NURSING ASSESSMENT: -
• Patient feels discomfort & verbally explains her pain level.
• Pain level is also assessed by pain scale & verbal expressions.
• Slightly increase in temperature (1000 F)
• Patient feels itching on wound site & feels discomfort.
• Patient feels weakness & decrease in appetite.
• Patient & family members are confuse when I am asking questions.
NURSING DIAGNOSIS: -
Acute pain related to surgical incision as manifested by verbally explaining or discomfortness.
Risk for infection related to hospitalisation as manifested by slightly increase in temperature.
Impaired skin integrity related to improper dressing & vaginal discharge as evidenced by poor hygienic condition.
Imbalanced nutritional status related to anorexia as manifested by fewer intakes.
Deficit knowledge related to postpartum care & newborn care as manifested by poor hygiene condition.
nurses/doctor will insert two lubricated, gloved fingers into your vagina with one hand, while the other hand presses gently on the outside of your lower abdomen. During this part of the exam, your doctor will check the size and shape of your uterus and ovaries, noting any tender areas or unusual growths.
Immediate care involves: Drying the baby with warm towels or cloths, while being placed on the mother's abdomen or in her arms. This mother-child skin-to-skin contact is important to maintain the baby's temperature, encourage bonding and expose the baby to the mother's skin bacteria
Perineal care involves washing the external genitalia and surrounding with soap and water or with water alone or in combination with any commercially prepared peri-wash.
nurses/doctor will insert two lubricated, gloved fingers into your vagina with one hand, while the other hand presses gently on the outside of your lower abdomen. During this part of the exam, your doctor will check the size and shape of your uterus and ovaries, noting any tender areas or unusual growths.
Immediate care involves: Drying the baby with warm towels or cloths, while being placed on the mother's abdomen or in her arms. This mother-child skin-to-skin contact is important to maintain the baby's temperature, encourage bonding and expose the baby to the mother's skin bacteria
Perineal care involves washing the external genitalia and surrounding with soap and water or with water alone or in combination with any commercially prepared peri-wash.
This presentation includes all the events , its sign and symptoms about IOL as well as management of women in the first stage of labor and how to assess the women in labor with the help of partograph.
This slides contain detailed description of radiant warmer used in hospital setting, various modes , alarms, do's and don't of radiant warmer and nursing care management for the baby under radiant warmer
An episiotomy is a cut (incision) through the area between your vaginal opening and your anus. This area is called the perineum. This procedure is done to make your vaginal opening larger for childbirth.
Globally the incidence of unwed mothers is rising.Unwed mothers remain a challenge in obstetric practice due to a complex interplay of obstetric,medical,social and psychological complications associated with them.so ,it is important to know who are unwed mothers,causes and nurses role.
This presentation includes all the events , its sign and symptoms about IOL as well as management of women in the first stage of labor and how to assess the women in labor with the help of partograph.
This slides contain detailed description of radiant warmer used in hospital setting, various modes , alarms, do's and don't of radiant warmer and nursing care management for the baby under radiant warmer
An episiotomy is a cut (incision) through the area between your vaginal opening and your anus. This area is called the perineum. This procedure is done to make your vaginal opening larger for childbirth.
Globally the incidence of unwed mothers is rising.Unwed mothers remain a challenge in obstetric practice due to a complex interplay of obstetric,medical,social and psychological complications associated with them.so ,it is important to know who are unwed mothers,causes and nurses role.
Nursing Process – SAMPLE Nursing DiagnosisNANDA (North American .docxkendalfarrier
Nursing Process – SAMPLE Nursing Diagnosis
NANDA (North American Nursing Diagnosis)
Chronic Painrelated to unknown etiology
as evidenced by self-reports of pain “I feel pain when sitting or lying down mostly at night” using a standardized pain scale, 4/10 on a 0 to 10 numeric rating scale. The patient reports an altered sleep-wake cycle.
Patient Goal/Outcome
Interventions
Rationale for Interventions
Evaluation of Each Goal/Intervention
1)The Patient’s pain will reduce and her sleep will promote by using nonpharmacological methods such as supplements or enhance pharmacological interventions within the next three months.
1a) RN will in addition to administering analgesics, support the client's use of nonpharmacological methods to help
control pain, such as distraction, imagery, relaxation, and application of heat and cold.
1b) RN will ask the client to describe prior experiences with pain, effectiveness of pain management interventions,
responses to analgesic medications (including occurrence of side effects), and concerns about pain and
its treatment (e.g., fear about addiction, worries, anxiety) and informational needs.
1a) Evidence
suggested efficacy and satisfaction when complementary therapies are integrated into pain treatment plans of
older adults (Bruckenthal, 2016 as cited in Ackley et al., 2022, p. 723).
1b) Sleep disturbance and decreased physical activity are adverse
effects of people with chronic pain. In a study of clients with chronic pain, those who participated in a 4 week
multiprofessional program that included psychoeducation and training related to pain, sleep, exercise, and
activity training had improvement in sleep quality and pain intensity (de la Vega, 2019, as cited in Ackley et al., 2022, p. 721).
1a) Goal partially met. Patient’s pain decreased to level 2/10, with relaxation therapy such as meditation and usage of heat pads.
1b) Goal met. Patients starts to drink Valerian root tea and states “It reduced the amount of time takes me to fall asleep and helped me sleep better.”
Health history assignment part 1
Section 1: Biographic Data
N.V is a 46-year-old married Iranian woman, who currently is a full-time financial manager at BMW company. She speaks fluent English and does not require an interpreter.
Section 2: Source of History
The patient provides the information herself. The patient seems reliable, as she is alert and oriented.
Section 3: Reason for Seeking Care
The patient states, “I am really exhausted and want to get rid of my leg pain. I have severe pain in my thighs and legs and it started six years ago.”
Section 4: History of Present Illness (HPI)
The patient’s thigh and leg pain began six years prior to the interview. Her pain started following the birth of her second child. The patient has frequent episodes, the last being three days ago. It has never been resolved. It is specially located in the thighs and .
12SOAP Note Patient with UTIUnited StateEttaBenton28
1
2
SOAP Note Patient with UTI
United State University
FNP xxx: Common Illness Across the Lifespan -Clinical Practicum
Dr. xxxx
SOAP Note Patient with UTI
ID: L.U. a female patient presented to the clinic accompany by self, patient is a reliable historian.
Client’s Initials: L.U
Age :65 years.
Race: African American
Gender: Female
Date of Birth: 08
Insurance: BlueCross BlueShield .
Marital Status: Married
Subjective: “ I have been having pain and burning during urination for two weeks now and the pain goes to my lower abdomen, and I have been unable to hold urine, I now urinate on myself because I can no longer hold it until I get to the bathroom”.
CC: Pain and burning during urination.
HPI:
Patient stated symptoms began within the past two weeks and have worsened over the past seven days. The patient complains of severe pain and burning sensation during urination that radiates to lower abdomen, with urgency. The urine is cloudy and has a foul smell odor. After attempting to pass urine, the pain subsides for a little while, yet it reoccurs. Patient states that she has been sexually active only with the same partner for the past 15 years. On assessment patient reports pain of 8 /10 on pain scale. Patient denies having blood in urine, fever, headache, shortness of breath or chest pain at the moment.
ROS
Constitutional: Patient states she is in good state of health she denies headache , chest pain weakness fever chills, weight loss or gain.
Eyes: Denies double vision, change in vision factors, or blurry vision.
Ears/Nose/Mouth/Throat: denies sore throat, hearing issues, or nose congestion.
Cardiovascular: denies any kind of orthopnea, rapid heart rate, palpitations, or chest pain.
Pulmonary: Denies
Gastrointestinal: c/o moderate to severe pain in the abdominal area.
Genitourinary: acknowledged presence of increase in urgency and frequency of urination. Major pain while urinating for the past ten days.
Musculoskeletal: Denies any kind of pain
Integumentary & breast: Denies issues
Neurological: Denies issues
Psychiatric: Denies any kind of depression or mood swing
Endocrine: Denies having any problem
Hematologic/Lymphatic: Denies
Allergic/Immunologic: No Known allergy
Past Medical History:
· Medical problem list: patient denies having any major illnesses and only reports headaches and sometimes common seasonal allergy or cold.
· Denies history of chronic medical problems with father or mother.
· Preventative care: None indicated
· Surgeries: Denies
· Hospitalizations: Denies
· LMP: Patient states she do have a 28 days menstrual cycle and the last cycle was 2 weeks ago. She has had three pregnancies and three cesarean section.
Allergies: No known food or drug allergy
· Medications: Patient takes only Centrum vitamins and sometimes Tylenol for headache. Family History: Patient’s mother has hypertension that she manages by taking daily medication and exercising. The patient’s father has hypertension too a ...
1
2
SOAP Note Patient with UTI
United State University
FNP xxx: Common Illness Across the Lifespan -Clinical Practicum
Dr. xxxx
SOAP Note Patient with UTI
ID: L.U. a female patient presented to the clinic accompany by self, patient is a reliable historian.
Client’s Initials: L.U
Age :65 years.
Race: African American
Gender: Female
Date of Birth: 08
Insurance: BlueCross BlueShield .
Marital Status: Married
Subjective: “ I have been having pain and burning during urination for two weeks now and the pain goes to my lower abdomen, and I have been unable to hold urine, I now urinate on myself because I can no longer hold it until I get to the bathroom”.
CC: Pain and burning during urination.
HPI:
Patient stated symptoms began within the past two weeks and have worsened over the past seven days. The patient complains of severe pain and burning sensation during urination that radiates to lower abdomen, with urgency. The urine is cloudy and has a foul smell odor. After attempting to pass urine, the pain subsides for a little while, yet it reoccurs. Patient states that she has been sexually active only with the same partner for the past 15 years. On assessment patient reports pain of 8 /10 on pain scale. Patient denies having blood in urine, fever, headache, shortness of breath or chest pain at the moment.
ROS
Constitutional: Patient states she is in good state of health she denies headache , chest pain weakness fever chills, weight loss or gain.
Eyes: Denies double vision, change in vision factors, or blurry vision.
Ears/Nose/Mouth/Throat: denies sore throat, hearing issues, or nose congestion.
Cardiovascular: denies any kind of orthopnea, rapid heart rate, palpitations, or chest pain.
Pulmonary: Denies
Gastrointestinal: c/o moderate to severe pain in the abdominal area.
Genitourinary: acknowledged presence of increase in urgency and frequency of urination. Major pain while urinating for the past ten days.
Musculoskeletal: Denies any kind of pain
Integumentary & breast: Denies issues
Neurological: Denies issues
Psychiatric: Denies any kind of depression or mood swing
Endocrine: Denies having any problem
Hematologic/Lymphatic: Denies
Allergic/Immunologic: No Known allergy
Past Medical History:
· Medical problem list: patient denies having any major illnesses and only reports headaches and sometimes common seasonal allergy or cold.
· Denies history of chronic medical problems with father or mother.
· Preventative care: None indicated
· Surgeries: Denies
· Hospitalizations: Denies
· LMP: Patient states she do have a 28 days menstrual cycle and the last cycle was 2 weeks ago. She has had three pregnancies and three cesarean section.
Allergies: No known food or drug allergy
· Medications: Patient takes only Centrum vitamins and sometimes Tylenol for headache. Family History: Patient’s mother has hypertension that she manages by taking daily medication and exercising. The patient’s father has hypertension too a ...
1[Shortened Title up to 50 Characters]16Week 9 Assignment.docxhallettfaustina
1
[Shortened Title up to 50 Characters] 16Week 9 Assignment
Bethel U. Godwins
Walden University
NURS 6551, Section 8, Primary Care of Women
July 31, 2016
Abnormal Uterine Bleeding
Society for Reproductive Endocrinology and Infertility (SREI, 2012) described abnormal uterine bleeding as bleeding that differs in quality and quantity from normal menstrual bleeding, such as women spotting or bleeding between the women’s menstrual periods; bleeding after sex; bleeding heavier or last more days than normal; and bleeding post menopause. According to SREI (2012), factors that can cause abnormal bleeding include structural abnormalities of the reproductive system, such as uterine polyps, fibroids, and adenomyosis. Furthermore, SREI (2012) explained that vaginal, uterine or cervical lesions, miscarriage, ectopic pregnancy, endometritis, adhesions in the endometrium, and use of an intrauterine device (IUD) can also cause abnormal bleeding. Johns Hopkins Medicine (2016) specified that early recognition of abnormal bleeding, and seeing a health care provider immediately for appropriate diagnosis and treatment increase the chance of successful treatment. Therefore, the author will focus on a single patient comprehensive evaluation, which includes the patient’s personal/health history; physical examination; laboratory/diagnostic tests; diagnosis; treatment/management plan; education strategies; and follow-up care. Comment by DeAllen B Millender: Good introduction.
General Patient Information
Age: 41-year-old
Race/Ethnicity: Hispanic American
Partner Status: Married Comment by DeAllen B Millender: This information is not in APA format.
Current Health Status
Chief Complaint: “I have heavy, prolonged menstrual bleeding with severe cramping for the past one year”.
History of Present Illness (HPI): RG is a 41-year-old Hispanic American female who presented to the clinic with complaint of heavy prolonged menstrual bleeding with severe cramping for the past one year. Patient reported sharp pelvic pain during menstruation, bleeding between periods, pain with intercourse, blood clots during periods. Abdominal pain/pressure and bloating. Patient suggested that these symptoms started after her second caesarean section surgery one year ago. Patient also reported that she takes over-the counter medication, such as ibuprofen to relieve the pain. she also suggested that she uses heating pad on her abdomen/pelvic for pain relief, and she stated that she soaks in a warm sitz bath to ease pelvic pain and cramping. Patient also reported fatigue and weakness. Patient further stated that she decided to see an obstetrician and gynecologist (OB/GYN) because the heavy prolonged bleeding with severe menstrual cramp interfere with her regular activities. Patient denied nausea, vomiting, diarrhea, fever, and chills.
Timing/Onset: Patient said one year ago.
Location: The location of the problem as stated by the patient is pelvic/uterus/vaginal.
Duration: 5 to7 days d ...
1[Shortened Title up to 50 Characters]2Week 9 Assignment.docxhallettfaustina
1
[Shortened Title up to 50 Characters] 2Week 9 Assignment
Bethel U. Godwins
Walden University
NURS 6551, Section 8, Primary Care of Women
July 31, 2016
Abnormal Uterine Bleeding
Society for Reproductive Endocrinology and Infertility (SREI, 2012) described abnormal uterine bleeding as bleeding that differs in quality and quantity from normal menstrual bleeding, such as women spotting or bleeding between the women’s menstrual periods; bleeding after sex; bleeding heavier or last more days than normal; and bleeding post menopause. According to SREI (2012), factors that can cause abnormal bleeding include structural abnormalities of the reproductive system, such as uterine polyps, fibroids, and adenomyosis. Furthermore, SREI (2012) explained that vaginal, uterine or cervical lesions, miscarriage, ectopic pregnancy, endometritis, adhesions in the endometrium, and use of an intrauterine device (IUD) can also cause abnormal bleeding. Johns Hopkins Medicine (2016) specified that early recognition of abnormal bleeding, and seeing a health care provider immediately for appropriate diagnosis and treatment increase the chance of successful treatment. Therefore, the author will focus on a single patient comprehensive evaluation, which includes the patient’s personal/health history; physical examination; laboratory/diagnostic tests; diagnosis; treatment/management plan; education strategies; and follow-up care. Comment by DeAllen B Millender: Good introduction.
General Patient Information
Age: 41-year-old
Race/Ethnicity: Hispanic American
Partner Status: Married Comment by DeAllen B Millender: This information is not in APA format.
Current Health Status
Chief Complaint: “I have heavy, prolonged menstrual bleeding with severe cramping for the past one year”.
History of Present Illness (HPI): RG is a 41-year-old Hispanic American female who presented to the clinic with complaint of heavy prolonged menstrual bleeding with severe cramping for the past one year. Patient reported sharp pelvic pain during menstruation, bleeding between periods, pain with intercourse, blood clots during periods. Abdominal pain/pressure and bloating. Patient suggested that these symptoms started after her second caesarean section surgery one year ago. Patient also reported that she takes over-the counter medication, such as ibuprofen to relieve the pain. she also suggested that she uses heating pad on her abdomen/pelvic for pain relief, and she stated that she soaks in a warm sitz bath to ease pelvic pain and cramping. Patient also reported fatigue and weakness. Patient further stated that she decided to see an obstetrician and gynecologist (OB/GYN) because the heavy prolonged bleeding with severe menstrual cramp interfere with her regular activities. Patient denied nausea, vomiting, diarrhea, fever, and chills.
Timing/Onset: Patient said one year ago.
Location: The location of the problem as stated by the patient is pelvic/uterus/vaginal.
Duration: 5 to7 days du ...
Module 02 - Multidimensional Care StrategiesNursing Care.docxaudeleypearl
Module 02 - Multidimensional Care Strategies
Nursing Care
Nursing care of the patient experiencing reproductive disorders requires a collaborative approach. Nursing care is dependent on the type of disorder and treatment. A multidimensional care approach encompasses the physical, developmental, emotional, cultural, intellectual, and spiritual aspects of nursing care to ensure that all needs of the patient are being met. Patient and family education is ongoing throughout the patient’s stay to improve overall health following discharge.
Nursing care of a patient experiencing male reproductive disorders, as well as sexually transmitted infections, includes general nursing care interventions such:
Monitoring vital signs.
System focused assessment.
Monitoring laboratory/other diagnostic study results and reporting abnormalities and providing prescribed treatment.
Monitoring intake and output.
Assessing for signs and symptoms of complications and adverse effects of treatment.
Administration of prescribed medication, including chemotherapy.
Specialized care must be taken when administering chemotherapy; chemotherapy precautions must be implemented to protect the patient, family, and staff. Specialized handling of chemotherapy agents is included in these precautions.
Multidimensional patient care needs can be met by conducting the appropriate psychosocial, nutritional, spiritual, and cultural assessment. Based on the assessment findings, patient care can be tailored to meet the patient’s needs. Male reproductive disorders and sexually transmitted infections can result in emotional stress as well as anxiety. Early identification of these stressors will help to identify coping strategies for the patient and family.
Patient and family education play a vital role in the care of a patient. Identification of knowledge deficits and providing education on the disease process and treatment options will enable the patient and family to deal with the diagnosis and decide on an appropriate plan that meets their needs.
Some male reproductive disorders may require surgical interventions; nursing care includes preparing the patient for the surgical procedure as well as post-operative monitoring. Post-operative monitoring to reduce the incidence of complications includes encouraging coughing and deep breathing to prevent respiratory complications. Interventions such as early ambulation and venous thromboembolism (pharmacological or mechanical) prophylaxis can assist in the prevention of deep venous thrombosis. Pain assessment and management must be performed to ensure the pain is controlled to promote early ambulation, and coughing and deep breathing to prevent post-operative complications.
Benign Prostatic Hyperplasia
Nursing care of a patient diagnosed with benign prostatic hyperplasia includes conducting a focused assessment regarding urinary elimination, providing privacy and emotional support to the patient, preparing the patient .
Intra uterine Growth Retardation includes Low birth weight (LBW)
Very low birth weight (VLBW)
Extremely low birth weight (ELBW)
Premature
Small for Gestational Age (SGA)
Large for Gestational Age (AGA)
Intrauterine Growth Retardation (IUGR)
Factors affecting Fetal/Baby size:
Conditions associated with symmetric IUGR
Mandeep Kaur. Associate Professor in a Nursing College.
Modalities of diagnosis of pregnancy. It includes routine personal tests and other pregnancy tests. RH test, Alpha Protein test, Triple test, Fetal Ultrasound, CFTS, Amniocentesis, CVS, Non-Stress Test, And Other so many tests , Contraction Stress Test, Fetal Bio physical Profile,
COVID-19 PCR tests remain a critical component of safe and responsible travel in 2024. They ensure compliance with international travel regulations, help detect and control the spread of new variants, protect vulnerable populations, and provide peace of mind. As we continue to navigate the complexities of global travel during the pandemic, PCR testing stands as a key measure to keep everyone safe and healthy. Whether you are planning a business trip, a family vacation, or an international adventure, incorporating PCR testing into your travel plans is a prudent and necessary step. Visit us at https://www.globaltravelclinics.com/
Medical Technology Tackles New Health Care Demand - Research Report - March 2...pchutichetpong
M Capital Group (“MCG”) predicts that with, against, despite, and even without the global pandemic, the medical technology (MedTech) industry shows signs of continuous healthy growth, driven by smaller, faster, and cheaper devices, growing demand for home-based applications, technological innovation, strategic acquisitions, investments, and SPAC listings. MCG predicts that this should reflects itself in annual growth of over 6%, well beyond 2028.
According to Chris Mouchabhani, Managing Partner at M Capital Group, “Despite all economic scenarios that one may consider, beyond overall economic shocks, medical technology should remain one of the most promising and robust sectors over the short to medium term and well beyond 2028.”
There is a movement towards home-based care for the elderly, next generation scanning and MRI devices, wearable technology, artificial intelligence incorporation, and online connectivity. Experts also see a focus on predictive, preventive, personalized, participatory, and precision medicine, with rising levels of integration of home care and technological innovation.
The average cost of treatment has been rising across the board, creating additional financial burdens to governments, healthcare providers and insurance companies. According to MCG, cost-per-inpatient-stay in the United States alone rose on average annually by over 13% between 2014 to 2021, leading MedTech to focus research efforts on optimized medical equipment at lower price points, whilst emphasizing portability and ease of use. Namely, 46% of the 1,008 medical technology companies in the 2021 MedTech Innovator (“MTI”) database are focusing on prevention, wellness, detection, or diagnosis, signaling a clear push for preventive care to also tackle costs.
In addition, there has also been a lasting impact on consumer and medical demand for home care, supported by the pandemic. Lockdowns, closure of care facilities, and healthcare systems subjected to capacity pressure, accelerated demand away from traditional inpatient care. Now, outpatient care solutions are driving industry production, with nearly 70% of recent diagnostics start-up companies producing products in areas such as ambulatory clinics, at-home care, and self-administered diagnostics.
India Clinical Trials Market: Industry Size and Growth Trends [2030] Analyzed...Kumar Satyam
According to TechSci Research report, "India Clinical Trials Market- By Region, Competition, Forecast & Opportunities, 2030F," the India Clinical Trials Market was valued at USD 2.05 billion in 2024 and is projected to grow at a compound annual growth rate (CAGR) of 8.64% through 2030. The market is driven by a variety of factors, making India an attractive destination for pharmaceutical companies and researchers. India's vast and diverse patient population, cost-effective operational environment, and a large pool of skilled medical professionals contribute significantly to the market's growth. Additionally, increasing government support in streamlining regulations and the growing prevalence of lifestyle diseases further propel the clinical trials market.
Growing Prevalence of Lifestyle Diseases
The rising incidence of lifestyle diseases such as diabetes, cardiovascular diseases, and cancer is a major trend driving the clinical trials market in India. These conditions necessitate the development and testing of new treatment methods, creating a robust demand for clinical trials. The increasing burden of these diseases highlights the need for innovative therapies and underscores the importance of India as a key player in global clinical research.
For those battling kidney disease and exploring treatment options, understanding when to consider a kidney transplant is crucial. This guide aims to provide valuable insights into the circumstances under which a kidney transplant at the renowned Hiranandani Hospital may be the most appropriate course of action. By addressing the key indicators and factors involved, we hope to empower patients and their families to make informed decisions about their kidney care journey.
LGBTQ+ Adults: Unique Opportunities and Inclusive Approaches to CareVITASAuthor
This webinar helps clinicians understand the unique healthcare needs of the LGBTQ+ community, primarily in relation to end-of-life care. Topics include social and cultural background and challenges, healthcare disparities, advanced care planning, and strategies for reaching the community and improving quality of care.
Empowering ACOs: Leveraging Quality Management Tools for MIPS and BeyondHealth Catalyst
Join us as we delve into the crucial realm of quality reporting for MSSP (Medicare Shared Savings Program) Accountable Care Organizations (ACOs).
In this session, we will explore how a robust quality management solution can empower your organization to meet regulatory requirements and improve processes for MIPS reporting and internal quality programs. Learn how our MeasureAble application enables compliance and fosters continuous improvement.
This document is designed as an introductory to medical students,nursing students,midwives or other healthcare trainees to improve their understanding about how health system in Sri Lanka cares children health.
Child Welfare Clinic and Well baby clinicin Sri Lanka.ppsx
NCP 2 Pregnancy with IUGR.docx
1. NURSING CARE PLAN
Topic: Intra uterine growth restriction
Subject: Obstetric and Gynecological nursing
Submitted To: Respected Madam Mrs. Gursangeet Kaur Sidhu
Submitted On: 3rd
March, 2016
Submitted By:-
Sukhpreet Kaur
M.Sc. (N) 2nd
Year
Roll No.6
2. HISTORY OF THE PATIENT
Name: Amandeep Kaur Husband’s name: Sahab singh
Age: 22 years Sex: female
Hospital: Civil Hospital, Ludhiana
Address: New Shakti Nagar,Ludhiana
Education: Matriculation Husband’s education: Matrix
Occupation: Housewife Husband’s occupation: Labourer
Religion: Sikh Date of Admission: 11-1-2016
Dr. Incharge: Dr. Ruchi
Diagnosis: PREGNANCY WITH INTRAUTERINE GROWTH RETARDATION
CHIEF COMPLAINTS: Patient admitted into civil hospital, Ludhiana with conscious & oriented state of mind for her safe confinement & for
IUGR management.
HISTORY OF PRESENT ILLNESS: Patient admitted into civil hospital, Ludhiana on dated 11-1-2016 for her safe confinement. Now, the
patient feels very tensed regarding less body weight of her baby & taking treatment under supervision of Dr.Ruchi.
OBSTETRICAL HISTORY:
Patient is primi gravida (G-1, P-0, A-0, L-0)
LMP: 24-5-2015
EDD: 2-3-2016
Duration of marriage – 2 years
Antenatal history: Her health status was good during antenatal period. No history of nausea or vomiting was present. She was immunised with
2 doses of injection TT. She was coming to civil hospital, ludhiana for her antenatal visit. NST was done & findings were normal.
Ultrasonography was done & showed low birth weight foetus (2 kg).
Contraceptive method used (if any): nil
3. MENSTRUAL HISTORY:
Menarche at: 14 years of age.
Cycle of: 24-25 days.
Period: 3-4 days.
Dysmenorrhoea: mild
Amount of blood flow: moderate
LMP: 24-5-2015
PERSONAL HISTORY:
Dietary habits: vegetarian
Any addiction: nil
Immunisation status: not know about this.
T.T. 1st dose: at 4th month 2nd dose: at 5th month
PAST MEDICAL HISTORY: There is no significant history of any medical disease e.g. diabetes, hypertension, etc.
PAST SURGICAL HISTORY: There is no any significant history of any surgery in her life.
FAMILY HISTORY: There is no significant family history of any medical disease e.g. diabetes, hypertension, tuberculosis, etc.
FAMILY TREE-
Patient Patient’s Husband
Amandeep Kaur (22years old) Sahab Singh (25 years old)
Diagnosis: IUGR
Name Relationship with
patient
Age Sex Education Occupation Health Status
Amandeep
Sahab
Patient
Husband
22 years
25 years
Female
Male
Matrix
Matrix
House wife
Labourer
IUGR
Healthy
4. VITAL SIGNS:-
Sr. No. Observation Patient’s value Normal value Remarks
1 Temperature 990F 98.6oF Normal
2 Pulse 78/min 72-80/ min Normal
3 Respiration 22/min 16-24/min Normal
4 Blood pressure 110/70mmhg 120/80mmhg Normal
LABORATORY INVESTIGATIONS:
Ultrasonography findings: - Single live intrauterine foetus with 34weeks4days of gestation without any abnormality.
S. No. Investigations Patient’s Value Normal Value Remarks
1. Hb 8.6 gm/dl 12-16 gm/dl Low
2. Blood group A+ A+, B+, ABO, O Normal
3. VDRL -ve - Normal
4. HIV -ve - Normal
5. HCV -ve - Normal
6. Blood sugar/albumin 80 mg/dl 70-150 mg/dl Normal
PHYSICAL EXAMINATION
Hair scalp: - no redness, lice’s and dandruff, brown black color hairs.
Eyes: - Both eyes are normal in size, shape and symmetry.
Mouth: - No coated and dry tongue.
Neck: - No tonsillitis
Breast: -
5. Inspection - Both breasts are normal in size, shape and symmetry.
Palpation - No any tenderness / engorgement is present
Abdomen: -
Inspection:
Linea nigra and straie gravidarum are present during antenatal period.
No any previous stretch mark present on abdomen.
Palpation: Fundal Height: 32 cm
Auscultation: FHR-158/min
Vaginal examination: - Doderlin’s bacillus (normal flora) with normal lochia
NURSING ASSESSMENT: -
• Patient feels discomfort & verbally explains her pain level.
• Pain level is also assessed by pain scale & verbal expressions.
• Slightly increase in temperature (1000 F)
• Patient feels itching on wound site & feels discomfort.
• Patient feels weakness & decrease in appetite.
• Patient & family members are confuse when I am asking questions.
NURSING DIAGNOSIS: -
Acute pain related to surgical incision as manifested by verbally explaining or discomfortness.
Risk for infection related to hospitalisation as manifested by slightly increase in temperature.
6. Impaired skin integrity related to improper dressing & vaginal discharge as evidenced by poor hygienic condition.
Imbalanced nutritional status related to anorexia as manifested by fewer intakes.
Deficit knowledge related to postpartum care & newborn care as manifested by poor hygiene condition.
GOALS
Short term goals
To provide comfortable environment.
To relieve the pain of patient.
To maintain the intake output chart.
To check the vital signs.
To prevent both mother & baby from the infection.
To provide well balanced diet.
To administer the medications as ordered.
To provide perineal hygienic care.
Long term goals
To provide comprehensive care to baby & mother.
To provide the emotional & psychological support.
To encourage for proper follow-up visits.
To rehabilitate the patient.
To provide the thorough knowledge regarding
hygienic care.
To maintain the nutritional & hydration level.
To teach about the importance of exclusive breast
feeding to mother.
To teach about the newborn care.
7. NURSING CARE PLAN
Sr.
No.
Nursing
Assessment
Nursing
Diagnosis
Goal Planning Implementation Rationale Evaluation
1. Patient feels
discomfort &
verbally
explains her
pain level.
Pain level is
also assessed
by pain scale
& verbal
expressions.
Acute pain
related to
surgical incision
as manifested
by verbally
explaining or
discomfortness.
To reduce
& relieve
the pain of
patient.
o Monitor characteristics of
pain i.e. location,
intensity, duration,
frequency & rotation.
o Discuss reasons for pain
and discomfort and
measures to be carried
out for relief.
o Provide diversion therapy
(imagination therapy).
o Administer analgesic as
ordered.
o Provide that position in
which she feels comfort.
o Acute pain was present.
o Patient is asked about
the reason for pain and
discomfort.
o Imagination therapy
was given to patient.
o Tab. Diclofenac was
given.
o Comfortable position
was provided.
o It provides baseline
data to plan care on
basis of data
collected.
o It help to express the
patient’s ideas and
anxiety
o It can divert mind of
patient from pain.
o It reduces & relieves
the pain level.
o It provides comfort.
Intensity of
pain level is
reduced as
evidenced by
verbalisation
& by
checking
pain scale.
2. Slightly
increase in
temperature
(1000 F)
Risk for
infection related
to
hospitalisation
To reduce
risk of
infection
to both
o Follow universal
precautions.
o Universal precautions
was followed e.g. hand
washing, gloving,
gowning.
o It prevents
nosocomial infection.
Risk of
infection is
reduced as
evidenced by
8. as manifested
by slightly
increase in
temperature.
mother &
foetus.
o Restrict entry of visitors.
o Monitor incision site
daily for redness,
oedema, and any
drainage & do proper
dressing.
o Monitor vital signs.
o Monitor WBC count as
ordered and report
abnormal values.
o Monitor culture urine,
wound drainage and
lochia.
o Instruct patient to
o Visitors are allowed in
visiting time only.
o Daily dressing was
done & monitor
incision site.
o Temperature, pulse and
respiration was
checked every hour 4
hourly & recorded.
o WBC’s were
monitored.
o Urine and vaginal swab
was sent for culture.
o The patient maintained
o It prevents cross
infection.
o It helps to predict
signs of infection.
o Elevated vital signs
indicate infection.
Temp >1000 F on two
consecutive readings
after first 24 hr
indicates mastitis and
other infections.
o Increased production
of leucocytes shows
bacterial infection.
o Abnormal findings
show infection.
o It reduces the risk of
using aseptic
techniques.
9. maintain proper personal
hygiene.
o Teach patient how to
apply perineal pad.
o Administered antibiotics
as ordered.
perineal care, do hand
washing and breast
care.
o Patient was applying
the pad from front
back.
o Inj. Cefataxim was
given.
infection.
o It help to prevent
wound
contamination.
o It helps to prevent
chance of infection.
3. Patient feels
itching on
wound site &
feels
discomfort.
Impaired skin
integrity related
to improper
dressing &
vaginal
discharge as
evidenced by
poor hygienic
condition.
To
improve
skin
condition
of patient.
o Inspect the incision daily
by REEDA scale.
o Instruct and assist the
patient with hygienic
practices such as hand
washing and toileting
practices.
o Carry out prescribed
treatment such as
cleaning and applying
medication and dressing
change.
o Incision was inspected
daily & does dressing
& recorded.
o Patient was doing hand
washing while toileting
clean the area from
perineum to back.
o Surgical wound was
cleaned and dressing
was changed daily.
o It helps to detect
signs of possible
infection.
o It helps to prevent
infection.
o It helps to decrease
bacterial
contamination.
Skin
condition is
improved as
manifested
by doing
dressing with
aseptic
techniques &
she maintain
her hygienic
condition.
10. o Instruct and assist the
patient in performing
perineal wash/ care 3-4
times a day.
o Maintain infection
control standards.
o Patient was applying
perineal pad from front
to back and remove it
from back to front.
o Sterile techniques were
used while caring the
patient.
o It helps to maintain
cleanliness and
promote healing.
o It helps to prevent
nosocomial
infections.
4. Patient feels
weakness &
decrease in
appetite.
Imbalanced
nutritional
status related to
anorexia as
manifested by
fewer intakes.
To
improve
nutritional
status.
o Check weight of patient
daily at same time with
same clothes.
o Check dietary patterns –
vegetarian / non –
vegetarian, likes /
dislikes.
o Maintain intake – output
chart.
o Provide well balanced
diet (protein diet- milk,
milk products) with
frequent meals.
o Plenty of fluids should be
o Weight of patient was
checked daily.
o Dietary pattern was
monitored by noting
liking & disliking
related to food.
o Intake-output chart was
recorded.
o Proper diet was taken
by patient.
o She drink a glass of hot
o It provides baseline
data.
o It provides variety to
food.
o It provides baseline
data.
o It provides nutrients
to patient.
o It promotes stool
Nutritional
status is
improved as
evidenced by
increase in
weight.
11. given in diet. water 30 min before
breakfast which may
stimulate bowel
evacuation.
consistency.
5. Patient &
family
members are
confuse when I
am asking
questions.
Deficit
knowledge
related to
postpartum care
& newborn care
as manifested
by poor hygiene
condition.
To
improve
understan
ding level
of patient
& family.
o Assess patient level of
understanding of
postpartum care self care
activities.
o Teach skills like perineal
care, breast care, care of
newborn and removal
and application of pads.
o Teach the patient about
importance of adequate
nutrition and hydration.
o Discuss the importance
of adequate rest.
o Patient understands
level was assessed by
asking fewer questions.
o Patient was taught
about perineal care,
breast care, newborn
care and removal and
application pads.
o Patient was taking
green leafy vegetables,
black grams and
fibrous food and avoids
spicy and fatty food.
o Patient was taking
proper rest.
o It will help to
establish a baseline
for learning.
o This will help to
prevent postpartum
infection and provide
a sense of well being.
o It helps to meet
nutritional needs of
mother body.
o It will develop
confidence and
enhance breast
Patient gives
answer with
confident.
12. o Explain the patient about
the breast feeding.
o Discuss with the patient
about importance of
contraceptive measures.
o The patient was giving
proper breast feeding &
does burping.
o Patient was advised to
prevent intercourse for
6 weeks and use
contraceptives for
family planning. Cu T
is contraceptive of
choice after delivery.
feeding and prevent
breast engorgement.
o It will help the patient
to get motivated
towards small family
norms.
o It will promote
emotional and
physical stability.
LYDIA E HALL THEORY OF NURSING
Lydia Eloise Hall, RN, M.A. (1906-1969): - Born in New York City on September 21, 1906, Hall grew up in York, Pennsylvania. She was an
innovator, motivator, and mentor to nurses in all phases of their careers, and advocate for the chronically ill patient. She promoted involvement
of the community in health-care issues. Hall stated that “from Psychology, I learned people can do three things with their feelings: express them
verbally, repress verbal expression leading to sickness and dis-ease, or become psychotic.”
• Lydia E Hall presents her theory of nursing visually by drawing three interlocking circles, each circle presenting a particular aspect of
nursing .The circles represent care, core and cure
13. According to the Care, Core, and Cure" model, nurses work in three areas: care (hands on bodily care), core (using the self in relationship to the
patient), and cure (applying medical knowledge). Hall was another nurse to the delineate the practice of nursing from the practice of medicine.
CORE
Nursing Assessment: -
Patient feels discomfort & verbally explains her
pain level.
Pain level is also assessed by pain scale &
verbal expressions.
CARE
Nursing Diagnosis: - Acute pain related to surgical incision as
manifested by verbally explaining or discomfortness.
Goal: - To reduce & relieve the pain of patient.
Planning: -
To monitor characteristics of pain i.e. location,
intensity, duration, frequency & rotation.
To discuss reasons for pain and discomfort and
measures to be carried out for relief.
To provide diversion therapy (imagination therapy).
To administer analgesic as ordered.
To provide that position in which she feels comfort.
CURE
Implementation: -
Acute pain was present.
Patient is asked about the reason for pain and discomfort.
Imagination therapy was given to patient.
Tab. Diclofenac was given.
Comfortable position was provided.
Evaluation: - Intensity of pain level is reduced as evidenced by
verbalisation & by checking pain scale.
14. HEALTH EDUCATION: -
1. Patient is instructed to maintain her personal hygiene especially of perineal care.
2. Instruct to patient regarding importance of follow up.
3. Take medications as ordered.
4. Explain about importance of postnatal exercises by giving demonstrations.
5. Give exclusive breastfeed to baby.
6. Instruct patient about importance of family planning. Take birth space between children is of at least 2 years.
7. Take well balanced diet. Take 2 glass of milk in a day.
8. Get baby immunised at proper time.
9. Bath the baby with warm water & massage with coconut oil.
10. Antimalarial chemoprophylaxis in selected groups.
11. Balanced protein and energy supplements especially in adolescent pregnancy and low socio economic status.
12. Avoid contact with individual with viral infection.
13. Testing for immunity of rubella in non pregnant population and immunization in non immunized mothers
14. Maternal oxygen therapy; it has shows conclusion benefits in management of IUGR.
15. Preventive measures for maternal disease causing IUGR: correction of maternal anaemia, treatment of hypertension can have
positive effects on birth weight.
16. Do her daily lightly routine work. Take proper rest & work period.
15. BIBLIOGRAPHY: -
1. DuttaD.C.text book of obstetrics.16thed.calcutta:central publisher;Pp-588-98.
2. Gupta sadhana. A comprehensive textbook of obstetrics & gynaecology. Ed.3rd .New Delhi; jaypeebrothers medical publishers; Pp-565-
67.
3. Dawn C.S. text book of obstetrics and neonatology. 15th ed. Calcutta:dawn books;Pp-362-367.
4. Jacob Annamma.A comprehensive textbook of midwifery & gynaecological Nursing.3rded.New Delhi: jaypee brothers;Pp-396-99.