Professional Documents
Culture Documents
CHIEF COMPLAINTS
PRESENT HISTORY
Patient Daljit Kaur is admitted in SGT Hospital with the diagnosis of full term pregnancy
but after delivery she is having present chief complaints of heaviness in both the breast,
tenderness in both breast, pain in both the breast and having difficulty to feed her baby.
FAMILY HISTORY
FAMILY TREE
Prabhjot Daljit
PERSONAL HISTORY
Hobbies- Watching T.V. and cooking.
Dietary Habits- Vegetarian
Addiction- Not present
PERSONAL HYGIENE
Oral hygiene- Maintains oral hygiene with toothpaste and brush 1 times a day
Bath- Takes bath daily
Diet- Non-vegetarian
No. of meals per day- 3 times per day.
Food preference- Homemade food
Fluid- 10-12 glasses/day
Tea & coffee- 2 cups/day
Sleep & rest- 2 hours in afternoon and 6 hours in night
ELIMINATION
Bowel per day- Regular, frequency, 1-2 times.
Urine frequency day- 3-4 times, night- 1 times, light yellow colour.
MARITAL HISTORY
Spouse Health- Good
Spouse occupation- Pvt. Job
Substance use- No history of any substance use
Addiction- No
OBSTETRIC HISTORY
P1L1A0
SEXUAL HISTORY
Frequency of sexual activity- 1-2 times/week
Method of contraception- Condom
Dyspareunia- Present
Relationship- Satisfactory
PHYSICAL ASSESSMENT
General appearance and behaviour
Build- Normal
Nutrition- Good nutrition
Anthropometric Measurement
Weight- 62 kg
Height- 5’5’’
Physical Assessment
VITAL SIGNS
MEDICATIONS
To relieve pain.
To prevent infection.
To prevent further complication.
To maintain the normal temperature of the newborn.
To feed the newborn at regular interval.
To maintain personal hygiene.
To provide comfort.
To enhance the physical mobility of the patient.
To enhance the knowledge of the patient the patient regarding breastfeeding technique.
NURSING DIAGNOSIS
3. Risk for To reduce Assess the breast for -Breast of the patient is Risk of
infection the risk of tenderness, redness and assessed for tenderness, infection is
related to infection. pain. redness and pain. reduced.
complication -Check the vital signs -Vital signs of the
of the breast of the patient especially patient are checked.
engorgement. temperature.
-Educate the patient to -Patient is advised to
clean her breast before clean her breast before
and after each and after each
breastfeeding. breastfeeding.
- Educate the patient to -Patient is advised to
maintain her personal maintain her personal
hygiene. hygiene.
-Educate the mother to -Mother is educated to
feed her baby every one feed her baby every one
hourly or demand feed hourly or demand feed
also. also.
-Advice the patient to -Patient is advised to
apply hot or cold apply hot or cold
compressions on the compressions on the
breast that helps to breast that helps to
reduce the tenderness. reduce the tenderness.
-Advice the patient for -Patient is advised for
manual expression of manual expression of
remaining milk after remaining milk after
each feed. each feed.
-Educate the patient for -Patient is advised for
use of breast pump use of breast pump
helps to reduce the helps to reduce the
tension in the breast. tension in the breast.
-Administer antibiotics -Antibiotics are
to the patient as administered to the
prescribed by the patient as prescribed by
physician such as the physician such as
Gentamycin. Gentamycin.
PROGRESS NOTES
Patient is stable, breast pain and tenderness is relieved. Now, patient is breastfeed her baby
normally. Vital signs are normal but she is having mild pain in stitches. Proper medication and
complete bed rest is taken by patient.
HEALTH EDUCATION
Diet
Advice regarding fat free diet.
Advice patient to take protein rich diet.
Advice to take 3 meals a day and in between snacks.
Advice patient to take more fluids per orally.
Advice regarding intake of haematinic and calcium supplement
Exercise
Educate the patient about medication regimen, route, dose, frequency and adverse effects.
Rest and sleep
Advice the patient to take proper rest and sleep at least 6 hours in night and 2 hours in a
day.
Immunization
Educate the parents of the newborn about immunization according to the age.
Breast feeding
Educate the mother about proper breastfeeding technique and its importance.
Educate the mother to breastfeed her baby every one hourly.
Ensues that the neonate is awake and alert during feeding.
Follow-up care
Advise the patient for regular medical check-up so that if any complication occurs can be
detected at right time.
Advise the family that follow-up care is very important and necessary to prevent
complication.
BIBLIOGRAPHY