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Intranatal Case Study 28

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0% found this document useful (0 votes)
166 views32 pages

Intranatal Case Study 28

Uploaded by

Shikha
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
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CASE STUDY ON

INTRANATAL MOTHER
DEMOGRAPHIC DATA [ /2M]
Name:________________________________________________________________________________________
Age: __________________________________________________________________________________________
Sex: __________________________________________________________________________________________
D.O.A: ________________________________________________________________________________________
IP No: _________________________________________________________________________________________
Ward: _________________________________________________________________________________________
Bed no: _______________________________________________________________________________________
Marital history: _________________________________________________________________________________
EDD: _________________________________________________________________________________________
GPALS SCORE: ________________________________________________________________________________
Diagnosis: ______________________________________________________________________________________
Surgery: _______________________________________________________________________________________
LMP: _________________________________________________________________________________________
D.O.S: ________________________________________________________________________________________
Address: ______________________________________________________________________________________
Hospital: ______________________________________________________________________________________

History of the patient: [ /18M]


Chief complaints:
_______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
Present illness:
_______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________

Past medical history:


_______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________

Past surgical history :


_______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
Socioeconomic history :
_______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________

Obstetrical &gynaecological history:


_______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________

Personal history :
_______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________

Menstrual history:
_______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________

Dietary history:
_______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
Family history:

Sr. Name of family Age Sex Relation Education Occupation Health


No member with HOF status
1

Family tree:

Marital history:
_______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________

Trimester history:
1st Trimester:
_______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
2nd Trimester:
_______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
3rd Trimester:
_______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________

PHYSICAL EXAMINATION: [ /7M]

1. General appearance:
Height

Weight

Body built

Look

posture

2. Vital signs:
Temperature

Pulse
B.P
Respiration
Spo2

3. Head to toe examination:


1. Head and neck:
Hair

Scalp

2. Face:
• Eyes:

Eye brow and eye


lashes
Pupils

Conjunctiva

Iris
• Nose:
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
• Ears:
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
• Mouth:
Lips

Teeth

Tongue

• Neck :
Thyroid

Range of motion

Throat

3. Chest :

Heart and breath sound: _________________________________________________________________________


• Breast:
Inspection:
Nipple condition: _______________________________________________________________________
Skin changes: __________________________________________________________________________
Palpation:
Any palpable lumps

Evidences of colostrum

Axillarynode enlargement

Engorgement Evident / not evident

Any other significant findings


4. Abdominal examination:
Inspection

Palpation

Consistency

Auscultation

Anything significant

5. Genitalia :
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
6. Rectum :
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
7. Back and spine :
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
8. Perineal examination:
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
9. Extremities :

Homans sign Positive/Negative

Edema Evident/Not evident

INTRANATAL EXAMINATION:
Vital signs:
Temperature
Respiration

Pulse

Blood pressure
Spo2
Past obstetrical history:

Sr Year Full Preterm Abortion Types of Sex of Alive Still Weight Remark
no term delivery baby birth

Prenatal visit:

Date of Weight Height Urine B.P FHR Weeks Height Position Treatment
booking of of
gestation fundus
USG finding:
__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________
has been ___________________ hours in labor __________________________ membrane
rupture / intact___________________________hours ago___________________________.
Condition on admission:
General condition: good/average/poor
Hydration: _________________________________________________________________
Anemia: ___________________________________________________________________
Edema: ____________________________________________________________________
Bladder: ___________________________________________________________________
Any other findings: __________________________________________________________
Abdominal examination:
Palpation:
Haight of the uterus in CM _____________________ in weeks _______________________
abdominal girth: _____________________ condition on uterus _______________________
Palpation: __________________________________________________________________
Fundal grip: ________________________________________________________________
Lateral grip: ________________________________________________________________
Pelvic grip: ________________________________________________________________
Pawlic grip: ________________________________________________________________
FSH: ______________________________________________________________________
Presentation: _______________________________________________________________
Position: ___________________________________________________________________
Engagement: _______________________________________________________________
P.V examination:
Date Time Findings
Management during first stage of labor:
Time of onset of labor __________________ time of fulldilation of cervix ______________
walk/rest: __________________________________________________________________
diet: ______________________________________________________________________
bowel: ____________________________________________________________________
bladder: ___________________________________________________________________
Relief of pain: ______________________________________________________________
General care: _______________________________________________________________
Vulval toileting: _____________________________________________________________
Bath: _________________________ clothing: ____________________________________
Encouragement: _____________________________________________________________
Progress notes of labor:
Stages of labor Time of onset Total duration Remark

Stage 1 _____hrs_____min

Stage 2 _____hrs_____min

Stage 3 _____hrs_____min

Preparation of labor:
__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________
time duration: _________________________ hrs _________________________ minutes.

Date and time of delivery: _____________________________________________________


Nature of delivery: normal/forcep/ventus/any other:
__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________

Placenta and membrane:


Spontaneous expulsion/ assisted expulsion/ manual
Removal: complete/ incomplete
Abnormalities: ______________________________________________________________
weight: ________________gm. Length of cord: ________________________________cm.

Condition of new born:

Record of any resuscitation measure done:


__________________________________________________________________________
__________________________________________________________________________
breathing: __________________________________________________________________
sex: ______________________ alive / still birth: __________________________________.

Term/preterm/post term: ______________________________________________________


weight: __________________ gm length: ___________________________________cm.

APGAR score:
__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________
airway:
__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________
circulation:
__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________
any abnormalities:
__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________
DISEASE CONDITION: [ /8M]

INTRODUCTION:
_______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
DEFINITION:
_______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________

ETIOLOGY:
In book In patient
SIGN AND SYMPTOMS:
In book In patient
DESCRIPTION (PICTURE/DIAGRAM):
INVESTIGATIONS: [ /4M]
In book In patients

DESCRIPTION (PICTURE/DIAGRAM):
TREATMENT & MANAGEMENT: [ /5M]
Medical management:
In book In patient

Surgical management:
In book In patient

DESCRIPTION (PICTURE/DIAGRAM):
NURSING ASESSMENT: [ /4M]
_______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
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_______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
NURSING DIAGNOSIS: [ /5M]
1. ____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
2. ____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
3. ____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
4. ____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
5. ____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
6. ____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
7. ____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
8. ____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
9. ____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
___________________________________________________________________________________
10. ____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
Assessment Diagnosis Goal Planning Implementation Rationale Evaluation

/2M
Assessment Diagnosis Goal Planning Implementation Rationale Evaluation

/2M
Assessment Diagnosis Goal Planning Implementation Rationale Evaluation

/2M
Assessment Diagnosis Goal Planning Implementation Rationale Evaluation

/2M
Assessment Diagnosis Goal Planning Implementation Rationale Evaluation

/2M
NURSE’S NOTES: [ /3M]
_______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
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_______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
HEALTH EDUCATION: [ /8M]

1._________________________

2.____________________________
3._________________________

4._________________________

5._________________________
CONCLUSION: [ /2M]
_______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
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_______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
REFERENCES: [ /3M]
Books:
1. _________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
2. _________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
3. _________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
4. _________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________

5. _________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
Websites:
1. ________________________________________________________________________________________
2. ________________________________________________________________________________________
3. ________________________________________________________________________________________
4. ________________________________________________________________________________________
5. ________________________________________________________________________________________

Other criteria for scoring:

1 Selection of patient [ /3M]

2 Content [ /3M]

3 Submission on time [ /2M]

4 Knowledge on the subject & topic [ /3M]

Remarks:
_______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________

[ /100M]

SIGNATURE OF STUDENT: SIGNATURE OF TEACHER:

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