Professional Documents
Culture Documents
Antenatal Case
Antenatal Case
Age:-24 years.
W/o:- Imran Gaji
Religion:-Muslim
Address:-Banagram,Bishnupur,South24 pgs.
Gravida:- G1 Parity:- P0 Living:- L0 Abortion:-A0
LMP:- 16/05/21 EDD:-23/02/22
Registration No:-13506
Ward:-Antenatal ward
Bed No:-25
Under:-Dr.M.Mani
Date of admission:-23/02/22
Provisional Diagnosis(on admission):-Postdated
Date of antenanal assessment:-25/02/22
SOCIAL:-
Type of Family:-Nuclear.
Family member:-04 Adult:- 04 Child:-nil
Earning member in the family:-01
Total Family Income:-7000/-per month
Education:- Husband: Madhyamik Wife:-H.S.Passed
Occupation:- Husband:- Business. Wife:- housewife.
Socioeconomic Class:-Lower middle.
Type of house:-Own
Housing:-Pacca.
No of rooms:-02
Ventilation:-Adequate
Sanitation:-Sanitary latrine
Source of drinking water:- Tap water.
Present:-Nothing significant
Nothing significant
:- Non vegetarian.
Breakfast:- Chapati,Mixed veg/puffed rice,egg.
Lunch:-Rice,Dhal,Mixed veg,(Chicken weekly,Fish twice weekly)
Dinner:-Rice,Dhal,Mixed veg.
No. of year Abortion Any Mode of Baby Any problem Remark
pregnancy (with problem delivery (alive/stillbirth during
period) during If C/s then puerperium
antenatal specify
period indication)
P R I M I
R A V
Booked/Unbooked:- Booked.
LMP:- 16/05/21 EDD:-23/02/22
Any problem during:-
1st trimester:-
According to Book:- According to Patient:-
o Tender/swollen breasts Vomiting
o Nausea with or without vomiting Headache
o Increased urination
o Fatigue
o Food cravings and aversions.
o Heartburn
o Constipation
o Amenorrhea/spoting
2nd trimester:-
According to Book:- According to Patient:-
o Growing belly and breasts Growing belly and breast
o Braxton Hicks contraction Braxton hicks contraction
o Skin changes.
o Nasal problems Linea nigra,striae graviderum
o Dizziness
o Leg cramps
o Vaginal discharge
o Urinary tract infections
3rd trimester :-
According to Book:- According to Patient:-
o Sleeping problems Rashes over abdomen
o Strech marks Stretch marks
o Swollen and bleeding gums
o Piles
o Indigestion and heatburn
o Constipation
o Feeling hot
o Vaginal infections
Blood 146
29/01/ 55.6k 11o/68mm gr-o bts/mi
22 g hg positive n
HISTORY REGARDING PRESENT COMPLAINTS:-
Physical Assessment:-
General condition:-good
Gait/Appearance:-normal
Build:-average
Height:-5’3” Weight:-56kg
Vital Signs:-
BP:- 130/80mmhg Temperature:- 98.4 0F Pulse:- 78 bts/min
Respiration:-18 brths/min
Head to Toe Examination:-
Hair and scalp:- Clean
Eyes:- No signs of anemia and jaundice.
Gum:- clean and normal
Dental problem:- nil
Ear:- NAD
Nose:-NAD
Throat:-NAD
Glands:-Not enlarged or palpable.
Chest:-NAD
Heart:-NAD
Liver:-NAD
Spleen:-NAD
Back and Spine:-NAD
Legs:-no sign of edema.
Vericose vein:-nil
Beast:-No crack nipple,abnormal discharge and palpable mass.
BLOOD:-(24/10/21)
Blood for HB:-12.2gm%
Blood Group:- O Rh:-Positive
VDRL:- NR HIV:- NR
HBsAg:- NR
Blood Sugar(fasting):-88mg/dl
Blood Sugar(PPBS):-110mg/dl
TORCH(If done):-Syphillis-NR
STOOL:-
Stool-RE/ME:- Not done
URINE:-
Urine-RE/ME:-Not done.
Urine for sugar:-Nil
Albumin:-Nil
Remarks/Impression:-
MedicalTreatments:-
Inj.Ceftriaxone 1 gm IV BD
Tab.IFA 1 tab OD
Tab calcium 1 tab OD
The care should be started from the beginning of pregnancy and end at the time of delivery.
Aims :-
1.To screen the high risk cases.
4.To educate the mother about the physiology of pregnancy and labour by demonstration,chart
and diagrams.
5.To discuss with the couple about the time,place and mode of delivery,provisionally care of new
born.
6.To motivate the couple about the need of family planning and also appropriate advice to couple
seeking medical termination of pregnancy.
Objectives:-
1. Prevention ,early detection and treatment of pregnancy related complications as
Preeclampsia,eclampsia and hemorrhage.
2. Prevention ,early detection and treatment of medical disorders as anemia and diabetes.
3. Detection of malpresentation,malpositions and disproportion that may influence the
decision of labour.
4. Instruct the pregnant women about hygiene ,diet and warning symptoms.
5. Laboratory studied of parameters may affect the fetus as blood group,toxoplasmosis and
syphilis.
NURSING CARE PROCESS:- Day 2
Nursing Diagnosis Expected Implementation Evaluation
Outcomes
Risk for fluid i.The client remain i.Removed nail polish
volume deficit related normotensive . on fingernails and Risk for fluid volume
to blood loss during ii.The client displays toes. deficit is reduced to
cesarean section,post stable vital ii.Placed a towel or some extent
surgical fluid signs,normal skin wedge under the
restriction. turgor,and client’s hip.
appropriate urine iii.Encouraged the
output. client fluid intake,as
indicated.
Iv.Administered IV
fluid as prescribed.
iv.Maintained intake
Knowledge deficit output chart.
related to cesarean Improve knowledge i.Explained mother Mother’s knowledge
section as evidenced level of mother. about process of is improved .
by cesarean section. Decrease fear and cesarean delivery. Decrease fear and
anxiety of mother. ii.Explained care of anxiety.
newborn after
cesarean delivery.
iii.Taught about
breast feeding to
mother.
iv.Explained about
physical activity after
surgery.