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INDEX
S.NO CONTENT PAGE NO
STUDENT PROFILE
NAME
COURSE
SUBJECT
NAME OF THE INSTITUTION
PATIENT SELECTED FROM
INTRODUCTION
Mrs……….. got admitted in the era hospital, lucknow on ……………with the complaints of
HISTORY OF PATIENT
IDENTIFICATION DATA
Name
Age
Sex
Bed no
Ipd no
Address
Nationality
Religion
Education
Occupation
Marital status
Family members
Addiction
Diagnosis
Doctor incharge
Source of information
Date of admission
Time of admission
Obstetric score
CHIEF COMPLAINTS
PRESENT HISTORY OF ILLNESS
PAST MEDICAL HISTORY

CHILDHOOD ILLNESS
IMMUNIZATION
MEDICAL HISTORY
PAST SURGICAL HISTORY
PERSONAL HISTORY
Drug addiction
Dietary habits
Sleeping pattern
Nutritional pattern
Exercise pattern
Work pattern
Hygiene
Bowel pattern
Allergies
Hobbies
MENSTRUAL HISTORY
Age of menarche-
Duration of menstruation
Amount of menstruation
Menstrual irregularities
Dysmenorrheal
LMP
EDD
MARITAL HISTORY
Age of marriage
Type of marriage
Consanguineous marriage
Relationship with husband
No. of children
Any sexual disorder
PAST OBSTETRICAL HISTORY
s.no date and year pregnancy event labor methods of nvd puerperium baby status
HEALTH OF PARENTS/SIBLINGS/SPOUSE/CHILDREN
Parents-
Siblings
Spouse
Children
FAMILY MEMBERS
S.no. Name age Sex Education Health Relationship Death if any

status
FAMILY MEDICAL HISTORY
FAMILY SURGICAL HISTORY
FAMILY TREE
PSYCHOSOCIAL HISTORY
Primary language
Secondary language
House
Type of family
Relationship of patient with family
Mood of patient
Social group of patient
Position of patient in society
Position of patient in family
Socioeconomic status of patient
ENVIRONMENTAL HISTORY
Cleanliness of house
Type of residence area
Village/city/town
Hazards
Pollutant
Water supply
Sanitation
Drainage system
Method of waste disposal
Method of cooking practice
Any epidemic disease
Mode of transportation
Miscellaneous
VITAL SIGN
S.no Vital sign Patient value Normal value Evaluation

1 Temperature 98.60F
2 Pulse 70-80 beats/min
3 Respiration 16-24breath /min
4 Blood pressure 120/80 mm of hg
5 Pain
6 SpO2 95-100%
INVESTIGATION
S.no investigation Patient value Normal value remark

1 CBC-Hb 12-14mg/dl
TLC 4.5-11000/cumm
DLC-Monocytes 2-10%
Neutrophils 40-80%
Lymphocytes 20-40%
Eosinophils 1-2%
Basophils 1-2%
Platelates 1.5-4 lakh
Blood group
2 PT 11-13.5sec.
3 INR 1.1-2 sec.
4 KFT- 0.6-1.2mg/dl
S.Creatinine
5 BUN 7-20 mg/dl
6 Uric acid 2.4-6.0 mg/dl
7 TFT-TSH 0.4-4.0mlIU/L
T3 100-200ng/dl
T4 0.7-1.9ng/dl
8 HbsAg
9 HCV
10 VDRL
ULTRASOUND FINDINGS
MEDICATION
S.No. Medicines Dose Route frequency Action

OTHER SUPPORTIVE THERAPIES
PHYSICAL EXAMINATON
GENERAL APPEARANCE
Look
Orientation
Consciousness
Nourishment
Body built
Height
Weight
Dress
Odour
Hygiene
Speech
Posture
Appearance
Pain
HEAD AND NECK
Scalp
Hair color
Symmetry of head
Shape and size
Dandruff
Pediculosis
Alopecia
Scar/lesions
Headache
Dizziness
FACE
Chloasma
Color
Turgor
Texture
Scar
EYES
Symmetry
Discharge
Eye lashes
Sclera
Conjunctiva
Periorbital oedema
Pallor
Spectacles
Color of iris
NOSE
Epistaxis
Discharge
Polyps
Sinuses
Symmetry
EARS
Pinna
Shape and size
Location
Discharge
Hearing power
Hearing aids
Cerumen impaction
Crust formation
MOUTH
 Lips
Color
Cracking
Symmetry
Cheilosis
 Mucosa
Hydration
Integrity
 Tongue
Coating
Halitosis
Color
 Teath
Color
Dental caries
Dental infection
Gums
 Neck
Lymphadenopathy
Thyroid enlargement
Range of motion
Lesions
Juglar vein distension
BREAST
 Inspection
Shape
Nipple shape
Primary areola
Secondary areola
Montogmerty tubercles
Dryness
Cracked nipples
Scar formation
 Palpation
Tenderness
Axillary lymph node tail
Enlargement
Masses
Lesion
CHEST
 Inspection
Symmetry
Lesion
Expansion
 Palpation
Respiration rate
Bilateral expansion
Apical pulse
 Percussion
Fluid accumulation
 Auscultation
Wheezing sound
S1 S2 heard
Heart rate
Heart murmur
 ABDOMEN
 Inspection
Size
Abdominal girth
Linea nigra
Striae albicans
Striae gravidarum
Lesion
 Palpation
Fundal grip
Lateral grip
Pelvic grip
Pawlick grip
Uterus
Fundal height
 Percussion
Braxton hicks contraction
 GENITAL AREA
 Palpation
Tenderness
Edema
Hygiene
PV examination
 EXTREMITIES
Range of motion
Pain
Mobilities
Human`s sign
Leg cramps
Muscle strength
Edema
 DELIVERY NOTES
NURSING DIAGNOSIS AND
CARE PLAN
NURSING DIAGNOSIS
1. Acute pain (lower pelvic area)related to episiotomy would as evidenced by verbal

communication.
2. Anxiety related to hospitalization as evidenced by verbal report.
3. Hyperthermia related wound infection as evidenced by increased body temperature and
WBC level.
4. Deficit fluid volume less than body requirement related to vaginal bleeding as evidenced
by decrease urine output.
5. Self care deficit related to episiotomy pain and presence of lochial discharge as evidenced
by poor personal hygiene.
6. Activity intolerance related to imbalance between oxygen supply and demand as
evidenced by low hemoglobin level.
7. Ineffective therapeutic regimen related to improper self care during postnatal period as
evidenced by less ambulation and post natal exercise.
NURSING GOALS
SHORT TERM GOALS
 To reduce pain
 To reduce infection
 To reduce anxiety and discomfort
 To improve condition of patient
 To provide comfort measures to patient
 To maintain hygiene
 To encourage for exclusive breast feeding
LONG TERM GOALS
 To prevent complication.
 To promote early wound healing
 To rehabilitate the patient
 To encourage client for follow up care
NURSING CARE
PLAN
Assessment Nursing Goal Intervention Implementatio Rationale Evaluation
diagnosis n
Subjective
data
Objective
data

diagnosis n
Subjective
data
Objective
data

diagnosis n
Subjective
data
Objective
data

diagnosis n
Subjective
data
Objective
data

diagnosis n
Subjective
data
Objective
data
OTHER INTERVENTIONS
 Vital signs should be checked daily

 All prescribed medication is given on right time with proper dose
 Intake and output charting is done
 Patient is under close observation
 Psychological support is given.
 Clarify all the doubts of patient.
 Documentation and reporting is done.
PROGRESS REPORT
DAY -1
 Fever reduced
 Vital signs monitored
 IV fluid on flow
 Patient is comfortable
DAY-2
 All investigation are done

 All medications are done
 FHS monitored.
 NVD conducted. Both mother and baby are stable and healthy.
DAY -3
 All blood values are normal

 Fundal height is recorded and reported
 Fluid and electrolyte balance is normal
 Input output record is maintained
DAY -4
 Anxiety is reduced
 Oral diet is allowed
 Bowel movement is normal
HEALTH EDUCATION
MEDICATION
 Educate patient to take medicine on time.

 Iron, folic acid, calcium and vitamin supplements are advised.
 The action and importance of medicines are explained to the patient.
 Follow up is advised
NUTRITIONAL ADVICE
 Advice to take protein and calcium rich diet, like soyabean, pulses, curd, milk.
 Advice to take plenty of fluids
 Advice to take small frequent meals
 Advice to avoid cold beverages.
REGULAR FOLLOW UP
 Advice patient to continue the follow up

 Educate patient about postnatal care
 Advice patient to visit hospital regularly
 Report to consultant on any emergency.
EXCLUSIVE BREAST FEEDING
 Educate patient about exclusive breast feeding techniques.

 Explain about different positions while breast feed the baby.
 Educate mother about feed on demand.
 Explain benefits of breast feeding.

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INDEX

S.NO CONTENT PAGE NO

NAME OF THE INSTITUTION

PATIENT SELECTED FROM

PRESENT HISTORY OF ILLNESS

PAST MEDICAL HISTORY

PAST SURGICAL HISTORY

Relationship with husband

Any sexual disorder

PAST OBSTETRICAL HISTORY

S.no. Name age Sex Education Health Relationship Death if any

FAMILY MEDICAL HISTORY

FAMILY SURGICAL HISTORY

Relationship of patient with family

Social group of patient

Position of patient in society

Position of patient in family

Socioeconomic status of patient

Type of residence area

Method of waste disposal

Method of cooking practice

Any epidemic disease

S.no Vital sign Patient value Normal value Evaluation

S.no investigation Patient value Normal value remark

S.No. Medicines Dose Route frequency Action

HEAD AND NECK

Shape and size

Shape and size

Axillary lymph node tail

Braxton hicks contraction

1. Acute pain (lower pelvic area)related to episiotomy would as evidenced by verbal

SHORT TERM GOALS

LONG TERM GOALS

Assessment Nursing Goal Intervention Implementatio Rationale Evaluation

Assessment Nursing Goal Intervention Implementatio Rationale Evaluation

Assessment Nursing Goal Intervention Implementatio Rationale Evaluation

Assessment Nursing Goal Intervention Implementatio Rationale Evaluation

 Vital signs should be checked daily

 All investigation are done

 All blood values are normal

 Educate patient to take medicine on time.

 Advice patient to continue the follow up

EXCLUSIVE BREAST FEEDING

 Educate patient about exclusive breast feeding techniques.

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