BORA INSTITUTE OF ALLIED HEALTH SCIENCES

LUCKNOW

OBSTETRIC AND GYNECOLOGY

NURSING CARE PLAN
ON
“DYSMENORRHEA”

SUBMITTED TO- SUBMITTED BY-

Mrs. SANDHYA VERMA BABLEE BHARTI
HOD OF OBG M.Sc. (N) 2nd year
BORA Institute of Nursing BORA Institute of Nursing

DATE OF SUBMISSION

05/07/2023
PATIENT PROFILE
1)-IDENTIFICATION DATA-
 Name- MS Laxmi Singh
 Age- 29 year
 Sex-Female
 Address- kanpur
 IP Number-048989
 Ward- General word
 Education-12th
 Occupation-housewife
 Religion-Hindu
 Nationality-Indian
 Marital status-Married
 Date of admission–25/06/2023
 Diagnosis- Dysmenorrhea
2) - Chief complaints-Ms laxmi Singh is admitted in General word on 18/06/2023 with the
complaint of general weakness, loss of appetite, abdominal pain, fever since 10 days.
3)-Medical/Surgical history-
 Past medical history -No significant of past medical history.
 Present Medical history-Ms. laxmi Singh is admitted in General word on 27/06/2023
with the complain of general weakness, loss of appetite, abdominal pain, fever vomiting
under treatment of Dr. Himanshu. He is Diagnosed her as dysmenorrhea.
 Past surgical history- Patient has undergone with hysterectomy surgery before 1
months ago.

4)-Socio-economic history-
 Bread winner of Family-Mr. Rajesh
 Socio-economic status-Satisfactory
 Type of house-Pakka
 Market Facility-Available
 Drainage System-Close
 Defecation System-Own Toilet
 Method Of refuse Disposal-Dumping
 5) - Family History-
 Family Tree-
Type of family-Nuclear
Head of family-Mrs. Shanti Devi

 Family Composition-

Sr.no. Name of Relationship Age Sex Education Occupation Health

family with patient status
Member
1 Mr. Rajesh Father in law 56 M Graduation Teacher Healthy
years
2 Mrs. Mother in law 54 F 5th House wife Healthy
Shanti years
Devi
3 Mr. Husband 33 M Graduation Private job Healthy
Ramesh years
Singh
4 Mrs. Patient 29ye F 12th House wife Unhealthy
Laxmi ar
Singh
5 Miss. Kajal Daughter 4 F - - Healthy
year

 Family Medical History- No significant

6)- Personal History-

 Nutrition- She is Non-Vegetarian

 Sleep-Normal
 Habits-She is having no any bad habits like smoking and tobacco chewing.
 History of known allergy-No allergy
 Elimination Pattern-Normal elimination pattens.
PHYSICAL EXAMINATION
GENERAL APPEARANCE-
 Body built- Moderate
 Posture- Normal Posture
 Level of consciousness- Conscious
 Orientation- oriented to time, place, person
 Activity- Dull
 Behaviour- Depressed
 Attitude-Co-operative
 Speech-Slow
 Cleanliness-Clean
VITAL SIGN-
 Temperaure-100 F
 Pulse-90 beats / min
 Blood Pressure- 110/90 mmHg
 Respiratory Rate-22 breaths / min
ANTHROPOMETRIC MEASUREMENT-
 Height-150 cm
 Weight-44 kg
 Abdominal Grith-36 cm
SKIN-
 Color-Fair
 Turgor-Normal
 Texture-Smooth
 Pigmentation-Present
 Temperature-Warm
 Sensitivity-sensitive
 Lesion-Present
 Scar-absent
HEAD-
 Shape-Normal
  Symmetry- Symmetrical
 Scalp-clean
 Dandruff-Absent
 Pediculi-Absent
 Lesions-Absent
 Hair-present
 Color- Black
 Texture-Normal
 Distribution-Evenly Distributed
FACE-
 Symmetry-Symmetrical
 Facial Movement- Symmetrical
 Facial Puffiness-present
 Sinuses-Normal
EYES-
 Eye Brows-Present
 Symmetry-Symmetrical
 Distribution of hair-Equally Distributed
 Lesion-Absent

 Dandruff-Absent
EYELIDES-
 Movement-Completely
 Position-Normal
 Puffiness-Absent
 Lesion-Absent
 Style-Absent
EYE LASHES-
 Distribution –Normal
 Dandruff-Absent
EYE BALL-
  Position-Normal
 Movement-Normal
 Conjunctiva-Pale yellow
 Sclera-Yellow
 Cornea-Transparent
 Visual Acuity-normal
 Use of Spectacles or contact lenses—No
EARS-
 Position-Normal
 Symmetry-Symmetrical
 Size and Shape-Normal
 Lesion and Lump of Pinna-Absent
 External Auditory Canal-Normal and Visible
 Mastoid Process- Normal
 Use Of hearing Aids-No
 Pain-Absent
NOSE-
 Nasal Septum-Normal
 Polyps-Present
 Mucus Membrane-Dry
 Discharge-No
MOUTH-
LIPS
 Color-Pale yellow
 Hydration-Dry
 Symmetry-Symmetrical
 Lesion-Present
 Mucus Membrane
 Color-Pale
 Hydration-Poor

TEETH-
  No. of Teeth- 32
 Color-Stained
 Alignment-Normal
 Use Of Denture-NO
GUMS- Healthy
Tongue-
 Color-coated
 Hydration-dry
 Lesions-Absent
 Thickness-Normal
 Frenulum- Toungue Tie
PALATE- Normal
UVULA-Midline
TONSIL-Normal
DYSPHASIA-Present
ODOR OF MOUTH- Normal

NECK-
 Range of Motion-Possible
 Thyroid Gland-Normal
 Trachea-midline
 Lymph Node-Palpable
 Jugular vein-distented
CHEST-
INSPECTION-
 Shape-Normal
 Movement-Symmetrical
 Retraction-Present
 Respiratory Rate-22 Breaths / Min
 Location of sternum-Midline
BREAST-
 Shape-Symmetrical
  Position-Normal
 Nipple-Cracked
PALPATION-
 Axillary Lymph Node-palpable
 Respiratory movement-symmetrical
 Fremitus-Normal
AUSCULATATION-
 Lung Sound-Clear & equal
 Heart Beat-92 Beats/min
 Heart sound-Normal
ABDOMEN-
INSPECTION-
 Shape-Rounded
 Skin-Normal
 Distension-Present
 Peristalsis-Not visible
 Distended-Absent
 Umbilicus-Normal
PALPATION-
 Hepatomegaly-Absent
 Spleenomegaly-Absent
 Tenderness-Present
 Mass-Absent
AUSCULTATION-
 Bowel Sound -Increased
 Character-Gurgring sound
PERCUSSION-
 Ascitis-Absent
 Fluid Thrill-Absent
BACK-
 Tenderness-Absent
 Mass-Absent
GENITALIA –
Anal opening- Clean
Perineal fissure-Absent
External heamorrhoids-Absent
FEMALE
 Urethral opening-clear
 Lesion-Absent
 Discharge-Present
EXTRIMITIES-
 Position-Symmetrical
 Gait-Normal
 Range of Motion-Normal
 Congenital deformity-Absent
 Digits- normal(5+5,5+5)
NAIL-
 Shape- Normal
 Color- yellow
 Capillary refill time- <2 sec
REFLEX-
 Biceps Reflex-Normal
 Triceps Reflex-Normal
 Patellar Reflex-Normal
VITAL SIGN.

VITAL SIGN PATIENT NORMAL REMARK

VALUE VALUE

Temperature 100 F 98.6 F Increases

Pulse Rate 90 Beats / min 70-80 beats/min Increases

Blood Pressure 110/90 mmHg 120/90 mmHg Normal

Respiratory Rate 22 Breaths / Min 16-20 breaths/min Trachypneoa

INVESTIGATION CHART
INVESTIGATION PATIENT NORMAL REMARK
VALUE VALUE
 Hemoglobin 10.4gm/dl 12.5gm/dl Normal
9900cells/mm3 4000- Normal
 TLC 11000cells/mm3

 Differential %
Leukocytes count-
70% 40-80 Normal
26% 20-40 Normal
02% 1-6 Normal
 Neutrophills
02%
 Lymphocyte 00%
2.81Lac million 1.5-4.5 Normal
 Eosinophills cells/ul
 Monocyte
9.4fl
 Basophill 3.29milliocells/ul 3.8-4.8 Normal
25.8pg 27-32 Decrease
 Platelet count
26.1% 36-46 Decrease
1.22 mg/l 0-6 Normal

 MPV
 Total RBc Normal
0.98ng/ml 0.58-1.59ng/ml
 MCH 4.87-11.72ug/dl Normal
6.65ug/dl
0.35-4.94ul/ml Normal
 HCT(Hemocrit) 2.32ug/ml
 C- reactive protein
Thyroid profile-
 Serum T3
 Serum T4
 Serum TSH
MEDICATION CHART

DRUG DOSE ROUTE FREQUENCY MECHANISM

OF ACTION
1gm IV BD Antibiotic
Inj. Ceftriaxone

40gm IV OD Antacid
Inj. Pantop

Tab. Meftol 250mg Oral OD Antianalgesic

spas

500mg Oral BD Ca supplements

Tab. Shelcal

Oral OD Folic acid

Tab.Fol-5 supplements
NURSING DIAGNOSIS

 Acute pain related to increased uterine contractility, hypersensitivity as evidenced by

diseases condition.

 Imbalanced nutrition less then body requirements related to the nausea, vomiting as
evidenced by condition of the patients.

 Ineffective individual coping related to emotional excess.

 Anxiety related to knowledge deficit regarding management and disease condition as

evidenced by parent asks many questions about the disease.
 NURSING CARE PLAN

ASSESSMENT DIAGNOSIS GOAL PLANNING IMPLEMENTATION EVALUATION

SUBJECTIVE Acute pain To -assess the -assessed the condition After nursing
DATA- Parent related to improv condition of of patients. intervention
is complaining increased e the patients. improved the
of have pain in uterine conditi condition of
abdomen . contractility, on of -monitor the -monitored the temp., patients.
hypersensitivi the vital sign of the pulse, respiratory rate
ty as patients patients. of the patients.
evidenced by .
-massage the -massaged the
diseases
abdomen area abdominal area that
condition. that feels pain. feels pain of the
patients.

-warm the -Warmed the abdomen

abdomen of the of the patient for
patients. abdominal pain relief.
OBJECTIVE
DATA- On
observation of -Perform light -Performed light
patient having exercise. exercise for pain relief.
lower abdominal
pain.
-provide the -provided the quite
quite environment to the
environment to patients.
the patients.
ASSESSMENT DIAGNOSIS GOAL PLANNING IMPLEMENTATION EVALUATION

SUBJECTIVE Imbalanced To -Assess the -Assessed the general After nursing

DATA- Patient nutrition less improve general condition of the patient. intervention
is complaining then body the condition of improved the
of that she is requirements nutrition the patient. condition of
have fever. related to the al level baby.
nausea, of the -Monitor -Monitored vital sign of
vomiting as patient. vital sign of the patient.
evidenced by the patient. Temp.-98.6F
condition of Pulse-40b/m
the patients. Resp.-30b/m

-Check the -Checked the weight of

weight of the the baby.
patients Weight-46gm

-monitor the -monitored the blood

OBJECTIVE blood glucose level
DATA- On glucose level
observation of
patient- weight - -Provide the -provided the quiet and
45gm quiet and restful environment.
restful
environment.

-place the -placed the semi sitting

semi sitting position for rest.
position for
rest.
ASSESSMENT DIAGNOSIS GOAL PLANNING IMPLEMENTATION EVALUATION

SUBJECTIVE Anxiety To -Assess the -Assessed the After nursing

DATA- Patient related to improv knowledge about knowledge about intervention
is say she is not knowledge e the disease disease condition. improve the
have knowledge deficit knowle condition. patient
about disease. regarding dge of -Clearified the all knowledge
management the -Clearify the all doubts of the patients level.
and disease patient. doubts of the regarding disease and
condition as patients. investigation.
evidenced by
parent asks -Provide the -Provided the some
many knowledge about knowledge about the
questions the personal personal hygiene.
about the hygiene.
disease.
-Treat the -Provided the emotional
OBJECTIVE patient calm, support of the patient.
DATA-On empathetic and
observation- supportive
patient not have attitude.
knowledge -accurate information
about disease. -provide
information can reduce the anxiety
about care and and fear of the
treatment. unknown.

-help clients -The expression can

identify a sense reduce feeling of
of anxiety. anxiety.
HEALTH -EDUCATION
1. Diet- Educate the patient to take proper and healthy diet. Advice the patient to take

balance diet. And advice the patient to take Iron rich and green vegetables.

2. Hygiene- Educate the patient to maintain her personal hygiene and to avoid other

infection. And take proper bath daily.

3. Medication- To teach the patient to take medication daily in the time and do not

skip any medicine.

4. Exercise- Educate the patient about active and passive exercise. Educate the patient

for bed rest.

5. Follow-up- educate the patient about regular follow-up care.

 BIBLIOGRAPHY

 Dutta DC ‘A Textbook of obstetric’, 6th Edition, Jaypee publisher’s page no. 544-548.

 Sanju Sera ‘A Textbook of obstetrics and Gynecology’, 4th Edition, lotus publishers,
page no.570-576.