IDENTIFICATION DATA:

Name - Mrs Poonam

Age - 25 years

Sex - Female

Religion - Hindu

I.P.D. NO -546785

Education -B.A

Marital status - Married

Address - parade

Occupation - Housewife

Date of admission - 30.05-2024

Obstetrical score -G2 P1 L1 A0

LMP- 27.08-2023
EDD- 03.06.2024
DIAGNOSIS- LSCS with placenta previa
Date of delivery- 02.06.2024
Gravid- G2 P1A0L1

CHEIF COMPLAINTS AT THE TIME OF ADMISSION-

Bleeding per vagina since morning.

HISTORY OF PRESENT ILLNESS-

Patient came to hospital at 7 am on 30.05.2024 with H/O bleeding per vagina.
CHEIF FINDINDS AT THE TIME OF ADMISSION-

B.P- 110/70 mm Hg
Pulse- 74 / min.
Pallor - +
P/A- 34-36 weeks
Cephalic
FHS + regular
Uterine contraction

HISTORY OF PAST ILLNESS-

She doesn’t have any significant medical illness even in her previous pregnancy. She does not
have any gynecological or other operation in the past.

OBSTETRICAL HISTORY-
G2 P1
Duration of marriage- 12 years
No. Of living children- 1

MENSTRUATION HISTORY-
Menstrual cycle- 28-30 days
Menarche - 16 years
Duration - 4-5 days
Amount of blood flow- normal
Contraceptive history- no any contraceptive devices used.

IMMUNIZATION HISTORY-
Patient has undergoes TT immunization at 4th month and 5th month of pregnancy.
 FAMILY HISTORY-
There is no communicable disease in the family. All family members are healthy.

TYPE OF THE FAMILY:

She is living in a nuclear family. She is living with her husband. All her family members do not
have any hereditary or communicable diseases. They do not have medical or surgical history even.

FAMILY COMPOSITION-

S.l. Name Relationship Age Sex Educatio occupation Marit Health

with the
no n al status
patient
status

1 Mr. Rohan Husband 27year Male B.com Bank Good Healthy

employee

2. Mrs. Poonam Self 25year Female B. A Housewife Good Caesarian

section

3. Baby Daughter 3year Female Nil Nil - -

 FAMILY TREE-

KEYS-

Male =

Female =

Client =

PHYSICAL EXAMINATION

General appearance:

She is well nourished and has a moderate body built. She is groomed neatly but she looks anxious.

Posture –

She has an erect body. She does not have any abnormal body curvature like lordosis, kyphosis or
scoliosis.
Skin–

She has a normal skin color. There is presence of no macules, papules, vesicles or skin rashes, etc.

Head and face:

Her hair is black in color. It is thin and smooth in texture. The scalp is clean and clear. Her face
looks anxious.

Eyes:

Her eyebrows are symmetrically present; there is equal distribution of eyelashes. Eyelids are free
of infection or sty; the conjunctiva is pink in color. Sclera is transparent in nature. The pupils are
equally reacted to light and her vision capacity is adequate.

Nose:

It is normal in shape and structure. The nostril is clean and it is free of discharges and crust
collection. Both the nostrils are symmetrical in opening as equally divided by the nasal septum.

Ears:

The external ears are normal in shape and structure. There free of discharges, cerumen collection
or the perforation of the tympanic membrane and infection in the internal ear.

Mouth:

The lips are smooth, the teeth are white in colour and they are free of dental carries. The gum is
pink in colour and it’s free from swelling and bleeding. The tongue is pink in colour, moist. The
tonsils are free from infection.

Neck:

During inspection there is no enlargement of the thyroid gland and all the range of movement are
possible without causing any pain. There is no enlargement of the lymph node during palpation.

Chest:
On inspection - There is symmetrical expansion of the thorax and she has a normal breathing
pattern.

On auscultation - There is no abnormal breath sound like whistling sound, rale or crackle sound,
etc. While doing examination there is no abnormal heart sound like cardiac murmur.

Breast –
Inspection - Secondary areolar present
No Montgomery’s tubercle
Nipple are not cracked
Palpation - There is no tenderness or any other abnormalities.

Abdominal examination –
 Inspection - Linea nigra is present
o Strae gravidarum present
o There are no incision marks
o Size of the uterus longitudinal
Palpation - Not done due to placenta previa
Fundal height- 34 cm
Auscultation- FHS- 142/ min.

Per vaginal examination- There was bleeding per vaginum at the time of examination.

NURSING DIAGNOSIS;

1. Acute pain related to physiological changes postnatal period and surgical incision wound
2. Imbalanced nutrition less that body requirement related to increased caloric requirement and
anorexia secondary to lactation.
3. Risk for infection related to post LSCS wound and indwelling catheter.
4. Deficient knowledge, family planning, related to planning for next child.
Assessment Nursing Goal planning Implementation Evaluation
diagnosis

SUBJECTIVE Acute pain Mother Assess the pain Assessed the pain and
related to will have and discomfort. discomfort.
DATA- -Provide the -Provided the comfort
physiological the Mother verbalizes
comfort position, position, assist in
changes reduced that is feeling
Mother assist in changing position and
postnatal changing provide additional comfortable.
verbalizes that pain and
period and position and pillows.
she is having discomfort
surgical provide -Reduced the anxiety
acute pain over
incision wound additional -Used diversional
the surgical pillows. activities such as Mother is doing
site. -Reduced the listening to slow music. by her -self some
anxiety -Maintained the aseptic
-Use diversional techniques activities.
activities such as -Changed the dressings
OBJECTIVE listening to slow regularly.
music. -Involved the patient in
DATA-
-Maintain the making decisions about
aseptic care to reduce the sense
She has techniques of powerlessness.
restlessness -Change the -Attended the mother`s
dressings comfort and needs to
and discomfort regularly increase her trust
-Involve the -Spend as much as time
patient in making possible with the mother
decisions about to provide comfort and
care to reduce assistance.
the sense of -Apply warm
powerlessness. applications
-Attend the -Encourage the mother to
mother`s comfort use the diversional
and needs to therapy
increase her trust -Encourage the mother to
-Spend as much do her simple self-care
as time possible activities by herself.
with the mother
to provide
comfort and
assistance.
-Applied warm
applications
-Encouraged the
mother to use the
diversional
therapy
Assessment Nursing Goal Planning Implementation Evaluation
diagnosis

SUBJECTIVE Imbalanced Mother Assess the general Assessed the general She is eating food
DATA- nutrition less will take conditions of the conditions of the now.
that body the mother mother
Mother-in-law requirement balanced
verbalizes that related to nutritional -Assess the pain -Assessed the pain
she is not taking and discomfort. and discomfort. She is looking
increased intake. calm and taking
food after caloric -Monitor the -Monitored the food.
requirement
Surgery. mother`s vitals. mother`s vitals.
and anorexia Playing with child
secondary to -Provide the -Provided the
lactation. comfort position comfort position
OBJECTIVE
-Find out the her -Found out the her
DATA- likes and dislikes likes and dislikes of
of food food
On physical
examination -Plan for balanced -Planed for balanced
Mother is diet diet
looking weak
-Educate the -Educated the mother
and restless.
mother about the about the importance
importance of the of the dietary intake
dietary intake during lactating
during lactating period.
period.
-Provided rest and
-Provide rest and sleep.
sleep.
-Encouraged the
-Encourage the mother to take more
mother to take fluids.
more fluids.
-Reduced the anxiety
-Reduce the
anxiety -Provided the
psychological &
-Provide the spiritual support.
psychological &
-Encouraged the
spiritual support.
mother to speak out
her fears.
-Encourage the -Used the diversional
mother to speak therapy
out her fears.
-Modified the
-Use the attitude of the
diversional mother and make her
therapy to accept the food
offered.
-Modify the
attitude of the -Made her
mother and make understand the needs
her to accept the the new born and
food offered. feed her properly
Assessment Nursing Goal Planning Implementation Evaluation
diagnosis
Subjective Risk for Mother will Make her Assessed the general There are no
data: infection have the understand the conditions of the signs of
related to reduced risk needs the new mother infection
Client’s post LSCS for infection born and feed her
-Assessed the pain
verbalizes her and discomfort.
wound and properly -Followed the strict
pain at incision indwelling aseptic techniques
site.
catheter. -Changed the
-Assess the
dressings regularly
general conditions
-Educated not keep
of the mother
hands over surgical
Objective data: -Assess the pain
site, keep clean& dry
and discomfort.
Mother is -Emptied the urinary
-Follow the strict
bag regularly
having surgical aseptic techniques
-Provided perineal
wound and -Change the
care
indwelling dressings
-Educated the mother
catheter regularly
about to inform if
-Educate not keep
anything happens.
hands over
-Administered the
surgical site, keep
antibiotics
clean& dry
-Reduced the anxiety
-Empty the
-Provided the
urinary bag
psychological &
regularly
spiritual support.
-Provide perineal
-Encouraged the
care
mother to speak out
-Educate the
her fears.
mother about to
-Record the findings.
inform if anything
happens
-Administer the
antibiotics
-Reduce the
anxiety
-Provide the
psychological &
spiritual support.
-Encourage the
mother to speak
out her fears.
-Record the
findings.
Assessment Nursing Goal Planning Implementation Evaluation
diagnosis

SUBJECTIVE Ineffective Mother will Encourage the Encouraged the Mother is

DATA- breast-feeding have the mother to feed the mother to feed the feeding the
techniques of feed the neonate neonate baby by lying
Mother -Encourage her to -Encouraged her to
child related child down position
verbalized that hold the neonate hold the neonate
to related to effectively -Encourage the -Encouraged the with support to
she has pain difficulty to the baby for
mother to speak out mother to speak out
on the surgical position the elevation.
her feelings her feelings
site and not baby -Involve the family -Involved the
able position secondary to in feeding the child family in feeding
the baby to immediate make them to assist the child make
feed. the mother them to assist the
post LSCS
-Position the child mother
mother properly and feed as -Position the child
per the demand of the properly and feed
OBJECTIVE child as per the demand
DATA- -Remind the needs of of the child
the new child and -Reminded the
Mother is on encourage her to feed needs of the new
bed rest after the child child and
immediate -Provide the encourage her to
psychological feed the child
post LSCS support -Provided the
-Involve the husband psychological
in the process of support
education and -Involved the
support and care husband in the
-Educate the mother process of
about the importance education and
of breast milk and its support and care
composition -Educate the
-Warn the mother mother about the
about the effects on importance of
the baby if breast breast milk and its
milk is not given. composition
-Warn the mother
about the effects on
the baby if breast
milk is not given.
SUMMARY:

My Patient Mrs.ponam came with labour pain with contractions for4 hours. Patient is full term
primi mother. On admission 4 finger tight and labour pains. She is having acute pain on back and
abdominal area. Due to unbearable pain for her she is ready for elective LSCS she delivered a male
baby. Bothe mother and baby are healthy. After providing 5 days care, Patient was maintaining
good nutritional status. Patient is maintaining stable vital parameters.

CONCLUSION:

During my clinical posting in postnatal ward at SMGS hospital Jammu. I got chance to provide
care to, Mrs Poonam with diagnosis of Postnatal mother with elective LSCS by this study I learn
in detail about LSCS and its management. I thank my client for his cooperation and my clinical
coordinator for her valuable guidance.

Bibliography:-
 Dutta D.C;”Text book of obstetrics”; published by New Central Book agency LTD; 6th
edition ;2004; pageno. 454 to 457
 Pearson j. Linda nurse practioners drug handbook third edition published by
Doonao.Carpenter pageno.530 to 535.
 www.slideshare.LSCS.net