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SCIENCES JAIPUR
ANTENATAL MOTHER
Submitted on:
22-4-2019
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IDENTIFICATION DATA OF THE PATIENT
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not significant
PAST HEALTH HISTORY:
Past Medical History:
Childhood illnesses: Not significant
Other illnesses: Not significant
Childhood immunization: All immunization is done
Past surgical history
Patient was not going any surgical procedure in past.
MENSTURAL HISTORY
She attaned he menarche at the age of 14 years. She don’t felt the
desmenorrehea during the menstrual cycle. And she having 30 days of
menstrual cycle.
LMP: 3/1/2019
EDD: 10/10/2019
POG: 14,(3) weeks
OBSTRACTICAL HISTORY
G2P1Ao
HISTORY OF 1ST TRIMESTER
No history of fever
No history of rashes
No history of burining micturition
No history of x-ray exposure
There was a history of vomiting and headache
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Any Illness: Thare is no history of Epilepsy, DM,HTN,Twins pregnancy,
congenital malformation.
FAMILY TREE
Sukhpal Rimti
Dinesh Mohini
Rakhi
Family Composition
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PERSONAL HISOTRY
Personal Hygiene:
Oral Hygiene: not maintained
Bath: Bath is taken once a day
Diet: non vegetarian diet
Food preferences: More fluids preferences
Sleep & Rest – 7 hours in night, 1 hrs. in a day
Elimination: Bowel –1-2 times in a day
Urine frequency: Normal
Exercise / Activity: moderate
Substance use: Not significant
PHYSICAL EXAMINATION
GENERAL EXAMINATION
Weight: 48 kg
Height: 154 cm
Foul Body Odour: Absent
Foul Breath: present
Sensorium: Conscious
Orientation: oriented to time, place & person
Nourishment- malnourished
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Body built: Modearate
Activity: moderate
Look: Anxious
Hygiene: not mantained
VITAL SIGNS
Temperature: 99*F
Pulse : 74bt / min
Respiration : 18 bt / min
Blood Pressure : 120/70 mmHg
INTEGUMENTARY SYSTEM
SKIN
Colour : Fair in complexion
Texture : Dry whem exmined
Skin Turgor : Dry
Hydration : Dehydrated
Discolouration : Pallor
Lesions/Masse : No any leasion and extra mass
present on skin
NAILS
On observation : Intact, Clubbing of the nails not found
Nail beds : Pale
Nail plate : White
Other signs/symptoms None
HAIR
Colour : Brown
Texture : Dry
Grooming : Well-groomed
Distribution : Scanty
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Other signs/symptom None
HEAD
Shape : Normal cephalic
Scalp : Clean
Face : Pallor
Subjective symptoms Patient feels headache
SENSORY SYSTEM
EYES
Eyebrows : Equally distributed
Eyelashes : Equally distributed
Eyelids : Normaly distributed
Pupillary reflex : Reacting to light
Pupil shape : Round in shpe
Sclera : White in colour
Conjunctiva : Normal
Vision : Normal
Subjective symptoms : No any complaints
Decreased tear production/ if any other- not significant
EARS
Pinna : Normally equal
Cerumen : Present
Ottorhoea : Absent
Hearing patient respond to sound and
differen intencity of volume
Subjective Symptoms -: No any other complaints
MOUTH & PHARYNX
Lips : Dry
Colour : Pale
Gums : no inflammation
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Tongue : Dry
Taste : Normal
Teeth : Dental caries absent
Mucous membrane : Lesions present
Breadth Odour Halitosis present
Pharynx : Irritation
Gag Reflex : Present
Tonsils : Not enlarged
Voice : clear
Subjective Symptoms : No complaints
NECK
Range of Motion : Possible
Lymph Nodes : Not enlarged
Trachea : Midline
Thyroid Gland : Normal not enlarged
Jugular Veins : Not distended
Subjective Symptoms No complaints
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Areola & nipple colour : Right side absent
Discharge : Absent
Axillary Lymph Nodes : Not Enlarged
Lesions/Masses : Absent
Subjective Symptoms Not significant
ABDOMEN
On Inspection : Globular
Umbilicus : Clean
On Percussion Not done
Bowel sound : Present
Inguinal Lymph Nodes : Not enlarged
Appetite : Anorexia
Subjective Symptoms Nausea, vomiting present
MUSCULOSKELETAL SYSTEM
Postural Curves : Normal
Muscle tone : Normal
Muscle Strength : Weaker than normal
Symmetry : Symmetrical
Finger nails : Normal
Range of motion : Possible
Oedema/ swelling : Absent
Cyanosis : Absent
Joints : No complaints
Deformity : Absent
Other signs / Symptoms - Not significant
GENITO URINARY SYSTEM
Lesions/scar : Absent
Discharge/infection : Absent
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RECTUM & ANUS
Bowel Elimination pattern : 1-2 times / day
INVESTIGATION:
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TREATMENT CHART
Sr. Name of the Dose Route Frequency Action Side effects Nursing
Drug responsibilitie
no.
s
1 Inj 10mg i/v B.D. Antiemetic Diziness, Assess
Metaclopram Tiredness the
ide Headache vital
diarrhoea signs
Anxiety of
Allergic reaction patient
Provide
hydrati
on
therapy
2. Inj. Metrogyl 500 IV TDS Antibiotics Dizziness to
patient
mg Headache Maintai
Diarrhea n I/o
chart of
Change in taste patient
Dry mouth About
over
4. inj Rantac 50 mg IV BD H2 Nausea dose of
receptor Vomiting drug
Educat
antagonist Constipation e about
Dehydration the side
effects
ypersensitivity Contin
Rash uous
monito
tachycardia ring of
5. Ing 75 mg IM BD analgesics Abdominal pain client
Provide
Diclofenac Bloating fiber
Heart burn rich
diet to
Itching skin the
Shortness of breath client
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DISEASE CONDITION
HYPEREMESIS GRAVIDERUM
INTRODUCTION
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INCIDENCE: There has been marked fall in the incidence during the last 30
years. It is now a rarity in hospital practices . Thr reason are better application
of the family planning , reduced the no of unplanned pregnancy .Early visit to
the antenatal visits
CAUSES
excessive vomiting is caused by a rise in hormone levels.
it is more common in first trimester
younger age
low body mass
history of motion
Fmily history it is more common in unplanned pregnancy
SYMPTOMS
Book picture Patient picture
increased frequency of vomiting Present
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Featured of dehydration
Dehydrated
Dry coated tongue
Present
Rise in temperature
Absent
jaundice
Absent
excessive salivation
Present
Emotional stress
DIAGNOSIS
TREATMENT
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Metoclopramide –it stimulates gastric and intestinal mortality with out
stimulating secreation. Metoclopramide is also used and relatively well
tolerated. Evidence for the use of corticosteroids is weak.
there is some evidence that corticosteroid use in pregnant women may slightly
increase the risk of cleft lip and cleft palate in the infant and may suppress fetal
activity.
However, hydrocortisone and prednisolone are inactivated
Nutritional supplements – vitamin 100mg daily, vit B6 , Vit C are also given
in some cases.
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After rehydration, treatment focuses on managing symptoms to allow normal
intake of food. However, cycles of hydration and dehydration can occur,
making continuing care necessary. Home care is available in the form of
a peripherally-inserted central catheter (PICC) line for hydration and nutrition.
Home treatment is often less expensive and reduces the risk for a hospital-
acquired infection compared with long-term or repeated hospitalization.
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DEVELOPMENTAL SELF CARE REQUISITIES:-
Sr.no. Components Patient components
01 Maintenance of developmental Not able to feed, difficult to perform
environment the
02 Prevention/ management of the conditions Feel that the problem are due to his
threatening the normal development own behavior .
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Knowledge deficit regarding disease condition as evidenced by
conversation.
Risk for complications related to alteration in normal fluid level
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Nursing care plan (1)
Assessment Nursing Goal Nursing Implementa Scientific Evaluati
Diagnosis interventio tion Rationale on
ns
Subjective Fluid Assess the Physical To collect The
Nor
data volume physical examination the base line patient’s
mal
Patient told deficit body condition of has been data fluid
fluid
that I have related to the patient. done level is
level
suffering excessive will Check thr To improve come to
be
from severe vomiting intke output RL and D5% the body normal
main
vomiting as taine chart of the has been normal fluid ata some
d
and I have evidenced patint. given to the To prevent extent.
also feeling by patient from any
the physical Provide the harm.
abdominal examinati fluid to the Provide bed To reduce
pain , on & patient . rest to the the
Objective Intake patient . vomoitting
data output Advise rest Antiemetics episodes.
I observed chart to the drugs has It will
the patient patient been given diminished
by vomiting Provide to the the episodes
episodes 5- antiemetic patient. of vomiting.
6 /day, drugs to the Provide
Facial mother. proper
expression Eliminate ventilation to
the smell of the patient.
the
environment
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Nursing care plan 2
Assessment Nursing Goal Nursing Implementa Scientific Evaluatio
Diagnos interventio tion Rationale n
is ns
Subjective Anxiety Anxiet Assess the General To provide Anxiety
general condition baseline
data related y will has been
condition of has been data for
Patient to be the patient assessed by planning of reduced to
the care
asked the hospitali reduce some
inspection.
questions zation as d to Ask the Patient has It will extent.
client to been reduces her
about her evidence some now the
express her ventilate anxiety
condition by extend feelings with general patient is
about the verbalization
treatment mother’s feeling
condition.
and the I facial It will help relax.
Advise Individual to improve
am feeling expressi
counselling counselling the
anxiety on. about the has been knowledge
condition provided to about the
Objective
the patient . condition .
data
Observed
Provide Psychologic it will help
the patient psychologic al support to reduced
al support to has been the anxirty
by facial
the patint provided to level.
expression the patint
Crying
questioning
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Nursing care plan 3
Assessment Nursing Goal Nursing Implementa Scientific Evaluati
Diagnosi interventio tion Rationale on
s ns
Subjective Risk Assess the Assessed the To know My
Risk for of
data general condition of the baseline patient
compl
complica
Mother told ication condition of patient data. has
tions will be
me that I client Dry skin and increased
minim
related to
am feeling ize Reduced fluid
alteratio
very urine output volume
n in
weak,restle nd
normal
ss and dry decreased
fluid
tounge and Provide Provided the
level as
mucus more fluids more water To hydrate chances
evidence
membrane . to patient & juices to the patient of
d by
patient. infection.
patient’s
Objective
lab
data Maintain Maintained To hydrate
reports
Observed intake intake output the patient
the patient output chart chart
by lab
reports Provide I/V provided I/V To maintain
Unable to hydrations hydration hydration.
stand therapy to
Dry skin patient
and tongue
Health education
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Date Topic Health education
14/4/19 Diet managemt Diet- patient is taught regarding
balanced diet , Patient is advised
to, fruits, juices & salad in diet
advise the patient to take plnty
of water.
Avoid the food that cause
irritation.
Avoid junk food
advise to note her intale output
chart.
15/4/19 Physical and rest Exercise – patient is advised to
management refused exercise for some time .
Hygiene –patient is advised to
keep her surroundings clear &
perform hand hygiene properly.
perform lab test after some times
repeat .
advised to walk in a fresh
environment.
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that she can divert her mind from
the feelings of vomiting during
the pregnancy period .
help the clint to gain her self
esteem
PROGRESS NOTES
Day- 1
Monitor the vital sign of the patient. ie.
temp =99*f
pulse =74 b/ min.
BP=110/80 mmhg
ADVICE
Provide personal hygiene to the patient.
advice the patient about the for ambulation
provide fluid to the patient.
DAY-2
patient fluid level is maintaing.
Advice regarding the personal hygiene.
help the patient in ambulation
Day -3
patient is afebrile
physical movement is in progress
Now the pain is reduced.
patient is feeling comfortable.
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RECORDING AND REPORTING
Provide medication to the patient
Help the patient in early ambulation.
Clean the suture and dressing over the sutures
Checked vital signs of the patient
Give health education to the patient
Maintain intake output of the patient
CONCLUSION
Taking this case is beneficial for me as well as my patient. Because I provided
psychological support and others life experience of the other vomiting patients,
that gives motivation to my patient. I learn many things from patient which I
can easly seen in patient. The case gives me the new experience that how we
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