PATIENT ASSESSMENT

A. History

1. Personal information of the client

Name : Sita Poudel

Date of Birth : Date of birth: 2051-12-15
Sex : Female
Address : Syanja, Bayarghari
Religion : Hindu
Occupation : Housewife
Education : Bachelor
Economic status : Adequate
Marital status : Married
No. of children (if married) : 1 child i.e. Son
Ward/Unit : Maternity ward
Date of Admission : 2074/11/12
Impatient No. : 276541
Diagnosis : G2P1A0@37 WOG with pre/c/s
with Pregnancy induced
hypertension

2. Chief complain in patient own word: Patient says “ I have refer from the
hospital due to blood pressure high and doctor advice to get admission
on hospital for observation and further decide to do c/s or normal
delivery.
3. History of present illness : Blood pressure high ( PIH)
4. Recent treatment history( if any specific): No
5. History of past illness :
Childhood illness: Patient has no any history of childhood illness.

Immunization if applicable: Patient said that she had applied all the
vaccines.

6. History of drug allergy: Patient has no any history of drugs allergy.

7. Previous hospitalization: Patient has hospitalized before 2 yrs. ago
because of her previous delivery
8. History of any chronic illness:

In patient: No any history of chronic illness.

In family: Her father is suffering from hypertension since 6 yrs.

Maternal family: No any history of chronic illness.

Family Tree (mention three generation)

9. Personal history:

10. Mensuration and obstetrics history

Age of menarche: At age of 15 yrs Blood flow: Normal Regularity:

Regular

Associated problem: Abdomen pain and cramps.

Date of last mensuration: 2076/5/1 Abortion history: No any history of

abortion Number of live birth: 1 son

Place of delivery: Hospital

Still birth: No any still birth If menopause, specify age:

11. Dietary habits

Vegetarian/ non vegetarian: Non vegetarian

Types of usual diet: number of meals taken in a day: Normal ( dal,

bhaat , tarkarii for 2 times)

Foods like/ dislike: No any food like and dislikes Food allergy if any: No

any food allergy

12. Elimination history Urine

Colour : Pale yellow Frequency: 5-6 times a day Amount: Normal Stool

Colour: Yellow Consistency: Soft stool Frequency: Once a day

Amount: Normal
13. Personal care habits

Oral care: Twice a day Nail care: Once a week Bath: Thrice

a week

14. Rest habits/ sleep habits in hour Day: 2-3 hrs a day
Night: 6-7 hrs at night

15. Recreational habits: Sleeping and watching movies in

day time.

16. Environmental history

Total no. of family members: 5

Number of room in home: 6 room

Ventilation (adequate/inadequate): Adequate

Separate kitchen: Yes

Type of fuel used in cooking: Gas

Source of drinking water: Jar

Types of toilet used: Sealed

Type of drainage:
17. Health practice: Beliefs in allopathic, homeopathic, Ayurveda rather than
traditional
# Antenatal related

a. Do you know about antenatal check up?

Ans. Yes
b. From where did you know about antenatal check up?
Ans. From community people
c. How many times should a mother visit for antenatal checkup?

Ans. 4 times

d. Why should a pregnant mother do antenatal checkup?

Ans. For better health of mother and to know how is the condition of baby.

e. Where did you go for antenatal check up?

Ans. Regional Hospital

# Postnatal related

a. Where did you delivery your baby?

Ans. At hospital
b. Who was there to help you during delivery?
Ans. Staff nurse
c. Do you know about postnatal visit?
Ans. Yes
d. How many time should a mother visit for postnatal checkup?
Ans. 3 times
e. Did you take capsules vitamin A after delivery? If yes from where.
Ans. Yes from maternity ward on Gandaki Hospital.
f. Have you taken iron capsule during postnatal period?
Ans. Yes

B. Physical examination

• General Inspection

State of consciousness: Patient was alter Gait: Balance

Posture: erect

Nutritional status: Well nourished General build:

Normal

Facial expression: Facial flushing presented Hygienic

state: Well maintained personal hygiene. Speech: A

little hoarseness present

• Measurement

Height: 5.5 feet Weight: 60 kg Body temperature:

Pulse: 82b/m

Respiration: 24 b/m
Blood pressure: 140/90 mm of hg Abdominal girth:
• Examination of Head, Face, and Neck

1. Inspect head for

Shape and size: Normal round shape Color and texture of

head: Black and dry Cleanness: Well maintained Dandruff

pediculosis: Not present Abrasion/Injuries others: Absent

Swelling, Tenderness, Depression: No any swelling,

tenderness, depression.

Mass, nodules: Absent

Inspect and palpate for:

Frontal sinuses: Absent

2. Inspect eyes for:

Swelling of eyelids: No any swelling of eyelids Squint eyes:

Absent
Eyebrows distribution: Normal Eye lashes: Black Discharge: No

any discharge

Color of sclera/conjunctiva: White sclera & pink conjuctiva

Cornea/lens opacity: Transparent

Pupil size / reaction of light: Equals and reactive to light

Eye movements: Equal

Vision problems: No vision problem

Cornel Reflex: Absent

3. Inspect ears for:

Appearance/Location: 1/3 from the outer canthus to eye

Discharge pain, bleeding: No any pain, discharge, and

bleeding. Wax/redness of external auditory canals: Slightly wax

present Hearing problem: No any hearing problems Foreign

body: No any foreign body Palpate ear for:

Lymph node (Periauricular and post auricular): No lymph node

Tenderness (pulling the upper pinna): Absent

Lateralization bone conduction (AC/PC): Air conduction is greater than
bone conduction

Weber test: Equally heard in both ear

4. Inspect nose for

Location, size of nostrils, flaring, foreign body: 1/3 from the outer canthus
to eye.

Discharge: No any discharge Bleeding: No any bleeding

Septal defect /any polyp: No any septal defect and polyp Problem with

smelling: No any problem with smelling Maxillary sinus: No pain palpation

Inspect mouth for:

Color of lips/color of mucous membranes: Pinkish colour of lips

Sores/crack on lips: Absent

Swelling/bleeding/painful gums/ tongue: Absent

Enlargement of tonsils: Absent

Oral hygiene/gag reflex: Hygiene maintained

Palpate for lymph nodes (sub mandibular and sub maxillary): Absent

5. Inspect neck for:

Mobility, stiffness, Enlargement of thyroid gland: No any mobility,
stiffness, enlargement of thyroid gland

Goiter, neck vein: Absent

Palpate neck for:

Lymph nodes: Normal

(Superficial cervical lymph node, superaclavical and subclavical):

Thyroid gland, jugular vein, carotid pulse: Absent

Back of neck (swelling, lump): No any swelling or lump in back of neck

• Examination of chest

1. Inspect chest for:

Size shape (normal, barrel, pigeon, funnel, kyphoscoliosis): Normal

Symmetry, location of Sternum: Normal

Equal movement of chest during breathing: Absent

Difficultly in breathing: Absent

Coughing reflex: Absent

Palpation:

Inspiration is longer than expiration

 Percussion:

Deep resonant sounds was present

2. Auscu Itation chest for

Breathing sound (anterior and posterior): Normal

Normal (vesicular breathing sound, Bronchial breathing sound, Broncho

vesicular sound, tracheal sound):

Abnormal (adventitious, crackles, wheezing, rhochi): Normal breathing

sound

Heart sound (4 areas)

Aortic: Normal

Pulmonic: Normal breathing sound i.e. lubdub Tricuspid: Normal Mitral:

Normal

3. Chest percussion (anterior and posterior)

Palpate chest for

Tenderness, lumps: No any tenderness and lumps

• Examination of breast

Inspect breasts for:

Symmetry, size, swelling: No any swelling Condition

of nipple: Normal Retraction, dimpling, cracks: Absent

Discharge from nipple: Absent Palpate breast for:

Abnormal masses, lump, swelling, tenderness:

Absent

• Examination of Abdomen

Inspect the abdomen for:

Size: Normal at time of pregnancy Shape: Globular

Scars: Striae gravidarum, linea nigra present

Enlarged veins: No any enlarge veins Swelling: No

any swelling

Auscultate for:

Bowel sounds: Normal

Abdominal percussion:

Air/fluid: fluid
Palpate the abdominal for:

Tenderness: Absent Masses: Absent Enlarged liver: Not

palpable Enlarged spleen: Not palpable Kidney: Normal

in size Superficial abdominal reflexes:

• Skin Inspection

Color: Pinkish

Excessive sweating: Sweating present but not

excessive Dehydration: Not present

Hair distribution: Equally distribution all over the body

Patches: Absent Lesion: Absent Edema: Absent

Scar, injury, wound: Birth marks present in lower back

Palpate skin for:

Temperature: 98.7° f

Texture: Smooth, soft

Edema: Absent

• Examination of limb Inspect limbs for

Joint mobility: Tenderness, redness, swelling

Temperature: Normal joint mobility, tenderness and redness not present
and slightly legs are swelling
Texture of skin, elasticity, bone deformity: No bone deformity

Color of nail, sensation, coldness, numbness of fingers, extra digits:

Normal colour of nail and tremors are present on fingers.
Palpate axilla, groin for lymph nodes: Not palpable

Muscle strength: Normal

Co-ordination of movement, brachial radial, ulnar pulse in upper limbs:

Normal

Femoral, popliteal, posterior tibial, dorsal pedis in lower limbs: Normal

• Examination of genital Inspect for:

Color of labia majora, minora, swelling, sore, warts: Normal colour of labia
majora minora, no swelling, sore, warts present
Vaginal discharge: Watery vaginal discharge Perineal hygiene: Well

maintained

• Inspect rectum for

Haemorrhoid, warts, birth marks, prolpase, fistula: Not present

• Reflexes:

Bicep:

Tricep: Normal, all present Knee jerk:

Achilles:

Planter:

• Examination of back

Inspection back for:

Condition of skin (prone to bedsore): Normal

Position of spine, chest movement, symmetrical size: (Absent of spinal
bifida, kyphosis, and normal chest movement)

Finding of examination:

After doing physical examination I came to know that physical general

condition of patient was fair, patient looks well nourished, normal gait
and
posture but facial expression was sad and edema was present.
During physical examination no any abnormalities were found in my
patient.

Baby Identification

Name of mother: Sita Poudel

Name of baby: Baby of Sita Poudel

Sex of baby: Male

Date of birth: 2074/11/23 at 5:00am

Time of birth: 5:00am

Address: Syangja

Gestational age of baby: 37 WOG

APGAR score at 1 min and 5 min: 7/10, 8/10

Weight of baby: 3kg

Neonatal Examination

General measurement:

Head circumference: 33cm Chest circumference: 31cm Head to heel

length: 52cm Birth weight: 3 kg Vital sign

Axiallary temperature: 97.6°F

Heart Rate: 140b/m

Respiration rate: 44b/m General appearance

General state of health: Chearful, good APGAR score Posture: flexion

of head and extremetries Tone: Extremetries flexed and fist cleanched

Skin
Inspection:

• Pinkish in colour.
• Vernix caeseosa is present.
• Lanugo is present.
• Melia is present.
• Mongalian spot was present in back side of buttocks.
• Evidence of injury: Absent
• Temperature: Warmth skin
• Texture: smooth, soft skin
• Edema: Absent
• Dehydration: Absent
1. Head
On Inspection
- Shape and size: Abnormal shape and size due to formation of
caput saccharidenum.
- Hair colour: Black
- Abrasion/Injury: No
 On Palpation

- Fontanel: flat, soft and firm

- Swelling tenderness: No any swelling and tenderness
- Mass/ hodules: No any masses or nodules are found
Note:

- Anterior fontanel was formed by the juction of the sagittal. Coronal

and frontal suture is diamond in shape.
- Posterior fontanel is formed by the juction of the sagittal and lambiold
suture which was triangle is shape.
2. Eye:
On Inspection
- Swelling of eyelid: Present
- Discharge: Not present
- Colour of sclera and conjuctiva: Sclera was white in colour and
conjuctiva was pinkish in colour.
No any anemia and jaundice present.
- Lacrimal duct: Present of tear.
- Nystagmus: Present
- Corneal reflex: Present
- Pupillary reflex: Present
- Blink reflexes: Present
- Glabellar reflex: Present

3. Ear
On Inspection
- Location: 1/3 part ( from outer canthus of ear)
- Discharge, Polyps: Dry wax was present, No any polyps was
present.

On Palpation

- Lymphnode: No any lymph node found in the pre auricle and post
auricle.
4. Nose
On Inspection
- Location: Normal / symmetrical in shape .
- Discharge: No any discharge from nose
- Inflammation of mucous membrane: Absent
- Deviated Nasal septam: Absent
- Flarring of nose: Absent
- Sneezing: Absent
- Nasal cavity: Absent
5. Mouth
On Inspection
- Colour of lips and mucous membrane: Pinkish in colour
- Cracks of lips: Absent
- Decidual teeth: Absent
- Vulva: Midline position
- Cleft lip, cleft palate: Absent

Reflexes
- Sucking reflexes: Present
- Rooting reflexes: Present
- Swallowing reflexes: Present
 Gay reflexes: Present

6. Neck
On Inspection
- Mobility: Normal no any stiffness of neck
- Skin ford: Present
On Palpation

- Enlarged lymph nodes and neck vein: Absent

- Congenital goiter: Absent
- Tonik neck reflexes: Absent
7. Chest
On Inspection
- Shape and size: Normal shape and size
- Location of sternum: Symmetrical located
- Movement of chest: Equal movement during respiration
- Cough: Absent

- Diameter: Anterior posterior diameter is equal with lateral diameter.

On Auscultation
- Heart sound: Normal ( lub-dub sound was present)
- Aortic
- Pulmonic
- Tricuspid
- Mitral area
8. Breast
On Inspection
- Shape and size: Normal

On Palpation

- Abnormal masses: Not present Enlarged

breast: Not present
9. Abdomen
On Inspection
- Shape: flat
- Umbilical hernia: Absent
- Umbilical cord: Normal with 2 arteries and 1
vein
- Redness pus: Not present
On Palpation

- Liver: Palpable
- Spleen: Palpable
- Kidney: Palpable
10. Genitalia
On Inspection
- Shape and size: Normal
- Pus or infection: No any pus or infection
- Urethral opening : Present
- Lump, sore: No any lump or sore
- Phimosis: Absent On Palpation
- Scrotum: Testes palpable in each scrotum.
11. Back and Rectum On Inspection
- Spinal currature: Normal ( No any presence of spinal bifida, vertebral
dislocation)
- Rectum: Anal canal is patent

12. Extremities
- Movement of hand and legs: Normal
- Extra finger( Polydatiles) : Not present
- Nail colour: Pink
- Capillary refill times: Normal times ( 3 second)
- Palmes, platter crease: Present
- Club foot: Not present
- Hip dislocation: Not present
- Fracture: Not present
13. Reflexes
- Grasping reflexes: Present
- Moro reflex: Present
- Ventral suspension: Present
- Traction: Present
14 Nervous system

- Facial palsy: Absent

- Muscle tone: Good
- Any abnormalities: No any

During neonatal Examination findings are as:

 - Caput succedaneum was present
- Milia was not present
- Mongolian spot was present on back
- Eyelid swelling was present and discharge was not present
- Lanugo vernix caseasa is also present other their all finding were
found normal during physical examination of new born.

Conclusion
During the time of neonatal examination I found some abnormality they
are eyelid swelling wax is present in ear. Caput succedaneum is present
and other finding were normal.

Care for mother

Breast care:

Breast care is the care of the breast before and after feeding the baby for
cleanliness purpose as well also detect any abnormal condition.

Purpose

I. To teach the mother about how to clean the breast and nipples.
II. To prevent from breast and nipples disorder during postpartum
period.
III. To stimulate blood circulation of breast.
IV. To provide health teaching about diet, breastfeeding, personal
hygiene & how to care baby etc.
Articles needed while performing breast care:

A tray containing with;

• Bowl of cotton swabs

• Sponge cloths
• Towel
• Kidney tray
• Small makintosh
• One basin with luke warm water
• Jug
• Screen
Advantages of breastfeeding for the baby

• Superior nutrition

. There is an increased resistance to infections, and therefore fewer

incidents of illness and hospitalization

• Decreased risk of allergies and lactose intolerance

• Breast milk is sterile

• Baby experiences less nappy rash and thrush

• Baby is less likely to develop allergies

• Baby experiences fewer stomach upsets and constipation

Breastfed infants tend to have fewer cavities

• Breastfeeding promotes the proper development of baby’s jaw and
teeth.
• Breastfed infants tend to have higher IQs due to good brain
development early in life
• Babies benefit emotionally, because they are held more

• Breastfeeding promotes mother-baby bonding

• In the long term, breastfed babies have a decreased risk of

malnutrition, obesity and heart disease compared to formula fed
babies.
Advantages of breastfeeding for the mother

• The baby's sucking causes a mothers uterus to contract and reduces

the flow of blood after delivery
• During lactation, menstruation ceases, offering a form of contraception

• Mothers who breastfeed tend to lose weight and achieve their

prepregnancy figure more easily than mothers who bottle feed
• Mothers who breastfeed are less likely to develop breast cancer later
in life
• Breastfeeding is more economical than formula feeding

• There are less trips to the doctor and less money is spent on
medications
• Breastfeeding promotes mother-baby bonding

• Hormones released during breast-feeding create feelings of warmth

and calm in the mother
Procedure of breast care;

• Prepare all the articles.

• Explain the procedure to the woman.
• Take articles to the bedside.
• Make the woman sit facing towards you to facilitate comfort and care
while carrying out procedure.
• Privacy should be maintained.
• Expose the breast.
• Examine the breast by inspection a palpation.
• Place the makintosh and towel under breasts.
• Pour water in the breasts, first clean the far side breast from care taker.
• Wash the breast with sponge by using lukewarm water.
• Clean the nipples and remove all the plugs with plain cotton swabs and
prevent blockage of the ducts.
• Check for cracked nipple or engorgement of the breast.
• If there is any engorgement, lift up the breast with one hand and grasp
the areola and compress the area with deep inward movement and
express the milk till the breast is soft.
• Give cold compress to promote comfort and relieve the pain due to
engorgement.
• Dry the breast with towel and put the baby on breast.
• Clean the breasts with wet clothes after feeding and leave small
amount of milk on nipple and dry on air to prevent crack nipple.
• Advice her to wear supportive brassier to prevent over stretching of the
tissue.
 • Make the child and mother
comfortable.
• After cleaning them, replace all
articles.
• Record if there are any abnormalities.
Conclusion:

After performing breast care patient have cracks in nipple before feeding and
provide information about the advantage and disadvantage of breast feeding
and cleanliness of breast after and before feeding.
Perineal Care

Perineal care is care of genital tract and the perineum during or after
delivery, abortion and after an operation of the birth canal or perineum. It
helps to keep the perineum and genital tract clean and provide comfort.

Purposes of perineal care:

• To keep the genital parts clean and provide comfort.

• To keep the stitch clean, dry and help in fast healing.
• To prevent infection and observe the condition of perineal area & stitches.
• To observe the condition of perineal areas and stitches.

Articles required while performing peri care;

Sterile bowl-1

Artery forceps-1
Thumb forceps-1

Sterile kidney tray-1 Chittle forceps with jar

Sterile drum containing sterile pad, cotton and gauze

Dettol or antiseptic solution

Perineal light

Tape measures

Macintosh

Bucket

Screen and bed pen.

Procedure of perineal care;

• Hand wash before setting the equipment.

• Keep the equipment on bedside or in care room.
• Explain the mother about need of pericare, purpose and
procedure.
• Advice the mother to clean the vagina area and empty the bladder in
toilet.
• If the mother cannot walk, we must clean and provide bed pan.
• Keep the mother in dorsal recumbent position.

• Put mackintosh and provide bedpan under buttock.

• Remove pad, observe lochia for types, amount, color, odour and kept
in bucket.
• Wash hand with soap and water.
• From sterile drum, take out necessary amount of cotton, sterile forceps
and keep on sterile bowel and antiseptic solution, wear sterile gloves.
• After that, left hand separates the labia majora and minora and pour
the Dettol solution on upper part of vulva.
• Then clean upward to downward and inner to outer side 1 st centre then
labia minora to majora and last stitches. We must use one cotton at
one time.
• After clean, we must dry with same method special emphasis to dry on
stitch.
• Put vulval pad and remove bed pan.
• Turn mother in lateral position and clean the buttock with sponge cloth
or gauze piece with right hand.
• Keep the mother in comfortable position
• Wash your hands.
• Take fundal height.
• If vulva is swelling and stitches are unhealthy, give perineal light
according to order 10-15 minutes 30 cm distance from vulva to light.
• Explain the mother about the condition of stitch, lochia and
uterus involution.
• Clean the equipment and replace in proper place.
• Recording and reporting properly.

Conculsion

After performing pericare patient complain of discomfort over perineal

,stitches pain before pericare and after she feel comfort and advise her to
wear loose soft under wear and change underwear 2 times a day and wash
perinea area in each voiding .
Care for baby
• Umbilical cord care
• Eye care

Umbilical Cord Care

The cleanliness of the umbilicus and umbilical cord stump thoroughly with
the surgical spirit and clean cotton swabs as soon as the birth to prevent
from infection is called cord care. The cleanliness of cord is essential in the
newborn baby.
Procedure

• Explained the procedure to the mother and visitors and importance of

cord care.
• Prepared all the necessary equipments for the cord care.
• Hand washed before and after handling the cord with soap and water.
• Dry the hands
• Placed the baby in comfortable position and kept in clean environment.
• Inspected the cord for infection and
• Provided teaching to the mother about not let the cord left exposed to
the air because it cause infection and it dries up and falls off much
earlier.
• Provided teaching to the mother to do not put oil, soap or any traditional
method on the umbilical stump.
• Provided teaching about daily cord care with clean cloths stabbed with
spirit and keep it open.
• Make sure to the mother that the cord should not be enclosed within the
baby’s napkin, donot enclosed contamination by urine or faeces.
• Covered the baby umbilicus with clean cloth after the procedure.

EYE CARE:
Cleaning of eyes of newborn after delivery with normal saline, sterile/
boiled
water is known as eye care. It has a certain method,

Procedure:

• Wash the hand properly with soap water.

• Explains the procedure to the mother and its importance, and advise
her to continue this at home.
• while cleaning we should start from inner canthus to outer canthus of
eye.
• One swab is used for only once.
Provided teaching to the mother about the importance of eye care
and informed mother, If eyes are sticky, eye care should be done
twice a day.
Use soft, clean and cotton cloth or cotton.
Don’t rub or press hardly, Use gentle method.
Do not put any eye drops with doctor consultation.