IDENTIFICATION DATA

NAME OF THE PATIENT: Rajjna Akter

AGE: 26 years

RELIGION: Hindu.

MARITAL STATUS: Married

ADDRESS: Bishalghar

ADMISSION/ IN-PATIENT NO: 20230054196

NAME OF WARD: Postnatal ward.

DATE OF ADMISSION: 22/11/23

LAST MENSTRUAL PERIOD

(LMP) : 7/9/22

EDD: 11/6/23

EDUCATIONAL STATUS: Matric Pass

OCCUPATION: Housewife.
PROVISIONAL DIGNOSIS: Pre-eclampsia with PoD1 of LSCS.

CHIEF COMPLAINTS: patient Mrs. Rajina Akter having at the time of admission High
blood pressure x8 month and Labour pain x2 hour.

HISTORY OF PRESENT ILLNESS

Patient is hospitalized in TMC &DR. BRAM TEACHING HOSPITAL. due to labour pain. The patient
noted on and off hypogastric intermittent pain radiating to the lower sacral area. On examination the high
blood pressure is nosed with pisting odena of about 2mm

PAST HISTORY
MEDICAL

-No H/o Hypertension prior to pregnancy .

- No H/o Diabetes Mellitus.
- No H/o Tuberculosis.
SURGICAL: Mothers Having no past significant.

GYNECOLOGICAL: Mothers having no Past Significant.

OBSTETRICAL HISTORY: G2 P1 A0 L1.

FAMILY HISTORY:-

NAME RELATIONS AGE/S MATERI HEALT EDUCATIO

OF HIP EX AL OCCUPATI H| NAL
THE WITH STATUS ON STATU BACKGROU
FAMIL PATIENT S ND
Y
MEMB
ER
Rajjna Pregnant 26 years Married Hose wife Good 12th std pass
Akter Mother
Akram Husband 30 years Married Factory Good B.A Pass
alam worker
Rakhi Daughter 4 years Unmarried No Good student
begam
Sahidul Father in law 60 years Married Retired Good 12 th std pass
islam person

Family History

Sahidul islam
60 years marina
akter

Male
 Female

Death Patient

HEALTH FACILTY NEAR HOME.

Health Center- Hospital
Transport Facility- Bike
Socio-economic Status -Middle class
Housing-Pakka
Number of rooms-2
Water supply-Tap
Family Income per month- Rs 12,000 month
Sanitation –Adequate

PERSONAL HISTORY
Hobbies: watching TV, Cooking Dietary
Habits: Vegetarian
Addiction- No H/o Drug Addiction

PERSONAL HYGIENE:
Oral hygiene : Toothpaste
Mode: brush. 2 time a day
Bath per day frequency-1
Diet: Vegetarian
No. of meals- 3 meals per day.
Food preferences Home made food
Type of food- Panjabi Food
Fluid - 4-5 glasses per day
Tea &coffee -Tea cups day

Sleep & rest her in afternoon/ day/ 7hrs in night day

Elimination
Bowel per day- Regular
Urine frequency- 3-4 times a day Colour pale yellow

Mobility & exercise

Exercise /activity Joints- Moderate
No pain in joint.

Menstrual history-
Age of menarche-12 years
Duration of menstruation: 4-5 days
Amount of menstruation: Normal Flow.

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Dymenorrhea- Present
LMP- 7/9/22
EDD- 11/6/23
POG - 39 week
Marital History
Spouse Health – Good
Spouse occupation- Self –employed.
Substance use –No H/o Substance abuse.
Addiction use- No addiction.

OBSTETRICAL HISTORY:
Sexual history

Any IUD being used method of contraception - No IUD insertion/ Other method-condoms
Dyspareunia: Mild level
Relationship: Satisfactory

PHYSICAL ASSESSMENT
General appearance & behavior: Moderate appearance with normal beight good

behavior Patient is comfortable, cooperative, well oriented 10 TPP Le.

Time place and person.

Vital signs:-
Temperature-98.2°F.
Pulse -110 beats/min
Respiration= 20 breaths/min
Blood Pressure-180/110 mm Hg

Anthropometric Measurement

Anthropometric Actual Expected

Measurement

Weight Gain during pregnancy 68 kg (PREGNANCY) 66-68 kg

57 kg ( Before 3 rd Trimester
Pregnancy)

Height 5, 3, 5’ 6”

Daily fluid requirement 3 liters At least 2.4 liters

Abdominal girth 14 inches 14-15 inches

Fundal height 38 cm 38 cm

Involution of uterus --------- ----------

Immunization Status TT1 – at 2nd month/Dose 0.5ml,I/M

TT2 – at 2nd month/Dose 0.5ml,I/M
Physical Assessment:-
General appearance-
Body Built - Thin
Activity – Dul
Posture-Normal
Pallor- Present
Consciousness - Patient is Conscious
Skin:
Colour-Patient skin colour is pallor.
Moisture-Skin moisture is dry
Texture-Skin texture is dry.
Edema- Edema is absent.
Head:
Hair-Hair colour is black, equally distributed
Scalp-Scalp is clear, dandruff absent.
Face
Anxiousness is present
Eyes
Eye brows-symmetrical
Eye lids- Eye lids is normal,
Eye lashes - Eye lashes is equally distributed
Eye balls- Eye balls is movable
Sclera-Sclera is normal whitish colour
Conjunctiva -conjunctiva is slight white
Pupils - Pupils is react with light
Vision-Normal•
Nose
Nasal Septum- Not deviated
Nostril- Nostril is normal.
EARS
External Ear - Extermal car is normal absent of any discharge.
Gross hearing- Gross hearing normal
Pinna - Pinna is symmetrical.
Discharge - Discharge absent.
MOUTH
Lips- Lips are dry.
Gums-Gums are normal and gingivitis absent
Teeth-Teeth are whitish and equally distributed
Tongue - Tongue are normal but slight white in colour
Throat - Throat are normal.
Neck:
Range of motion-Ronge of motion normal
Thyroid gland-Thyroid gland are not enlarged
Lymph nodes - Lymph nodes are not enlarged
Chest:
Inspection
Shape-chest shape is normal.
Symmetry of expansion Respiration rate - 20b / m –
Breast - Primary and secondary areola present Montgomery tubercles are also present ,nipples are
erected.
Palpation-Absence of any abnormal mass
Auscultation-S1andS2 sound are present
Abdomen:
Inspection:-
Size-Normal
Shape-cylindrical shape
Linea nigra-present
Striae gravidrum - Present
Umbilicus - Protruded.
Scar marks-Absent.
Palpation:
Abdominal girth-80 com
Fundal height-32 cm
Fundal palpation-Broad irregular mass I felt, suggest as buttock of fetus.
Lateral Palpation:
Left Side-Smooth and continuous resistant is feel suggest as back of fetus.
Right Side-Knob like Structure are present Suggest as limbs.
Pelvic Grip- The fetal head is not engaged
Pawlick grip: In the Pawlick grip smooth hand felt, Suggest of fetal head is present in the lower
part of uterus.
Auscultation:
Fetal Heart Sound-130 b/min
Finding of the abdominal Examination
Lie-Longitudinal
Presentation-Cephalic presentation.
Attitude-flexion
Position - LOA
Denominaton-occiput
Extremities:
Upper:
capillary refill - Normal.
Numbness- Absent.
Range of motion-Performed, but dull.
Nails: Nails are clean and short.
Lower:
Range of motion-very dull
Edema-Absent.
varicosity-Absent.
Homan's sign-pain absent.
Back:
Curves- Absent, Lordosis on kyphosis are absent
Genito urinary system:
Discharge- Absent
Bleeding -Absent
Vulva- Normal

VITAL SIGNS & PROGRESS NOTES:

SL NO VITALS DAY -1 DAY-2 DAY-3
1. Temparature 98.6OF 98.6o F 98o F
2. Pulse 110 b/m 90 b/m 80 b/m
3. Respiration 23 b/m 21 b/m 19 b/m
4. Blood 180/110 mm 140/ 80 mm 130/90 mm of
pressure of hg of hg hg

INVESTIGATION :

Lab Test Patients Lab Test Value Normal Value Remarks

Hb 11.5 gm% 12-17 gm% Normal

B.T
1-5 min 1-5 min Normal
CT
4-9 min
4-9 min Normal
TLC
8,600/cumm
4000- Normal
RBS 11000/cumm
89 mgm
VDRL test 80-140 mgm% Normal
NR
SGOT NR Normal
34 Unit/ lit
SGPT 5 to 43 unit/lit Normal
45 Unit/lit
Albumin in urine 7 to 56 unit/lit Abnormal
3+
Nil
Blood Urea
 21 mg/dl 10-50 mg/dl
Blood Creatinine Normal
1.2 mg/dl 0.5-1.4 mg/dl
Bleeding Time Normal
2 min 1-3 min
Normal

SPECIAL INVESTIGATION:
ULTRASOUND: Impression: Alive fetus corresponding 3twerks in cephalic
presentation.

DOPPLER STUDY: FHS is board, 148pm

NST= Not performed

ENDOSCOPY = No performed

PLAN OF TREATMENT

MEDICAL MANAGEMENT

Sl No Name of drug Route/ Dose/ Time Action

1. Inj. Taxim Salt- IV/1 gm/ BD Antibiotics

cefotaxime

2. Inj. genta Salt- IV/80 mg/BD Antibiotics

Gentamiacin

Inj. Diclofenac IM/3ml/T.D.S Analgesic

3. Salt-Diclofenac
Sodium

4. Ringer lactate IV/BD/500ml Parentally fluid

 5. Inj.pantoprazole IV/OD/ 40 mg Antacid

Anatomy & Physiology

The Circulatory (Cardiovascular)

System

The Circulatory System is designed to deliver oxygen and nutrients to all parts of the body and
pick up waste materials and toxins for elimination. This system is made up of the heart, the
veins, the arteries, and the capillaries.

Circulation is achieved by a continuous one-way movement of blood throughout the body. The
network of blood vessels that flow through the body is so extensive that blood flows within close
proximity to almost every cell.

Heart
The heart is a muscular pump that propels blood throughout the body. The heart is located
between the lungs, slightly to the left of center in the chest. The heart is broken down into four
chambers including:

1.The right atrium, which is a chamber which receives oxygen- poor blood from the veins.
2.The right ventricle which pumps the oxygen-poor blood from the right atrium to the lungs.

3.The left atrium which receives the now oxygen-rich blood that is returning from the lungs.

4.The left ventricle, which pumps the oxygenated blood through the arteries to the rest of the
body.

Blood Vessels
Blood vessels are broken down into three groups: the arteries which carry blood out of the heart
to the capillaries, the veins which transport oxygen-poor blood back to the heart, and the
capillaries which transfer oxygen and other nutrients into the cells and removes carbon dioxide
and other metabolic waste from these body tissues.

Blood Pressure
Blood pressure is the force exerted by the blood against the walls of the blood vessels. The
output or direct pumping of the heart and the resistance to blood flow in the vessels determines
blood pressure. Resistance is determined by blood viscosity and by friction.

PATHOPHYSIOLOGY OF PREGNANCY-INDUCED
HYPERTENSION

Vasopasm

Peripheral Arteriole
Vasoconstriction
 Blurring of vison, headache

Blurring of vison, headache

Increased blood pressure

Pregnancy-induced hypertension
(pre-eclampsia)

CLINICAL MANIFASTATION:-

BOOK PICTURE PATIENT PICTURE

1.Headache Nausea/ Vomiting

2. Sweeling Seizures
3. Fetus Distress Fetal Distress
4. Nausea/ Vomiting Headache
5.Sweeling in Extremities
6.Seizure
7.PIH
DIAGNOSTIC EVALUATION:-

BOOK PICTURE PATIENT PICTURE

Blood Test

1.LFT
2. KFT
3.Platelate
4. CBC 4. CBC

Urine test
1.Protein in the Urine Urine test
2. Fetal ultrasound
3. Uric Acid test
MEDICAL MANAGEMENT:-

Sl No Name of drug Route/ Dose/ Action

Time
1. Inj. Labetalol IV/ OD Antihypertensive

2. Inj.Megnesium
sulfate IV/OD Anticonvulsant

3. Inj Methyldopa IV/ BD Antisedation

OBSTETRICAL MANAGEMENT:-

BOOK PICTURE PATIENT PICTURE

General Examination Done

Abdominal Examination Done
Inspection Done
Palpation Done
Auscultation Done
NURSING MANAGEMEN

BOOK PICTURE PATIENT PICTURE

1. Maintain blood pressure Done

2. Assess Fetal Heart Rate Done

3. Send blood & Urine for Testing. Done

4.Take regular medicine. Done

5. Oxygen Administration ( if Done

distress)

ASSESSMENT
1.Assess the patient pain level
2.Assess the nutrition level of the patient
3.Assess the activity level of the patient
4.Assess the breathing pattern of the patient
5.Assess the knowledge level of the patient
6.Assess the sleeping pattern of the patient.
NURSING DIAGNOSIS:-
 1. Risk of developing eclampsia related to severe pre- eclampsia as evidence by BP
of 180/110mmHg measured, a dipstick Proteinuria of 2+, oedema +++, a severe
headache and visual blurring.
2. Excess fluid volume related to increase fluid intake as evidence by edema and
frequency urination.

3. Activity intolerance related to hypertension as evidence by feels dizziness, slight

headache and abdominal pains.

4. Sleep pattern disturbance related to feeling of birth process as evidence by

patient complained that she having irregular sleep.

5. Fear related to hospitalization as evidence by increased tension, increased

systolic blood pressure 183/100mmHg

NURSING CARE PLAN:-

Assessments Diagnosi Goal Intervention Implementation Evaluatio

s n
Subjective Risk of To -Assess the -Assessed the Now her
Data: developi Reduce patient condtion. patient condtion Bp will be
ng the reduce
Patient eclampsi Chronic - Cheeck the vital - Cheecked the (bp-
Verbalized a related Hyperte signs every 2 vital signs 140/90).a
that she is to severe nsion hours as per as every 2 hours nd .her
having pre- and doctors order( as per as some
dizziness, eclampsi other TPR,BP). doctors order( symptoms
blurred a as Sympto TPR,BP). also
vision,Fatigue,evidence mes - Maintain - Maintained reduced.
Headache by BP of also. regular exercise. regular
180/110 exercise.
mmHg -Take rest
Objectives measure atleast 8 hours. -Take rest
Data: d, a atleast 8 hours.
dipstick -Psychological
Her Bp will be Proteinu support to be -Psychological
increased Bp- ria of 2+, given. support to be
180/110 mm oedema given.
of hg +++, a -Administer -Administer
And look like severe Medication as per Medication as
dull headach as doctors order. per as doctors
e and ( Inj. Labrtalol order.
visual iv/od ) .
blurring.

Assessment Diagnosis Goal Intervention Implementa Evaluation

s tion
Subjective Knowled After 1 hour 1.Assess the -To provide 1. Patient
data: ge of Nursing patient including details on was able to
deficient intervention the husband or the areas verbalize
related to the patient relatives about where understand
insufficie will able to understanding of learning is ing of the
nt mk : the disease reuired. disease
informati process by ,precaution
on -Verbalize providing a and
regarding Understandi through possible
Objectives pre- ng of the explanation treatment .
data: eclampsia disease about the
-Insufficient as ,precaution,a disease,
Knowledge evidence nd possible etiology,signs &
about by treatment. symptoms, risk
pre- repetitive -Recognize factors and
eclampsia. requests signs or consequences if
for an symptoms of not controlled.
-Prone for explanati pre- 2.Patient
severe on. eclampsia -Inform the -To aid in was able to
compication that require patient to reportensuring recognize
of pre- medical immediately if that the signs and
eclampsia ( attention . any sings or patient symptoms
eg Seizures symptoms that seeks care of
,Hypertensi indicate as soon as the disease.
on,Kidney worsening of possible and
disorder. the condition potentially
and when to Preventing
contact health pre-
care provider. eclampsia
from
-Instruct the worsening
client to report or causing
any new-onset of further
headaches , problems.
vision,
abnormalities , -These
abdominal signs and
pain,bipedal symptoms
enema ,high indicate
bp,severe severe pre-
dyspnea. eclampsia
which can
proceed to
eclampsia
and help
syndrome
and require
immediate
medical
attention
ROY ADOPTATION THEORY:-

INPUT THROUGH PUT OUT PUT

FOCAL STIMULI PHYSIOLOGIC

MODE
Labour pain
Fluid,respiration,r
CONTEXTUAL Feeling
est and sleep
STIMULI better as
CONTR
SELP CONCEPT before.
-Over crowded ward OL
PROCE Anxiety, stream as Improved
-Absence of family SS knowlrdge
postnatal period
member level.
ROLE FUNCTION
- Patient feeling
uncomfortable Perform role,
,anxiety , knowledge activity of daily
deficit living

RESIDUAL STIMULI INTERDEPENDENC

E
Less IPR with health
staff Dependent of
family member

FEED BACK

NURSING CARE PLAN :(APPLIED ROY ADAPTATION THEORY)

 INPUT CENTRAL EFFECTORS OUTPUT
PROCESS
Focal Coping Physiological Patient feeling
Stumuli Mechanism and fuction: better as before as .
-Labour pain Regulator & -Assess the patient
Contextual Cognator condition as
Stimuli Respiration,fluid
- Over crowded -Reduce the level electrolyte
ward. of Pain. balance,elimination
- Absense of family - Keep silence of habit ,rest & sleep.
Members. the word .
- Other patient with -Family support. Self- Concept Patient Knowledge
same diagnosis but - Reduce the -Anxiety ,stream as level should be
having a low Anxiety Level. Postnatal period increased regarding
prognosis. -Increased the Pre-eclampsia.
- Patient feeling Knowledge level. Role Function
uncomfortable or -Comfortable -Inability to
Anxiety,Knowledge position given to perform daily
Deficit. the patient. activity as walking
,maintening proper
Residual body mechanics &
Stimuli Breast feeding
-Care giver or were personal
Patient maintenance Hygiene etc.
of IPR.
Interdependence
-Depends on family
member

CONCLUSION
• Pre-Eclampsia is a comman complication still associated with high level of
maternal and perinatel mortality as well as morbidity. ANC coverage should be
strengthened to detect pre-eclampsia, and prevent eclampsia. Management in the
hospital should be optimized to prevent recurrent convulsion and complication
after admission.

BIBLIOGRAPHY
1.Dc Dutta's “The textbook of obstetrics” , page no: 230-236.
2., E. malcolm symonds & Ian. m. symonds, Essential obstetrics and gynacology page no: 107-
110.