POSTNATAL ASSESSMENT

PATIENT IDENTIFICATION

Name : Mrs. Manjulla

Age : 25 years

Ward : Post operative ward

Religion : Hindu

Date of admission : 22/9/12

Date of delivery : 24/9/12

Type of delivery : Caesarean section

Indication : Previous caesarean section

Diagnosis : Hbs AG positive

Obstetrical score : G2P2L2A0

Date of care started : 23/9/12

Date of care ended : 3/10/12

INTRODUCTION

During my posting in St Mary’s Hospital I was posted in postoperative ward

and I took Mrs. Manjulla post natal mother for care study .She delivered a male baby

with birth weight 2900 gms on 24/9/12 at 1.30 pm by caesarean section. I introduced

myself to her and explained how I will be helping her cope with postnatal problem

FAMILY HISTORY

Mrs. Manjulla has no family history of Diabetes mellitus, Hypertenssion,

multiple pregnancy, cardiac problem, and psychiatry problems. But the patient is

suffering with chronic hepatitis B.

SOCIO-ECONOMIC STATUS

She belongs to lower class family. They live in house of their own with all

minimum basic requirements such as electricity, water supply. Her husband is the bread

winner of her family.

PERSONAL HISTORY

Diet: She is taking mixed diet

Hygiene : She is not maintaining good personal hygiene

Sleep : She used to sleep 8 hours at night and 2 hours in day time. She has no sleeping

disturbance

Bowel and bladder : No history of bowel and bladder pattern disturbance.

Habits: She has no bad habits like chewing tobacco or drinking alcohol

MENSTRUAL HISTORY

She attained menarche at the age of 14 years . She is having regular cycle of 28 days

with moderate flow. Her menstrual flow lasts for 4-5 days.

MARITAL HISTORY

She got married at the age of20 years. Her marital life is 5 years and her marriage is

non –consanguinous marriage.

PAST MEDICAL HISTORY

Mrs. Manjulla is known Hbs Ag positive patient.

PAST SURGICAL HISTORY

She underwent LSCS 2 years back.

OBSTETRICAL HISTORY

Past obstetrical history

No.

Of

preg

nanc

is

Typ

e of

de

live

ry

Dat

e

Ges

tati

ona

l wee

ks

Bab

y

Cou

rse

of

preg

nanc

y

Rem

arks

1 LSCS 201038

Girl baby with 2500gms

Uneventful Mother and the baby were healthy

Present obstetrical history

Obstetrical score : G2P2L2A0

LMP : 23/12/11

EDD : 30/9/12

Gestational age : 39 weeks

Ist trimester

12/2/12

IInd trimester

20/5/12

IIIrd trimester

12/8/12

She had ante Had ante natal Had ante natal visits.

natal visit regularly.

Taken folic acid

tablets.

No exposure to

radiations.

She had vomiting

from 3rd week up to

8thth week

Body

weight:45kg

Haemoglobin:

10 gms%

First trimester

was uneventful

visit.

Taken Iron, Folic

acid and Calcium

tablets regularly.

Fetal movements

were felt.

Inj.T.T taken.

Body

weight:50kg

Haemoglobin:

9.9gms%

Second trimester

was uneventful

Taken iron folic acid and

calcium tablets.

Inj. T.T taken

Fetal movements was

good

Body weight:54kg

Haemoglobin : 9.9 gms%

Third trimester was

uneventful

REASON FOR CAESAREAN SECTION

Previous LSCS and Hbs Ag positive

PHYSICAL EXAMINATION

Vital signs

Temp : 99.90 F

Pulse : 86 b/m

Respiration : 24 br/m

BP : 120/70mmHg

Weight : 50kg

Height : 162cm

General appearance : Moderately built

Mood : Cheerful

HEAD TO FOT EXAMINATION

Head : Healthy hair. Clean scalp. No dandruff or lesions

Face : No edema, rashes on the face

Skin : Acne vulgarise is present all over the body

Eyes : Conjunctiva pale in colour, normal vision

Ear : Hearing normal, no abnormal discharge

Nose : No septal deviation , no abnormal discharge

Mouth : Lips and tongue are dry

Teeth : No dental carries

Neck : No thyroid and lymph node enlargement

Chest : Expansion of the chest is normal

CVS : S1and S2 heard

Breast : Soft, nipple erect, no cracks , no tenderness on palpation

Abdomen : On inspection linear nigra and stria gravid present

LSCS incision present .

On palpation uterus well contracted.

bowel and bladder : she passed urine and bowel sounds are normal

Genitalia : Lochia rubra present

Extremities : Normal range of motion, no oedema , human sign is negative

INVESTIGATIONS

Date Name of

investigation

Patient

value

Normal value Remark

20/5/12 Blood grouping AB + ve

20/5/12 Hb% 9.9gm/dl 13-14mg/dl She is an

anaemic mother

20/5/12 RBS 120mg/dl 80-120mg/dl She is not a

diabetic mother

20/5/12 Hbs Ag Positive Negative

20/5/12 HIV Negative Negative

MEDICATION

Sl n

o

Dru

g n

ame

Rou

te

Doz

e

Fre

qu

en

cy

Act

ion

Ind

icat

ion

s

Sid

e ef

fect

s

Con

tra

ind

icat

ion

s

1 Inj .Taxim

IV 1.5gm BD

Bind to bacterial cell wall membrane causing cell death

Skin and skin infections, prophylactic for surgery

GI effects; anaphylactic shock (rare).

Allergy or hypersensitivity to cephalosporins.

2 Inj. Metrogyl

IV 500 gm

BD

Disrupts DNA and protein synthesis in susceptible organisms

Perioperative prophylactic, intra abdominal infection

Head ache, anorexia, nausea, rashes, phlebitis at IV site, unpleasant taste

Hypersensitivity, first trimester of pregnancy

3 Inj. pantop

IV 40 mg BD

Binds to an enzyme in the presence of acidic gastric Ph, preventing the final transport of hydrogen ions in to the gastric lumen

GERD, gastritis Head ache, abdominal pain, diarrhoea, flatulence, hyper glycemia

Hypersensitivity, pregnancy

4 Inj .Tromdal

IV 50 mg HS

Inhibits reuptake of serotonin and nor epinephrine in CNS

Moderate to moderately severe pain

Dizziness, head ache, somnolence, vaso dilation, constipation, nausea

Alcohol intoxication, opioid dependence

DELIVERY NOTES

Mrs.Manjulla was admitted on 22/9/12 due to previous LSCS. She

was taken for LSCS on 24/9/12. Inj. Taxim 1 gm IV, Inj emest 2mg and Inj Pantop 40

mg IV given. Foly’s catheter inserted. Pre preparations given and she was taken to

OT at 1.15 PM. Spinal anaesthesia is given by using 5ml of Buppivaccaine 25%. A Boy

baby with birth weight 2900 gms was extracted by LSCS AT 1.30 pm . Baby cried

immediately after the birth. Post partum sterilisation was done. Wound sutured with 2.0

catgut and 1.0 polypropylene suture and sterile dressing given. She was shifted to post

operative unit at 2.00 pm. IV fluids were continued. She was kept nil per oral for next

24 hrs. Fluids were given after that and oral food intake started after checking bowel

sounds.

POST NATAL MIOTHER WITH HBSAG POSITIVE

INTRODUCTION

Hepatitis B virus (HBV) is a blood borne and sexually transmitted virus. Rates of new

infection and acute disease are highest among adults, but chronic infection is more likely to

occur in persons infected as infants or young children. Before hepatitis B vaccination

programs became routine in the United States, an estimated 30%–40% of chronic infections

are believed to have resulted from perinatal or early childhood transmission, even though

<10% of reported cases of hepatitis B occurred in children aged <10 years Chronically

infected persons are at increased lifetime risk for cirrhosis and hepato cellular carcinoma

(HCC) and also serve as the main reservoir for continued HBV transmission.

HEPATITIS

The term 'hepatitis' simply means inflammation of the liver. Hepatitis may be caused

by a virus or a toxin such as alcohol. Other viruses that can cause injury to liver cells include

the hepatitis A and hepatitis C viruses. These viruses are not related to each other or to

hepatitis B virus and differ in their structure, the ways they are spread among individuals, the

severity of symptoms they can cause, the way they are treated, and the outcome of the

infection.

HEPATITIS B

Hepatitis B is an infection of the liver caused by the hepatitis B virus (HBV). It is

estimated that 350 million individuals worldwide are infected with the virus, which causes

620,000 deaths worldwide each year.

The hepatitis B virus is a DNA virus, meaning that its genetic material is made up of

deoxyribonucleic acids. It belongs to a family of viruses known as Hepadnaviridae. The virus

is primarily found in the liver but is also present in the blood and certain body fluids.

INCUBATION PERIOD

The average incubation period is 90 days from time of exposure to onset of

symptoms, but may vary from 6 weeks to 6 months

TRANSMISSION OF HEPATITS B VIRUS

Hepatitis B is spread mainly by exposure to infected blood or body secretions. Hepatitis B is

not spread through food, water, or by casual contact.

BOOK PICTURE PATIENT PICTURE

Semen, vaginal discharge, breast milk,

and saliva

Blood and blood products

Sexual contact

Using contaminated needles Mrs.Manjulla got hepatitis B due to

contaminated needles.

Tattooing

Body piercing

Sharing toothbrushes and razors

contaminated with infected fluids or blood.

Infected mothers to their babies at birth

Donated livers , and other organs

However, blood and organ donors are routinely screened for hepatitis which typically

prevents this type of transmission.

HIGH RISK PERSONS

The high risk persons getting hepatitis B includes

Health care workers

Dentists

Intimate and household contacts of patients with chronic hepatitis B infection

Public safety workers who may be exposed to blood

Men who have sex with men

Individuals with multiple sexual partners

Dialysis patients

Injection drug users

Persons with chronic liver disease

Residents and staff in institutions that care for persons with developmental disabilities

Persons infected with HIV

Persons who require repeated transfusions or blood products.

THE SYMPTOMS OF ACUTE HEPATITIS B

Acute hepatitis B is the period of illness that occurs during the first one to four months after

acquiring the virus. Only 30% to 50% of adults develop significant symptoms during acute

infection. Early symptoms may be non-specific, including fever, a flu-like illness, and joint

pains.

BOOK PICTURE PATIENT PICTURE

Fatigue Fatigue present

Loss of appetite

Nausea

Jaundice

Pain in the right upper abdomen (due to

inflammated liver)

Pain in the abdomen

THE SYMPTOMS OF CHRONIC HEPATITIS B

The liver is a vital organ that has many functions. These include a role in the immune

system, production of clotting factors, producing bile for digestion, and breaking down toxic

substances, etc. Patients with chronic hepatitis B develop symptoms in proportion to the

degree of abnormalities in these functions. The signs and symptoms of chronic hepatitis B

vary widely depending on the severity of the liver damage. They range from few and

relatively mild signs and symptoms to signs and symptoms of severe liver disease such as

cirrhosis or liver failure.

Book picture

Because of chronic hepatitis the patient is feeling fatigue , puss formed at the surgical wound

and got difficulty to heal the wound . Baby is diagnosed with jaundice.

Cirrhosis of the liver due to hepatitis B

Inflammation from chronic hepatitis B can progress to cirrhosis of the liver. Significant

Symptoms may include:

Weakness,

Fatigue,

Loss of appetite,

Weight loss,

Breast enlargement in men,

Rash on the palms,

Difficulty with blood clotting, and

DIAGNOSTIC MEASURES

Book picture Patient picture

History collection Information through history collection

Physical examination

For detection of hepatitis B virus infection

involve serum or blood tests that detect either

viral antigens (proteins produced by the

virus) or antibodies produced by the host

Blood test shows mother is HbsAg positive

Liver biopsy examined under microscopy

MEDICATIONS

prednisone: used to treat many diseases, including asthma, inflammatory bowel disease,

and certain types of skin disease and arthritis

methotrexate (Rheumatrex, Trexall): used to treat certain types of skin disease, arthritis,

and cancer;

cyclophosphamide (Cytoxan): used to treat some cancers.

PREVENTION OF PERINATAL HBV INFECTION AND MANAGEMENT OF

PREGNANT WOMEN

Treatment

Acute hepatitis B usually resolves on its own and does not require medical treatment. If very

severe, symptoms such as vomiting or diarrhoea are present, the affected person may require

treatment to restore fluids and electrolytes. There are no medications that can prevent acute

hepatitis B from becoming chronic.

If a person has chronic hepatitis B, they should see their health care provider regularly

Prevention

Two available  hepatitis B vaccines for immunization are Recombivax HB and Engerix-B

Pregnancy is not a contraindication to vaccination. 

For vaccination of adults 20 years of age and older:

1-mL dose by intramuscular injection into the deltoid muscle, at initial visit, then one

month and six months after the first dose, for a total of three doses

After Exposure to Persons Who Have Acute Hepatitis B

When exposure has occurred as a result of sexual contact within 14 days after the most

recent sexual contact administer

A course of HBV vaccine into the deltoid as above

A dose of Hepatitis B immune globulin (HBIG) 0.06 mL/kg IM

For prophylaxis after percutaneous or mucous membrane injury, a second dose of

HBIG should be given 1 month later.

Exposure to Persons Who Have Chronic HBV Infection

Active post exposure prophylaxis with hepatitis B vaccine alone is recommended for

sex or needle-sharing partners and non-sexual household contacts of persons with

chronic HBV infection

Ante partum 

At time of admission for delivery

o Review hepatitis B surface antigen (HBsAg) status of all pregnant women.

o Record maternal HBsAg test results on both labor and delivery record and

on infant’s delivery summary sheet. Perform HBsAg testing as soon as

possible on women who

do not have a documented HBsAg test result,

were at risk for HBV infection during pregnancy (e.g., more than one sex

partner in the previous 6 months, evaluation or treatment for a sexually

transmitted disease, recent or current injection-drug use, or HBsAg-

positive sex partner), or

had clinical hepatitis since previous testing

Pregnant Hepatitis B carriers should be advised to

Obtain vaccination against hepatitis viruses as indicated.

Abstain form alcohol use

Avoid hepato toxic drugs such as acetaminophen (Tylenol) that may worsen liver

damage. 

Not donate blood, body organs, or other tissue.

Not share any personal items that may have blood on them (e.g., toothbrushes and

razors).

Inform the infant’s pediatrician, OB/GYN, and labor staff that they are a hepatitis B

carrier. 

Make sure their baby receives hepatitis B vaccine at birth, one month, and six months

of age as well as H-BIG at birth.

Be seen at least annually by their regular medical doctor.

DELIVERY

BOOK PICTURE PATIENT PICTURE

Although cesarean delivery has been

proposed as a means of reducing mother to

child transmission (MCT) of HBV The mode

of delivery does not appear to have a

significant effect on the interruption of HBV

maternal-baby transmission by immune

prophylaxis. Delivery by cesarean section for

the purpose of reducing MCT of HBV is note

presently recommended

LSCS

CARE OF THE NEWBORN BABY

BOOK PICTURE PATIENT PICTURE

Standard precautions should be utilised when

handling the babyFollowed

The skin at the injection site should be

cleaned with soap and water or with an

alcohol swab before administering hepatitis

B vaccine, immunoglobulin and vitamin K

Followed

The baby should remain in the birthing room

until transfer to the ward unless transfer to

the nursery is indicated

Babies direct rooming in with their mother

may be cared for in the ward nursery as

require

Practised

Breastfeeding is encouragedThe baby is sucking

Give hepatitis B immune globulin and

hepatitis B within 12 hours of birthImmunisation given

For preterm infants weighing <2,000 g, the initial vaccine dose (birth dose) should not be

counted as part of the vaccine series because of the potentially reduced immunogenicity of

hepatitis B vaccine in these infants; 3 additional doses of vaccine (for a total of 4 doses)

should be administered beginning when the infant reaches age 1 month

POST PARTUM PERIOD.

BOOK PICTURE PATIENT PICTURE

Provide information regarding hepatitis B to

HBsAg positive mothers, including

advice that they may breast feed their

infants upon delivery;

modes of HBV transmission;

need for vaccination of their susceptible

household, sexual, and needle-sharing

contacts;

need for substance abuse treatment, if

appropriate

Information given

At time infant is discharged

• Provide infant’s immunization record to mother

and remind her to take it to the infant’s first visit

Information given

to paediatric health-care provider

Mothers with unknown HBsAg status and their infants

Administer single-antigen hepatitis B vaccine (without HBIG) to all infants born to

mothers with unknown HBsAg status <12 hours after birth and record date and time

of administration of hepatitis B vaccine on infant’s medical record.

Alert infant’s paediatric health-care provider if an infant is discharged before the

mother’s HBsAg test result is available; if the mother is determined to be HBsAg

positive, HBIG should be administered to the infant as soon as possible, but no later

than age 7 days.

All mothers and their infants

Administer a dose of single-antigen hepatitis B vaccine to all infants weighing >2,000

g.

Ensure that all mothers have been tested for HBsAg prenatally or at the timeof

admission for delivery and document test results.

PROBLEMS IDENTIFIED

Pain

Impaired skin integrity and spread of sepsis

Insomnia

Risk for fluid volume imbalance

Risk for impaired infant –parent attachment

NURSIND DIAGNOSIS

Acute pain related to surgical incision.

Impaired skin integrity and spread of sepsis due to chronic infection

Disturbed sleep pattern related to hospitalisation.

Risk for fluid volume imbalance related to nill per oral status.

Risk for impaired parent attachment due to presence of infection

ASSESSMENT NURSING DIAGNOSIS

EXPECTED OUTCOME

INTERVENTION RATIONALE IMPLEMENTATION EVALUATION

Subjective data:The mother says that she has pain over the incision site.

Objective data:The mother has difficulty to get up from the bed and walk.Her facial expression shows that she is having severe pain. She is having pain score 8 in pain scale.

Acute pain relate to surgical incision.

Mother experiences less pain with in 2 hrs as evidence by relaxed facial expression.

Provide comfortable position.

Instruct the mother to do deep breathing and coughing exercise

Advice to support the incision area with pillow while coughing or sneezing or moving

Ensure adequate rest

Provide divertional activities Initiate active range of motion exercise and walking

Administer medications as per order

To relieve tension over the incision.

For pulmonary ventilation especially to remove stress and promote relaxation

To relieve tension over the incision.

To reduce pain due to movement.

To promote circulation ,to prevent venous thrombosis and reduce pressure on the surgical site

To reduce perception of pain.

Provided comfortable position

Instructed the mother to do deep breathing and coughing exercise

Advised to support the incision site with pillow while sneezing or coughing.

Ensured adequate rest.

Provided divertional activities Initiated active range of motion exercise and walking

Administered inj. tremadol

She got slight relief from the pain after 2 hours. Pain scale score reduced to 4

ASSESSMENT NURSING DIAGNOSIS

EXPECTED OUTCOME

INTERVENTION RATIONALE IMPLEMENTATION EVALUATION

Subjective data Mother says I am having fever and pain on the surgical site

Objective dataThe unhealed wound and puss formation at the surgical site.Increased body temperature

Impaired skin integrity and spread of sepsis due to chronic infection

The mother achieves timely healing and free of additional complication as evidence by heeling wound and normal body temperature.

Demonstrate strict hand washing policy for patient ,visitors and staff.

Provide proper contamination of infected material

Clean the surgical site with Betadine solution and apply sterile dressing

Demonstrate proper fundal massage

Monitor the vital signs

Monitor oral intake and output and encourage the mother to take more fluids

Administer proper antibiotics to mother

Hand washing prevent cross infection

It prevent the spread of infection

It reduce the growth of the bacteria and virus

It helps in involution of the uterus and remove retained content To identify the fluctuations in the temperature levelIncreased intake replaces the losses and enhance circulation

To reduce growth of the micro organism

Demonstrated strict hand washing policy for patient ,visitors and staff.

Provided proper contamination of infected material

Cleaned the surgical site with Betadine solution and applied sterile dressing

Demonstrated proper fundal massage

Monitored the vital signs

Monitored oral intake and output and encouraged the mother to take more fluids

Administered proper antibiotics to mother

The mother

maintained

normal skin

integrity as

evidenced by

healed wound

within 6 days

ASSESSMENT NURSING DIAGNOSIS

EXPECTED OUTCOME

INTERVENTION RATIONALE IMPLEMENTATION EVALUATION

Subjective data:Mother says that she can’t sleep last night because of pain

Subjective data:She looks very tired .Falling asleep in between feeding the baby.

Disturbed sleep pattern related to hospitalisation .

Mother experiences better sleep with in 24 hrs as evidence by verbal expression.

Provide comfortable

position for sleep

Advice to take sleep

when baby sleeps.

Provide calm

environment in the ward.

Provide comfort devices

like pillows while

positioning the mother

Enhance relaxation.

To avoid interruption in

sleep due to baby’s cry

and feeding

To avoid sleep

disturbance

To get more

comfort.

Provided comfortable

position for sleep.

Advised to take sleep

while baby sleeps.

Provided calm

environment in the ward

by limiting the visitors

and by putting curtains

around the bed.

Kept pillows at back to

position the mother.

She had better sleeping pattern on the next day.

ASSESSMENT NURSING DIAGNOSIS

EXPECTED OUTCOME

INTERVENTION RATIONALE IMPLEMENTATION EVALUATION

Objective data :Chronic infection of motherJaundice of the baby

Risk for

impaired

parent

attachment due

to presence of

infection

The mother

experiences

comfort

parenting as

evidence by

good parent

infant

attachment.

Observe the maternal and infant interaction

Provide opportunity for maternal and infant contact whenever possible

Monitor mother’s emotional response to illness and separation from infant

Encourage the mother to feed the baby whenever possible

Discuss the availability of supportive system in the home setting Administer Hepatitis B immune globulin

To identify copying pattern of the mother

It will improve the bonding between mother and the baby

It helps in identify the mother’s problem and protect the mother from getting post partum depression

Feeding will improve the bonding between mother and the babyIt helps to maintain time for spending the time with the baby.To prevent Hbs Ag transmission from mother to child

Observed the maternal and infant interaction

Provided opportunity for maternal and infant contact whenever possible

Monitored mother’s emotional response to illness and separation from infant

Encouraged the mother to feed the baby whenever possible

Discussed the availability of supportive system in the home setting Administered Hepatitis B immune globulin

The mother

maintained

good

attachment

with the baby

as evidenced

frequent

feeding .

NEW BORN ASSESSMENT

Name of the baby : B/O Manjulla

Sex : Boy baby

Date of birth : 24/9/12

Birth weight : 2900gm

Apgar score : 7 at 1 minute and 9 at5 minutes .

Head circumference : 34cm

Chest circumference : 32cm

Length : 50cm

Skin : Pink in colour, vernix caseosa present

Head : Anterior frontenella and posterior frontenalla

palpable.

Nose : No deviated septum, milia present

Mouth : Pink in colour, no cleft lip or cleft palate

Eyes : No discharges, symmetry in size and shape,

yellowish discolouration

Ears : Corrected placement, no discharges

Neck : No swellings, normal range of motion

Chest` : Symmetric chest movement nipple prominent

Heart rate : 130 b/mt

Respiratory rate : 40 b/mt

Abdomen : Round and dome shape

Bowel pattern : Meconium passed

Bladder pattern : Urine voided

Genitalia : Testis descend to scrotum, no abnormalities

Extremities : No congenital malformations, flexed position

REFLEXES

Rooting : Present

Sucking : present

Swallowing : present

Sneezing and coughing : present

Gagging : present

Blinking : present

Doll’s eye movement : present

Palmar grasp : present

Plantar grasp reflex : present

Moro reflex : present

PROBLEMS IDENTIFIED

Risk for ineffective breast feeding

Risk for hypoglycaemia

Risk for impaired skin integrity

NURSIND DIAGNOSIS

Risk for infection related to immature immune system.

Risk for ineffective breast feeding related to maternal infection

Risk for hypoglycaemia related to ineffective feeding.

Risk for impaired skin integrity related to side effects of phototherapy.

ASSESSMENT NURSING DIAGNOSIS

EXPECTED OUTCOME

PLAN OF ACTION RATIONALE IMPLEMENTATION EVALUATION

Subjective data: Mother asks whether her baby will get any infection from hospital.

Objective data:The baby’s immune system is immature.

Risk for infection related to immature immune system.

The baby remains free from infection

Educate mother about keeping the umbilical cord stump clean.

Advice to reduce the number of visitors.

Advice to change the soiled diaper frequently.

Ensure hourly breast feeding.

Ensure the breast hygiene of the mother.

Administer Hepatitis B immune globulin

To prevent cord contamination.

To prevent cross infection.

To prevent urinary infection and skin rashes.

Breast milk adds to infants immunity.

To prevent the transfer of micro organisms.

To prevent the transmission of mother to the baby

Educated the mother about keeping umbilical cord stump clean and avoid touching it with hand.

Advised to reduce the number of visitors.

Advised to change the soiled diaper frequently.

Educated mother about need for hourly feeding

Advised mother to keep her breast clean before and after feeding the baby.Administered Hepatitis B immune globulin

The baby has no signs of infection

ASSESSMENT NURSING DIAGNOSIS

EXPECTED OUTCOME

INTERVENTION RATIONALE IMPLEMENTATION EVALUATION

Subjective data:Mother says that baby is crying when she try to give breast feed.

Objective data :Mother not holding the baby properly during breast feeding.Baby is not attached to the breast properly.Baby looks sleepy.

Risk for

hypoglycaemia

related to

ineffective

feeding

Baby remains

free from the

risk for

hypoglycaem

ia during the

period of

hospitalisatio

n.

Teach proper feeding techniques.

Advice the mother to feed the baby in time.

Advice the mother to wake up the baby if he sleeps in between feeding.

Teach the mother the importance of breast feeding.

Assist the mother in feeding the baby.

Teach the mother the signs of hypoglycaemia of baby.

To help her to feed baby properly

To avoid risk for hypoglycaemia.

To avoid baby going to hypoglycaemia.

To make her to breast feed the baby properly.

To make sure that the mother is feeding baby properly.

Help to take necessary interventions.

Taught proper positions for feeding

Advised mother to feed the baby atleast 2 hourly.

Adviced mother to keep the baby awake during feeding by ticling on sole or ears.

Educated mother about importance of breast feeding.

Assisted mother in feeding the baby.

Educated mother to notice weather the baby is drowsy or always sleeping.

Baby had no hypoglycaemia and the baby is active.

ASSESSMENT NURSING DIAGNOSIS

EXPECTED OUTCOME

INTERVENTION RATIONALE IMPLEMENTATION EVALUATION

Objective data:

Continuous

phototherapy and

fluorescent lights

Risk for

impaired skin

integrity

related to side

effects of

phototherapy.

The baby

maintains

normal skin

integrity as

evidenced by

proper

phototherapy

Measure the quality of photo

energy of fluorescent bulbs

Apply patches to closed eyes

and inspect eyes every 2 hours

Monitor skin temperature

every 2 hours.

Reposition the infant every 2

hours

Monitor fluid intake and output

and provide breast milk

The intensity of blue

light striking the skin

surface from blue light

To prevent the damage of

the retina from high

density of light

To know the fluctuations

in the body temperature

To allow equal exposure

to fluorescent light

It helps in prevention of

dehydration and maintain

good attachment

Measured the quality of photo

energy of fluorescent bulbs

Applied patches to closed eyes

and inspect eyes every 2 hours

Monitored skin temperature

every 2 hours.

Repositioned the infant every 2

hours

Monitored fluid intake and output and provided breast milk

The baby

maintain

normal skin

integrity as

evidenced by

proper

phototherapy

treatment

SUat 1.3MMARY

I took Mrs. Manjulla a 25 year old post natal mother during my clinical posting in

cooperation hospital, as a part of my clinical requirement. She was on her third post natal

day. She underwent caesarean section on 24/9/11 at 1.30 pm and delivered a male baby with

birth weight 2900 gms. I collected her health history and performed post natal examination.

She was having problems like pain, insomnia, nutritional imbalance and wound infection.

Her baby was having problems like, jaundice ,risk for infection and in adequate breast

feeding. I tried to solve their problems by giving health educations and advising her about

necessary interventions. Some of her problems like pain and insomnia has reduced with the

interventions. Her surgical site stitches were removed on 9 th postoperative day. She acquired

adequate knowledge regarding wound care new born care and she started breast feeding the

baby properly.

CONCLUSION

I took Mrs. Manjulla Hbs Ag positive mother as my postnatal care study. She underwent

caesarean section on 24/9/12 at 1.30pm and delivered a boy baby with birth weight 2900

gms. I was able to study about the care of a postnatal patient who has undergone a caesarean

section and her baby and to provide care for her.

REFERENCES

DuttaD.C . Text Book Of Obstetrics Including Perinatology And Contraception. VIth

ed .Culcutta :New Central Book Agency ; 2004. P 145-54

Care- postnatal and puerperium. Amarson collections. Available at

:http://www.planbaby.com/care%20post%20PUER HTM

Deglin J H, Vallerant A H. Drug guides for nurses. 9th ed. Davis

publications;philadalphia:2005. P 127, 395, 856,960, 734

Doenges M. MoorhouseM. Maternal and newborn plans of care. 3rd edition. USA;FA

Davis company. Philadelphia. 1994

Hepatitis B in pregnancy . Available

from:http://www.perinatology.com/exposures/Infection/HepatitisB.htm

Hepatitis B immunization .Available from: http://www.immunize.org.

UNIVERSAL COLLEGE OF NURSING

POSTNATAL CASE STUDY

SUBMITTED TO : MRS PRATHIMA.P

ASST.PROFESSOR

HOD DEPARTMENT OF OBG

UNIVERSAL COLLEGE OF NURSING

BANGALORE

SUBMITTED BY: MS AMALA GEORGE

2ND YEAR MSC NURSING

UNIVERSAL COLLEGE OF NURSING

BANGALORE