SARASWATI COLLEGE OF NURSING

UDAIPUR , RJ

CASE PRESENTATION
ON
PUERPERIAL SEPSIS

Submitted To: Mrs. HariBala

(Associate Professor)
(Head of Deptt.)
OBG

Submitted By: Shabnam Amin

M. Sc. Nursing
(1st year)
 PATIENT'S IDENTIFICATION DATA:
Name of Patient: Mrs. Kirti Sharma
Age / sex: 26yrs / female
Education: Graduate
Occupation: House wife
Blood Group: A +ve
Marital status: Married
Religion: Hindu
Name of Husband: Mr. Kuldeep Sharma
Education: Post Graduate
Occupation: Computer engineer
Total Income: 30,000 per month
Address: Amritsar
Date of admission: 15-10-2023
C.R. No.: 61449
I.P.D. No : 202030113
Obstetrical Score: G-2, P-2, A-0, L-2
Doctor In charge: Dr. Daksha Gupta
Diagnosis: PUERPERIAL SEPSIS

CHIEF COMPLAINTS:
The chief complains of the patient is fever, pus formation at the site of episiotomy and foul
smell from vagina since 1 week.

HISTORY OF PRESENT ILLNESS:

1) MEDICAL HISTORY: Patient has admitted in hospital with the chief complains of
fever, pus formation at the site of episiotomy and foul smell from vagina since 1 week. After
investigations Doctor diagnosed her with PURPERIAL SEPSIS. Now she is under treatment
in PIMS HOSPITAL UDAIPUR...
2) SURGICAL HISTORY: No any significant of present surgical history.

HISTORY OF PAST ILLNESS:

PAST MEDICAL HISTORY: No any significant of past medical history.
PAST SURGICAL HISTORY: No any significant of past surgical history.

FAMILY HISTORY: Patient lives in nuclear family with her husband. All the family
members are good & healthy. No any medical or congenital disorder present in family.

FAMILY MEMBERS:-
S. NAME OF AGE/ RELATIONSHI EDUCATION OCCUPATION HEALTH
NO FAMILY SEX P WITH STATUS
. MEMBERS CLIENT
1. Mr. Kuldeep 30y/M Husband Post graduate Computer Healthy
 Sharma engineer
2. Mrs. Kirti 26y/F Patient Graduate House-wife Unhealthy
Sharma
3. Mr. Akhsit 3y/M Son _ Nothing Healthy
4. Baby Preeti 10 Son _ Nothing Healthy
days/F

FAMILY TREE

Mr. Kuldeep Sharma Mrs. Kirti Sharma

30 yrs old 26 yrs old

Mr. Akshit Baby Preeti

3 yrs old 10 days

Keys:
Male

Female patient

Female

MENSTRUAL HISTORY:
Age of menarche: 13 years
Duration of cycle: 30 days
Number of days: 5-6 days
Flow: Normal
Discomfort during menstruation: Mild Dysmenorrhoea

MARITAL HISTORY:
Age of Marriage: 22 years
Nature of marriage: Arranged marriage

OBSTETRICAL HISTORY:
 S. YEAR Pregnancy LABOUR/ METHOD PUERPERIUM BABY WEIGHT AT
NO. / EVENT Delivery BIRTH/SEX/DURATION OF
DATE BREAST FEEDING
1. 12- About 36 Normal Normal 6 weeks 1) 3 Kg birth weight/
01- weeks vaginal vaginal (Normal) Male baby/ 1 year
2017 delivery delivery breast feeding
(1st) duration
2. 17- 39 weeks 2 Normal Normal Post partum 2) 2.9 Kg birth
02- days (2nd) vaginal hemorrhage weight/Male/breast
2020 delivery feeding started

 Number of living children : 2 Babies

 Health status of babies : Healthy
 Immunization : Partial
 Last Issue : No any last issue

DELIVERY NOTES:
 Type of delivery
 Date of delivery
 Duration of delivery
 Episiotomy if done
: Normal vaginal delivery
: 05-10-2023
: 12 hours approximately
: Medio-lateral episiotomy

SOCIO-ECONOMIC STATUS:
 Type of house : Cemented house
 Number of Rooms : 3 rooms
 Total income per month : 30,000 from all sources
 Latrine facility : Available
 Drainage facility : Good

PERSONAL HISTORY:
 Sleeping pattern
 Diet Habit
 Bowel and bladder Habit
 Allergic to diet
 Personal hygiene
 Amount of water intake
: About 7 hours
: Good (Three times in a day)
: Good
: Not any significant
: Good
:10-12 glasses per day

PHYSICAL EXAMINATION:

GENERAL APPEARANCE:
Nourishment : Well Nourished
Body Build : Good
Health : Unhealthy
Activity : Dull

VITAL SIGNS:
Temperature : 100.2 F
Pulse : 110/min
Respiration : 24/min
B.P :100/60mm (Hg)

MENTAL STATUS:
Consciousness : Conscious
Look : Depressed

POSTURE:
Body curves : Normal
Movement : Allowed

HEIGHT & WEIGHT:

Height : 5’4”
Weight : 60 kg
SKIN CONDITION:
Colour : Fair
Texture : Normal

HEAD:
Hair Colour : Black
Texture of hairs : Rough
Dandruff : Present
Scalp : Clean

EYES:
Eye brows : Symmetrical
Conjunctiva : Normal
Eye Lids : No infection present
Pupillary reaction : Reacting to light
Vision : Normal
Sclera : White

NOSE:
Nasal drainage : Absent
Nostrils : Normal
Epistaxis : Absent

MOUTH:
Lip colour : Pink
Lip Texture : Rough
Teeth : Pale yellow in colour (Normal)
Colour of teeth : Pale yellow
Dental carries : Absent
Gums : No inflammation

TONGUE:
Colour : Pink
Pharynx : Normal

EAR:
Alignment : Normal (Symmetrical)
Discharge : Absent
Hearing : Normal

NECK:
Range of motion : Normal
Lymph nodes : Not palpable
Thyroid glands : Normal, no enlargement

CHEST:
Chest measurement : Normal
Respiratory rate : 24 per minute
Breath sound : Normal, no wheezing sound
Heart sound : S1 and S2 sound present

BREAST:
Shape : Round
Axillary lymph nodes : Not palpable
Nipples : Symmetrical, not cracked and not inverted
Discharge : Adequate
Tenderness : Present
Pain : Present

NAILS:
Shape : Round
Texture : Smooth
Colour : Pink

ABDOMEN:
Inspection:
 Skin colour: Fair
 Linea nigra: Present
  Umblicus: Flattened
 Striae gravidarum: Present
Suture line on lower segment of abdomen is normal without any discharge.

Palpation : Abdominal organs are normal.

Auscultation : Normal bowel sound

BACK:
Back ache : Present
Lesions : Absent

EXTREMITIES:
Deformities : No any deformity present
Edema : Present
Range of motion : Proper
Homan’s sign : Absent

GENITALIA:
Lesions : Absent
Inguinal lymph node : Present
Anal patency : Good
Vaginal discharge : Lochial discharge
Colour of lochia : Red
Odour of lochia : Foul smell, fishy

VITAL SIGNS:

S. VITALS PATIENT NORMAL REMARKS

No VALUE VALUE
1 Temperature 100.2 F 98.6F High
2 Pulse 110/Min 72-80/ Min Tachycardia
3 Respiration 24/min 16-24/ Min Normal
4 B.P 100/60 mm(Hg) 120/80 mm (Hg) Hypotension

INVESTIGATIONS:

S. NO TEST PATIENT VALUE NORMAL VALUE

1. TLC 13,000/cu mm 4-11000/cu mm

2. DLC :
 Polymorph 39% 50-60%
 Neutrophils 43% 40-70%
  Eosinophil 2% 1-6%
 Basophils 1% 0-1%
3. Blood group A +ve -
4. Hb% 11gm 12-16mg/dl
5. Blood sugar R-130mg/dl 70-130mg/dl
6. Serum potassium 3.7 g 3.5-4.5g/day
7. S. Sodium (Na+) 12 g 135-145g/day
8. S. Creatinin 0.4mg/dl 0.2-1.2 mg/dl
9. HIV Negative -
10. HbsAg Negative -
11. Bleeding time 1’-6” min -
12. Clotting time 4’-16” min -

MEDICATIONS:

S.NO DRUG DOSE ROUTE FREQ ACTION

1. Inj. Diclofenac 75mg with I.V SOS Analgesics
1oo ml NS
2. Inj. Novamox 1.2g P.O BD Antibiotic
3. Inj. Ondasteron 4mg I.V TDS Antiemetic
a. Inj. Ranitidine 1amp I.V BD Antacid
4. IV Fluids - - - Caloric agent

HEALTH EDUCATION:
Regarding Diet:
 Instruct the client to take meal thrice in a day.
 Instruct the client to avoid more spicy & fatty food.
 Instruct client to take plenty off fluids.

Regarding Activity:
 Instruct the client to do antenatal exercise.
 Teach the client to take the proper rest & sleep in left lateral position.

Regarding Hygiene:
 Instruct the client to change vaginal pad time to time.
 Instruct the client to take sitz bath.
  Instruct the client & family members to maintain proper personal & environmental
hygiene.
 Teach the client & family members about hand washing methods.

Regarding Treatment:
 Instruct the client to complete her full course of medications.
 Instruct the client about every procedure done on client.

Regarding Follow-up:
 Instruct the client for follow up visits.
 Instruct the woman to notify her health care provider if the experiences respiratory
distress.
 Teach the woman signs of Preterm labor and the need to report them to health care
provider.

SUMMARY:
I have taken the patient Mrs. Jasmeen kaur, 26 years old diagnosed with Puerperial sepsis.
She came in hospital with the chief complaints of fever, pus formation in sutures and foul
smell from vagina since 1 week. Advised is given to take proper rest, nutritious diet and
plenty of fluids.
In this case study, I have presented:-
 Introduction of patient
 Obstetrical history
 Menstrual history
 Personal history
 Physical examination
 Investigations
 Medications
 Disease condition
 Nursing diagnosis and
 Health education
RECAPITULATION:
After this presentation, group will able to give answers to my questions:
 Define Puerperial sepsis?
 Explain causes of Puerperial sepsis?
 What are the sign and symptoms of Puerperial sepsis?
 Explain diagnostic evaluation of Puerperial sepsis?
 What are the managements of Puerperial sepsis?
 Explain its complications?

CONCLUSION
Through this case presentation, group has learned about Puerperial sepsis, its:
 Definition
 Causes
 Clinical manifestations
 Diagnostic evaluations
 Managements
 Complications and
 Nursing management
Now, they have sufficient knowledge about Puerperial sepsis.

BIBLIOGRAPHY:

 Dutta DC “A textbook of obstetrics 6th edition” published by –Hiralal Konar.

 William & Wilkins, Lippincott “A textbook of Manuals of Nursing Practice 9th
edition” published by- Wolters Kluwer.
 Jacob Annamma “A comprehensive textbook of Midwifery and Gynaecological
Nursing” Published by- Jaypee.