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AGE : 24 Years
SEX : Female
BED NO. : 15
WARD : Postnatal
GPAL G1P1A0L1
OBJECTIVE DATA
PERSONAL HISTORY
EDUCATION : H.S.
OCCUATION : Housewife
SOCIAL HISTORY
SANITATION : Well
Latrine
FAMILY HISTORY
MENSTRUAL HISTORY
DURATION : 4 days
CYCLE : 28 days 3 days
FLOW : Normal
OBSTATIC HISTORY
PARITY : P0+0
GRAVIDA : Primi
L.M.P. : 17/5/2016
E.D.D. : 24/02/2017
EMOTIONAL STATE
ANXIOUS (/X) : X
CALM (/X) :
ANGRY (/X) : X
FEARFUL (/X) : X
RESTLESS (/X) : X
WITHDRAW (/X) : X
LEBEL OF CONSCIOUSNESS
ALERT (/X) :
DROWSY (/X) : X
CONFUSED (/X) : X
COMATOSE (/X) : X
ORIENTED TO :
TIME (/X) :
PLACE (/X) :
PERSON (/X) :
SPEECH
RELEVANT (/X) :
IRRELEVENT (/X) : X
SLURRED (/X) : X
APHASIA (/X) : X
RESPIRATORY SYSTEM :
CHEST MOVEMENT :
UNILATERAL (/X) : X
BILATERAL (/X) :
ABSENT (/X) : X
RESPIRATORY PATTERN :
NORMAL (/X) :
DYSPHNOEA (/X) : X
OPTHOPNOEA (/X) : X
P.N.D. (/X) : X
TACHYPNOEA (/X) : X
DRADYPHNOEA (/X) : X
AIR-ENTRY :
BIRTH SOUND :
NORMAL (/X) :
RALE (/X) : X
RONCHI (/X) : X
WHEEZE (/X) : X
STRIDOR (/X) : X
COUGH :
PRESENT (/X) : X
ABSENT (/X) :
PRODUCTIVE (/X) : X
NON-PRODUCTIVE (/X) : X
CARDIO-VASCULAR SYSTEM
PULSE
TACHYARRYTHMIA (/X) : X
BRADYARRYTHMIA(/X) : X
BLOOD PRESSURE
HYPOTENSION (/X) : X
HYPERTENSION (/X) : X
PERIPHERAL PULSE
PRESENT (/X) :
ABSENT (/X) : X
FEEBLE (/X) : X
REDIAL (/X) :
POPLETIAL (/X) :
DORSALPEDIS (/X) :
HEART SOUND
S1(/X) :
S2(/X) :
S3(/X) : X
S4(/X) : X
MURMUR (/X) : X
GASTRO-INTESTINAL SYSTEM
MOUTH
CLEAN (/X) :
SORE (/X) : X
HALITOSIS (/X) : X
TEETH
CLEAN (/X) :
PLAGUE (/X) : X
TONGUE (/X) :
CLEAN (/X) :
COATED (/X) : X
PERISTOLSIS (/X) :
NAUSEA (/X) : X
VOMITING (/X) : X
NUTRITIONAL ROUTE
ORAL (/X) : X
PARENTERAL (/X) :
BOWEL OPEN
CONSTIPATION (/X) : X
DIARRHOEA (/X) : X
MALENA (/X) : X
GENITO-URENARY SYSTEM
VOID : X
FREELY (/X) : X
CATHETER (/X)
URINE
CLEAR (/X) :
SEDIMENT (/X) : X
HAEMATURIA (/X) : X
RETENTION (/X) : X
INCONTINENCE (/X) : X
INTEGUMENTARY SYSTEM
SKIN
INTACT (/X) :
RASH (/X) : X
CYANOSIS (/X) : X
PERIPHERAL (/X) : X
CENTRAL (/X) : X
PERIPHERIES :
WARM (/X) :
COLD (/X) : X
NAIL-CLUBBING (/X) : X
HOMAN’S SIGN X
ICTERUS (/X) : X
TEMPERATURE
FEBRILE (/X) : X
AFEBRILE (/X) :
PULSE (/X) :
RESPIRATION (/X) :
SCALP
PEDICULOSIS (/X) : X
DANDRUFF (/X) : X
RASH (/X) : X
EYE
CLEAN (/X) :
DISCHARGE (/X) : X
NOSE
CLEAN (/X) :
DISCHARGE (/X) : X
EAR
CLEAN (/X) :
DISCHARGE (/X) : X
SLEEP
ADEQUATE (/X) :
MUSCULO-SKELETAL SYSTEM
JOINT
MOBILE (/X) :
STIFF (/X) : X
PAINFUL (/X) : X
CONTRACTURE (/X) : X
AMBULENT (/X) :
INVESIVE LINE
HEALTHY (/X) :
OOZING (/X) : X
DRESSING (/X) :
Obstetrical examination:
Inspection: No undue enlargement
Palpation of uterus: Uterus is soft and tender .Fundal height – 15 cm, subinvoluted .
(Consistency , shape and descent)
Per vaginal inspection / examination :
Vulval edema : Nil
Vagina : Copius discharge,
(Any vaginal bleeding , clots , warts / mole / infection / discharge )
Perineal area / anus: painful
(Intact , lacerations or haemorrhoids , any pain )
Inspect REEDA for episiotomy wound: Wound is redness and edematous .
(Redness , edema , ecchymosis , discharge and apposition )
Colour and amount of lochia odour: Lochia rubra present , copius Smell –offensive odor
Any complaints : Pain in episiotomy wound site
Laboratory reports:
Delivery notes( from records):Normal delivery with mediolateral episiotomy done .A full term
living baby boy was born on 23/02/18 at 10.58 pm .Inj oxytocin 10 IU given .
Treatment: Cap Amoxycillin 500 mg 1 cap TDS , Tab Brufen ,tab metrogyl , tab famotidine .
BABY
Physical Examination Findings
Condition of the newborn :Good , posture-flexed ,well cried ,alert
Vital signs:
Colour of skin :Pink texture - soft smooth .Dryness over hands and feet .Good turgor .Vernix
present.
Heart rate (Apex bit):138 beats/ min
Respiration :40 breaths/ min
Physical measurement:
Weight:2.6 kg
Length :49 cm
Head circumference :34 cm
Chest circumference :31 cm
Reflexes:
Grasp: Present .
Moro: Present .
Glabellar: Present .
Rooting: present .
Sucking: Present .
Planter and Babinski : Present .
There has been marked decline in puerperal sepsis during the past few years due to:-
i) Endometritis
ii) Endomyometritis
iii) Endoparametritis or a combination of all these when it is called pelvic cellulitis .
IN BOOK IN PATIENT
PREDISPOSING FACTORS OF
PUERPERAL SEPSIS :-
The pathogenicity of the
vaginal flora may be influenced by
certain factors :-
1) The cervicovaginal mucous
membrane is damaged even in normal
delivery .
2) The uterine surface too , especially
the placental site , is converted into
an open wound by the cleavage of
the decidua which takes place during
the third stage of labor , and
3) The blood clots present at the
placental site are excellent media for
the growth of the bacteria .
Antepartum risk factors :-
1) Malnutrition and anemia Predisposing factors of my mother is
2) Preterm labour Malnutrition and anemia
3) Premature rupture of the membranes
4) Immunocompromised (HIV) Premature rupture of the membranes
5) Prolonged ruptured of membrane more
than 18 hours ,
6) Diabetes
Intrapartum risk factors :-
1) Repeated vaginal examinations .
2) Dehydration and ketoacidosis during Repeated vaginal examinations done in labour
labour room
3) Traumatic vaginal delivery
4) Haemorrhage --antepatum or postpartum ,
5) Retained bits of placental tissue or
membranes
6) Prolonged labour
7) Obstructed labour
8) Cesarean delivery
Microorganisms responsible for puerperal sepsis and the major pathology
Aerobic :- Group Aemolytic beta –hemolytic Streptococcus (GAS ) –Toxic shock
syndrome , necrotizing fasciitis in episiotomy or caesarean section wound .
Others :- Staphylococcus pyogenes , S. Aureus , E . coli , Klebsiella , Pseudomonas ,
Proteus , Chlamydia .
Anaerobic :- Streptococcus , Peptococcus , Bacteroides , Fusobacteria etc .
Most of the infections in the genital tract are polymicrobial with a mixture of
aerobic anaerobic organisms .
MODE OF INFECTION :-
Puerperal sepsis is essentially a wound infection . Placental site ( being a raw
surface ) lacerations of the genital tract or caesarean section wounds may be infected
in the following ways :-
Source of infection may be endogenous where organisms are present in the genital tract
before delivery .
Infection may be autogenous where organisms present elsewhere ( skin , throat ) in the
body and migrate to the genital organs by bloodstream or by the patient herself .Beta –
hemolytic , Streptococcus , E.coli , Staphylococcus are important .
Infection may be exogenous where infection is contracted from sources outside the
patient . Beta –hemolytic , Streptococcus , Staphylococcus and E. Coli are important .
PATHOLOGY :-
The primary sites of infection are :-
1) Perineum
2) Vagina
3) Cervix
4) Uterus
The infection is either localized to the site or spreads to distant sites . The lacerations on
the perineum , vagina and the cervix are often infected by the organisms due to the presence
of blood clots or dead space . The wound become red , swollen and there is associated
seropulent discharge . There may be disruptionof the if repaired before control of infection .
Diabetes , obesity , immunocompromised state (HIV) are the other high risk factors for wound
infection .
Endogenous
Exogenous
Endometrium (placental implantation site ) , cervical lacerated wound , vaginal wound or
perineal lacerated wound are the favourable sites for bacterial growth and multiplication .
The devitalized tissue , blood clots , foreign body ( retained cotton swabs ) , and surgical
trauma favour polymicrobial growth , proliferation and spread of infection . This ultimately
leads to metritis , parametritis and / or cellulitis .
Uterine infection :-
MILD :-
1) There is rise of temperature (> 100.4 ₒ F ) and pulse rate (>90) ,
2) Lochial discharge becomes offensive and copious ,
3) The uterus is subinvoluted and tender . Lochial discharge becomes
SEVERE :- offensive and copious ,
1) The onset is acute with high rise of temperature , often with chills and
Fundal height is 15 cm
rigor . The uterus is
2) Pulse rate is rapid , out of proportion to temperature , subinvoluted and
3) Often there is breathlessness , coughs , abdominal pain and dysuria , tender
4) Lochia may be scanty and odourless ,
5) Uterus may be subinvoluted , tender and softer .
6) There may be associated wound infection ( perineum , vagina or the cervix
).
TREATMENT :-
General care :- Isolation of the
Isolation of the patient is preferred specially when haemolytic patient
streptococcus is obtained on culture .
Adequate fluid and calorie is supplied if needed by intravenous Adequate fluid and
infusion. calorie is supplied
Anaemia is corrected by oral iron and if needed by blood
transfusion .
Pain is relieved by adequate analgesia . Anaemia is
An indwelling catheter is used to relieve any urine retention corrected by oral
due to pelvic abscess. It also help to record urinary output, iron
A chart is maintained by recording pulse, respiration, temperature,
lochial discharge, and fluid intake and output. Pain is relieved by
Antibiotics :- Depend on the culture and sensitivity report adequate analgesia
pending the report,
Inj. Gentamicine (2mg / kg IV loading dose, followed by 1.5mg / PCM 1 Tab TDS
kg IV every 8 hours ) and
Inj. clindamycin ( 900mg IV every 8 hours) should be started . A chart is
Inj. Metronidazole 0.5 g.IV is given at 8 hours interval tocontrol the maintained by
anaerobic group . recording pulse,
The treatment is continued until the infection is controlled for respiration,
atleast 7 – 10 days. temperature,
In case of severe sepsis :- lochial discharge,
A combination of either piperacillin – tazobactam or carbapenem and fluid intake
puls clindamycin has broadest range of antimicrobial coverage . and output.
IN BOOK
IN PATIENT
SURGICAL TREATMENT : there is little role of major surgery
in the treatment of puerperal sepsis. NO NEED
Perineal wound – the stitches of the perineal wound may have
to be removed to facilitate drainage of pus and relieve pain. The
wound is to be cleaned with sitz bath several times a day and is
dressed with an antiseptic ointment or powder. After the
infection is controlled, secondary suture may be given.
Retained uterine products with a diameter of 3 cm or less may
be disregarded and left alone. Otherwise surgical evacuation
after antibiotic coverage for 24 hours should be done to avoid the
risk of septicemia. Cases with septic pelvic thrombophlebitis are
treated with IV heparin for for 7- 10 days.
Pelvic abscess should be drained by colostomy under
theultrasound guidance.
Wound dehiscence :-
Dehiscence of episiotomy or abdominal wound following
cesarean sectionis maintained by scrubbing the wound twice
daily, debridment of all necrotic tissue and then closing the
wound with secondary suture. Appropriate antimicrobials are
used following culture and sensitivity .
Laparotomy has got limited indications .
Maintenance of electrolytic balance by intravenous fluid along
with appropriated antibiotic therapy usually controls the
peritonitis . However, in unresponsive peritonitis, lapatomy is
indicated.
If no palpable pathology is found, drainage of pus may be
effective.
Hysterectomy:-
It is indicated in case with rupture or perforation, having
multiple abscesses, gangrenous uterus or gas gangrene infection .
Ruptured tubo – ovarian abscess should be removed .
IN BOOK IN PATIENT
Necrotizing fascilitis :-
Is rare but fatal complication of wound infection
(abdominal , perineal , vaginal ), involving muscles and fascia.
Risk factors are diabetes , obesity and hypertension.
Infection is caused by Group A hemolytic streptococcus
and often it is polymicrobial. Tissue necrosis is the
significant pathology.
Treatement includes: rehydration wound scrubbing
,debridement of all necrotic tissues, and use of high dose
broad – spectrum(IV)antibiotics.
Indication of intensive caree management:
Hypotension.
Oliguruia .
Raised serum creatinine.
Rised serum lactate
Thrombocytopenia ,
ARDS,
Hypothermia .
Management of bacteremic or septic shock :-
o Fluid and electrolyte balance (to monitor CVP),
o Respiratory supports (to maintain arterial PO2 and
PCO2),
o Circulatory support (dopamine or dobutamine),
o Infection control (intensive antibiotic therapy, surgical
removal of septic foci) and septic management ( as
haemodialysis for renal failure) .
NURSING MANAGEMENT :-
Assessment :-
Elevation in temperature to 100.4⁰ F or above with chills
Foul smelling lochia
Abdominal tenderness and pelvic pain
Pain and burning sensation during micturation
Tachycardia
Increased white blood cells (WBCs )
Presence of predisposing factors
Traumatic birth
Prolonged difficult labour , Prolonged ruptured of membranes\
Excessive vaginal discharge
Anemia
Retained placentral fragment
Hemorrhage
Mother is dehydrated , frustrated due to extreme fatigue .
Pain in lower Pain should *Mother should be *Mother should be Pain is slightly
abdomen related to be assessed assessed. assessed. reduced
growth of organism *emotional support *Emotional support is
in uterus as should be given given
evidenced by mother *antibiotics should be *antibiotics should be
verbalises administered as doctor’s administered as doctor’s
advice advice
*Antipyuretics should be *Antipyuretics should be
administered as doctor’s administered as doctor’s
advice advice
*aseptic technique should *aseptic technique should
be maintained upto six be maintained upto six
weeks weeks
Nursing Diagnosis Expected Planning Implementation Evaluation
outcome
Fatigue related to Fatigue will *Mother should be *Mother is assessed Mother understands
disease process as be reduced. assessed and takes food.
evidenced by Lack
of interest to take *Mother should be *Mother is encouraged to
food, tierd, lack of encouraged to take food take food
sleep.
*Mother should be *Mother is informed about
informed about the the disease process.
disease process.
Impaired nutrition less than Unaltered Breastfeeding :Initiated with Baby is active and
body requirement related to nutritional status . colostrum . passed urine .
newborn’s transition to Baby is sucking breast milk
extrauterine life . properly .
Checked passage of urine .
Checked baby’s body weight .
*Cleanliness is maintained
*Tepid sponge is provided
Pain in lower Pain should be *Mother should be assessed. *Mother should be assessed. Pain is
abdomen related assessed *emotional support should be *Emotional support is given slightly
to growth of given *antibiotics should be reduced
organism in *antibiotics should be administered as doctor’s
uterus as administered as doctor’s advice advice
evidenced by *Antipyuretics should be *Antipyuretics should be
mother administered as doctor’s advice administered as doctor’s
verbalises *aseptic technique should be advice
maintained upto six weeks *aseptic technique should be
maintained upto six weeks
Disturbed Sleeping pattern *Sleeping pattern of mother *Sleeping pattern of mother Sleeping
sleeping pattern will be should be observed. is observed. pattern is
related to anxiety improved. improved.
for illness/nausea *Emotional support should be
and vomiting as given. *Emotional support is given.
evidenced by
mother *Divertional terapy should be *Divertional therapy is
verbalizes. provided. provided.
Impaired nutrition less than Unaltered Breastfeeding :Initiated with Baby is active and
body requirement related to nutritional status . colostrum . passed urine .
newborn’s transition to Baby is sucking breast milk
extrauterine life . properly .
Checked passage of urine .
Checked baby’s body weight .
Pain in lower Pain should be *Mother should be assessed. *Mother should be assessed. Pain is
abdomen related assessed slightly
to growth of *emotional support should be *Emotional support is given reduced
organism in given
uterus as
evidenced by *antibiotics should be
mother *antibiotics should be administered as doctor’s
verbalises administered as doctor’s advice advice
Disturbed Sleeping pattern *Sleeping pattern of mother *Sleeping pattern of mother Sleeping
sleeping pattern will be should be observed. is observed. pattern is
related to anxiety improved. improved.
for illness/nausea *Emotional support should be
and vomiting as given. *Emotional support is given.
evidenced by
mother *Divertional terapy should be *Divertional therapy is
verbalizes. provided. provided.
Impaired nutrition less than Unaltered Breastfeeding :Initiated with Baby is active and
body requirement related to nutritional status . colostrum . passed urine .
newborn’s transition to Baby is sucking breast milk
extrauterine life . properly .
Checked passage of urine .
Checked baby’s body weight .
PROGRESS REPORT
Day – 1 (24/02/18) Day – 2 (25/02/18) Day – 3 (26/02/18)
REFERENCES
1. Dutta, D.C. Text Book of Obstetrics; ( 7th edition ); 2010;Kolkata;New Central Book
Agency Private Limited; page no 144-57.
5. Raman A.V, Maternity Nursing; 19th edition;2014; New Delhi , Wolters Kluwer (India)
Pvt. Ltd.,page no.414-429
RESEARCH AARTICLES