
3 Respiration 16-24breath /min
4 Blood pressure 120/80 mm of hg
5 Pain
6 SpO2 95-100%
INVESTIGATION

S.no investigation Patient value Normal value remark

1 CBC-Hb 12-14mg/dl
TLC 4.5-11000/cumm
DLC-Monocytes 2-10%
Neutrophils 40-80%
Lymphocytes 20-40%
Eosinophils 1-2%
Basophils 1-2%
Platelates 1.5-4 lakh
Blood group
2 PT 11-13.5sec.
3 INR 1.1-2 sec.
4 KFT- 0.6-1.2mg/dl
S.Creatinine
5 BUN 7-20 mg/dl
6 Uric acid 2.4-6.0 mg/dl
7 TFT-TSH 0.4-4.0mlIU/L
T3 100-200ng/dl
T4 0.7-1.9ng/dl
8 HbsAg
9 HCV
10 VDRL

ULTRASOUND FINDINGS

MEDICATION

S.No. Medicines Dose Route frequency Action

OTHER SUPPORTIVE THERAPIES

PHYSICAL EXAMINATON

GENERAL APPEARANCE

Look

Orientation

Consciousness

Nourishment
Body built

Height

Weight

Dress

Odour

Hygiene

Speech

Posture

Appearance

Pain

HEAD AND NECK

Scalp

Hair color

Symmetry of head

Shape and size

Dandruff

Pediculosis

Alopecia

Scar/lesions

Headache

Dizziness

FACE

Chloasma

Color

Turgor

Texture

Scar
EYES

Symmetry

Discharge

Eye lashes

Sclera

Conjunctiva

Periorbital oedema

Pallor

Spectacles

Color of iris

NOSE

Epistaxis

Discharge

Polyps

Sinuses

Symmetry

EARS

Pinna

Shape and size

Location

Discharge

Hearing power

Hearing aids

Cerumen impaction

Crust formation

MOUTH

 Lips
Color
 Cracking
Symmetry
Cheilosis
 Mucosa
Hydration
Integrity
 Tongue
Coating
Halitosis
Color
 Teath
Color
Dental caries
Dental infection
Gums
 Neck
Lymphadenopathy
Thyroid enlargement
Range of motion
Lesions
Juglar vein distension

BREAST

 Inspection

Shape

Nipple shape

Primary areola

Secondary areola

Montogmerty tubercles

Dryness

Cracked nipples

Scar formation

 Palpation

Tenderness

Axillary lymph node tail

Enlargement
Masses

Lesion

CHEST

 Inspection

Symmetry

Lesion

Expansion

 Palpation

Respiration rate

Bilateral expansion

Apical pulse

 Percussion

Fluid accumulation

 Auscultation

Wheezing sound

S1 S2 heard

Heart rate

Heart murmur

 ABDOMEN
 Inspection

Size

Abdominal girth

Linea nigra

Striae albicans

Striae gravidarum

Lesion

 Palpation

Fundal grip
Lateral grip

Pelvic grip

Pawlick grip

Uterus

Fundal height

 Percussion

Braxton hicks contraction

 GENITAL AREA
 Palpation

Tenderness

Edema

Hygiene

PV examination

 EXTREMITIES

Range of motion

Pain

Mobilities

Human`s sign

Leg cramps

Muscle strength

Edema

 DELIVERY NOTES
NURSING DIAGNOSIS AND
CARE PLAN
NURSING DIAGNOSIS

1. Acute pain (lower pelvic area)related to episiotomy would as evidenced by verbal

communication.
2. Anxiety related to hospitalization as evidenced by verbal report.
3. Hyperthermia related wound infection as evidenced by increased body temperature and
WBC level.
4. Deficit fluid volume less than body requirement related to vaginal bleeding as evidenced
by decrease urine output.
5. Self care deficit related to episiotomy pain and presence of lochial discharge as evidenced
by poor personal hygiene.
6. Activity intolerance related to imbalance between oxygen supply and demand as
evidenced by low hemoglobin level.
7. Ineffective therapeutic regimen related to improper self care during postnatal period as
evidenced by less ambulation and post natal exercise.

NURSING GOALS

SHORT TERM GOALS

 To reduce pain
 To reduce infection
 To reduce anxiety and discomfort
 To improve condition of patient
 To provide comfort measures to patient
 To maintain hygiene
 To encourage for exclusive breast feeding

LONG TERM GOALS

 To prevent complication.
 To promote early wound healing
 To rehabilitate the patient
 To encourage client for follow up care
NURSING CARE
PLAN
Assessment Nursing Goal Intervention Implementatio Rationale Evaluation
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Objective
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Assessment Nursing Goal Intervention Implementatio Rationale Evaluation

diagnosis n
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Assessment Nursing Goal Intervention Implementatio Rationale Evaluation

diagnosis n
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Assessment Nursing Goal Intervention Implementatio Rationale Evaluation

diagnosis n
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Assessment Nursing Goal Intervention Implementatio Rationale Evaluation

diagnosis n
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Objective
data
OTHER INTERVENTIONS

 Vital signs should be checked daily

 All prescribed medication is given on right time with proper dose
 Intake and output charting is done
 Patient is under close observation
 Psychological support is given.
 Clarify all the doubts of patient.
 Documentation and reporting is done.

PROGRESS REPORT

DAY -1

 Fever reduced
 Vital signs monitored
 IV fluid on flow
 Patient is comfortable

DAY-2

 All investigation are done

 All medications are done
 FHS monitored.
 NVD conducted. Both mother and baby are stable and healthy.

DAY -3

 All blood values are normal

 Fundal height is recorded and reported
 Fluid and electrolyte balance is normal
 Input output record is maintained

DAY -4

 Anxiety is reduced
 Oral diet is allowed
 Bowel movement is normal

HEALTH EDUCATION

MEDICATION

 Educate patient to take medicine on time.

 Iron, folic acid, calcium and vitamin supplements are advised.
 The action and importance of medicines are explained to the patient.
 Follow up is advised
NUTRITIONAL ADVICE

 Advice to take protein and calcium rich diet, like soyabean, pulses, curd, milk.
 Advice to take plenty of fluids
 Advice to take small frequent meals
 Advice to avoid cold beverages.

REGULAR FOLLOW UP

 Advice patient to continue the follow up

 Educate patient about postnatal care
 Advice patient to visit hospital regularly
 Report to consultant on any emergency.

EXCLUSIVE BREAST FEEDING

 Educate patient about exclusive breast feeding techniques.

 Explain about different positions while breast feed the baby.
 Educate mother about feed on demand.
 Explain benefits of breast feeding.