Case presentation on Post natal care (PNC).pptx

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my file, Case presentation on Post natal care (PNC).pptx covers the aspects of PNC including Gordon's 11 health patterns, nursing diagnosis and nursing care plan. I have get my best efforts. Jazakallah Khayer.

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2. Case Presentation on Post Natal Care ( 1 st post natal day following normal vaginal delivery). Presented by Rabeya Sultana Reta 2 nd semester WHMN BSMMU

3. Principles of Post natal care 3 Care of the mother Care of the newborn baby Health education to the mother Counseling about family planning Involving husband to the Care Education to the family members

4. Client’s Information Name of Patient : Mrs. R. Age: 23 years. Occupation: Housewife Father’s Name: Md.SAlam . Mother’s Name: M. Begum. Religion: Islam Address : 32/2, Buter Goli , Dhaka ( present) Bhola , Barishal , ( permanent ). Name of Hospital: BSMMU Hospital. Reg. No. : 1156/3 W ard: 8/B, Bed: LT-3 Unit: orange. ( Prof. T.R.. Das). Date of Admission: 11/06/24, Date of Discharge: 01/04/24 Contact number: 018 00000 453 4

5. Presenting health status 1 st post natal day following normal vaginal delivery. Mild lower abdominal pain. General appearance is mild ill looking. Well oriented and cooperative. Vital signs are within normal range. Bed in with her healthy baby. Ineffective breastfeeding. Lochia rubra present in Average. 5

6. Obstetric history Menstrual history: Age of menarche : 13 yrs. Menstrual Cycle: 28-30 days. Menstrual period: 4-5 days. Menstrual flow: Average . Menstrual problems: No any. Marital history: Non- concengunious marriage. Age of marriage: 16 yrs. Married for: 8 yrs . 6

7. Obstetric history cont’d. Para: 2 (NVD)+0 Space Between birth: 5 yrs . Gestational age: 39 +6 weeks. Presentation : Cephalic . Number of ANC visit: 4 visit done. LMP: 26.08.23 , EDD: 02.06.24 TT vaccine: 5 dose completed . High fever during pregnancy: No any. HBsAg : N egetive . VDRL: Non-reactive. Complications during pregnancy: No any. 7

8. Labor conduction note Mode of Delivery: Normal Vaginal Delivery (NVD ). Date and Time: 11.06.24 at 12:30 PM. Augmentation was done properly. Conducted by: Dr. Sorifa. Assisted by: Dr. Boishakhi and Nurse Hafsa. Amount of bleeding: A verage. Episiotomy not needed. Complications of 2 nd stage: Vaginal laceration. 3 rd stage managed by AMTSL. 8

9. Labor conduction note cont’d. Mode of placenta delivery: Control cord traction (CCT ). Complications of 3 rd stage : No any complications. Placenta and membrane: Complete and normal. Baby note: 3.1 kg. weighted female baby. APGAR score was 7/10. Immediate newborn care was given properly and Initiation of breast feeding done successfully within 20 minutes after delivery. 9

10. Nursing Assessment using Gordon’s functional health patterns 10

11. Health perception-Health management pattern Subjective: Her baby is most important to keep her in well-being. Last three months she has no any gross illness. No history of accidents at home or outside. Uses herbal medicines such as, isobgul and ginger. Rarely takes over the counter drugs such as, Mefenamic acid, metronidazole, paracitamol , emistat ect . When sick, goes to the doctor, sometimes waits for heal. 11

12. Health perception-Health management pattern cont’d. No history of tobacco or alcohol but exposed to have passive smoking. No history of accidents at home or outside. No family history of any chronic illness. Objective: General health status is good . No hearing Problems were detected and No vision problems. 12

13. Nutritional-Metabolic pattern Subjective: Have good appetite, she likes to eat more of fruits and vegetables. Eat her meals 3 times a day with snacks in between. Drink up to 2L of water or 6-8 glasses a day. Claimed to be allergic on shrimps and beef. Takes supplementary iron, folic acid and calcium. Objective: No dental problems like cavity, carries, erosion etc. Healthy oral mucous membrane. Skin was hot but no lesions, edema and cyanosis. Body temperature was 98.7 F and BMI 27 kg/m 2 . Average body weight gained in pregnancy 12 kg. 13

14. Elimination pattern Subjective: Bowel move 1-2 times in a day having norma l consistency and color. She suffered from constipation following pregnancy. History of excessive perspiration in daily activities. Last 2 months feel difficulties to eliminate due to gravidation . Voiding frequency was 10-15 times/day with Straw in color. Feel disturbed in sleep due to voiding frequency. After delivery, bowel moved and passed urine normally . 14

15. Activity-Exercise pattern Subjective : She had sufficient energy for labor process. She did slight physical exercise regularly. She did full self care without any help , devices and any supervision . (functional level code-0) Spare-time spent with her babies, sometimes reading Islamic books etc. Objective: Normal range of motion. No difficulty in breathing, R/R was- 19 breath/m. Pulse rate- 78 b/m. Blood pressure- 110/70 mmHg. 15

16. Sleep-Rest pattern Subjective: Sleep at night- 6 to 8 hours, sometimes take rest in day time. But in hospital bed unable to sleep. Fatigue during pregnancy, Increased level of quiet sleep as fetus developed . Early awakening and sleep onset problem was experienced during pregnancy. Sleep interruptions due to frequent urination, postural discomfort was common. Objective : Rest – relaxation period was normal. Looks sleepy and slight tired. 16

17. Cognitive perception pattern Subjective: She was well oriented about time, place, person and explained her childhood memory. Complain of mild abdominal pain. Psychological change following labor, progesterone affects emotionally on mood-focus on baby. Transitioning process to motherhood, influenced by infant context. Objective: Well understood the questions and give answer during history taking. 17

18. Self perception-Self concept pattern Subjective: She feel good about herself, never fell hopeless. She concerned about her baby. No any significant issues in life changes. No any identified major losses. She feel anxious when her baby become sick. She had emotional state on her grandmother’s death. Objective: Her eye contact, voice and speech pattern was in good during history taking. 18

19. Roles-Relationships pattern Subjective: She lived in joint family with her sister-in-law and husband’s parents. She plays proper roles in her family . She has good relationships with her husband & other family members. Family members were very supportive to her in pregnancy. Social and feel part of neighborhood in her community. Objective: The interactions with family members was good in hospital. 19

20. Sexuality-Reproductive pattern Subjective: She maintain faithful conjugal sexual life with her husband. She has satisfying relationship with her husband. She used contraceptive oral pill (mini pill) for 3 yrs. after her 1 st baby born. She and her husband had no history of STDs. 20

21. Copping stress tolerance pattern Subjective: Feel relaxed most of the time. No history of taking sedative for sleep. She exposed to crisis situation for hospital admission of her 1 st baby due to diarrhoea in last year. When she faced any stress, she shared with her husband sometimes with her mother. She prays attentively to almighty Allah . 21

22. Values-Beliefs pattern Subjective: She wants to better life of her children in future. She get plan for give religious education to the baby. As a Muslim she tries to pray 5 times daily. For labor in hospital admission can’t maintain payer now. She feels belief to A llah as religion as important in life. 22

23. Laboratory findings Name of investigations Findings Normal values CBC: HB% 11.5 g/dl 12-16 g/dl RBC 3.14 ×10 6 /mm 3 [3.44-4.78] ×10 6 /mm 3 Platelet 2 lac. 1.5-3.5 lac ESR 73 mm in 1st hour 0-10 mm in 1st hour Blood grouping & Rh typing O + ( ve ) Urine for R/M/E Pus cell 1-2, epithelial 0.2 FBS 4.71 mmol/L 3.6-6 mmol /L 2HABS 6.05 mmol/L <7.8mmol/L HBsAg Negative TSH 1.04 µIU/L 0.4-4.0 µIU/L 23

24. Abdomen & breast assessment Abdomen assessment: Assess the pain location and characteristics. Assess the uterine contractions . Upper abdomen was soft. Fundus of uterus feel hard and bellow the umbilicus (20 cm.) Breast assessment: Nipple in center and upright. Skin temperature slightly raised. No cracked and no any lesion in the breast. Colostrum present on press. 24

25. Nursing diagnosis Mild abdominal pain due to uterine contractions caused by normal vaginal delivery. Bright red color vaginal discharge related to 1 st day of labor process (lochia rubra ). Ineffective breast feeding related to knowledge deficit about positioning and attachment. Knowledge deficit related to post natal care at home. 25

26. Nursing care plan Assessment Nursing diagnosis Planning Nursing Interventions Rationale Evaluation Subjective: I feel pain in abdomen. Objective: -Hard and tender in lower abdomen. -contracted uterus. Mild abdominal pain due to uterine contractions caused by normal vaginal delivery. -to reduce pain . -to give comfort to the mother. -Administered medications(analgesics) as ordered. -comfortable position was given. -Encouraged the use of relaxation techniques for pain reduction-like deep breathing, and back massage. -Encouraged early ambulation as tolerated. -Provided support for change cloths and vaginal pad. Berens , P. (2022, January). -Analgesics reduce pain. -positioning is one factor of reluxation . -Patient had report of reduced pain. -demonstrate comfort measures.. 26

27. Nursing care plan Assessment Nursing diagnosis Planning Nursing Interventions Rationale Evaluation Subjective: 2 pad soaked with red blood. Objective: Seeing the lochia in pad and genital area . Bright red color vaginal discharge related to 1st day of labor process (lochia rubra ). -to reduce dyscomfort . -to provide hydration. -to give nutritional supplements. -to prevent anemia & infections. -advice to take iron, vitamins and supplements. –Encourage the patient to drink fluid in plenty. -changed pad. -keep clean the genital area. -instruct to count the used pad in a day. Boushra M,2021 -iron prevent anemia. -fluid correct dehydration. -pad count help to estimate blood loss. -Nursing interventions were effective as reduced discomfort and prevention of infection. 27

28. Nursing care plan Assessment Nursing diagnosis Planning Nursing Interventions Rationale Evaluation Subjective: -Baby make sound of sucking. - baby pass less urine. Objective: observed difficulty in breastfeeding -observed faulty positioning and attachment. Ineffective breast feeding related to knowledge deficit about positioning and attachment. -to teach positioning and attachment to the mother. -to establish effective breastfeeding. -to prevent complications. -Provide support –Explain the importance of breastfeeding.  -Teach proper positioning and attachment.   -Display positivity and -Allow time for bonding with the baby. Lactation Consultant, 2022 -teaching make correction to the technique. -bonding encourage mother to the baby. effective breastfeeding as evidenced by 6-8 times urination of baby. -mother feel comfort to the breast. 28

29. Health educations Focus on the:- promotion of newborn care (exclusive breastfeeding, warmth, hygiene, immunization etc ). Baby bathing and hair cutting after discharge. promotion of nutrition & personal hygiene to the mothers. Advise on rest and sleep and fluid intake to the mother. providing information about danger signs of both the mother and newborn. Post natal exercise to the mother for proper involution. Avoid heavy load at least 3 months. Supplementary iron and folic acid up to 42 days of delivery. 29

30. FP Counseling It provides awareness of the importance of birth spacing (HBS 3-5 yrs.) and postpartum contraceptive options . Barrier methods (Condom) can be used in breast feeding mother, starting 6 weeks after childbirth. Exclusive Breastfeeding provide natural contraception. Advice to take contraceptive implant. contraceptive injection, Progestogen-only pill. For use of IUCD-long term & non hormonal method, the uterus and cervix have returned to normal size. 30 Advice on Post natal follow up at 3-5, 7-14 and 42 days.

31. References BMJ Global Health. WHO recommendations on maternal and newborn care for a positive postnatal experience: strengthening the maternal and newborn care continuum, January 2023. Available link: https :// doi.org/10.1136/bmjgh-2022-010992 Berens , P. (2022, January). Overview of the postpartum period: Normal physiology and routine maternal care . World Health Organization (WHO). Medical Eligibility Criteria for Contraceptive 5th ed. WHO; 2015. Accessed October 5, 2022 http ://en.wikipedia.org/wiki/Gordon's_functional_health_patterns. 31

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