1.

IDENTIFICATION DATA OF MOTHER:

a. Patient’s Name: sankari Barman
b. Wife of – laltu barman
c. Age in years - 23 years
d. Address – Vill- bhanu pally,PS- Rajganj, Dist- Jalpaiguri
e. Registration number - 38657
f. Educational status- HS Passed
g. Occupation- Housewife
h. Religion- Hindu
i. Duration of marriage- 1 year
j. Obstetric score – G1P0L0A1
k. Bed No- 21
l. Date of admission- 14.07.24 at 6:30 AM
m. Diagnosis- Incomplete Abortion

2. STUDENT DATA:
a. Name of student- Shreya Putatunda
b. Year - M.Sc. Nursing Part-I
c. Date of care started- 18.07.24
d. Date of care ended- 21.07.24
e. Number of days care provided- 3 days

3. CHIEF COMPLAINTS AT THE TIME OF ADMISSION:

Mrs Sankari Barman was admitted to Gynae Ward of NBMCH with the chief complaints of:
Per Vaginal Bleeding & pain in abdomen in a case of Early First Trimester Pregnancy.

4. HISTORY COLLECTION:
a. HISTORY OF PRESENT ILLNESS : Mother came to Labour room of NBMCH on
14.07.24 at 1:30 AM with Per Vaginal Bleeding & pain in abdomen in a case of Early First
Trimester Pregnancy. After initial inspection patient shifted to Gynae ward of NBMCH. As
per Ultrasonography result, Incomplete Abortion Dagnosed & after taking High Risk Consent
from Patient & Family members she undergone EVA( Electric Vacuum Aspiration ) on
14.06.24 at 10:30 PM.
b. PAST MEDICAL HISTORY : There is no significant past medical history of
hypertension, asthma, tuberculosis, pneumonia, hyper or hypothyroidism , any drug allergy,
jaundice etc.
c. PAST SURGICAL HISTORY- She is having a history of
d. FAMILY HISTORY: No significant family history of any illness in family members like
hypertension and tuberculosis etc.
● No of family members- there are a total 4 members in the family.
● Monthly income- Rs. 20000/ month

S.NO NAME RELATIONSHIP AGE SEX OCCUPATION HEALTH

WITH PATIENT STATUS
1 Laltu Husband 31 M Service Healthy
barman Years
2 Lakhi Mother-in-law 48 F Housewife Healthy
barman Years
3 Asish Father –in Law 54 M Shopkeeper Healthy
barman Years

Family Tree

Asish Lakhi barman

barman

INDEX
Laltu barman Sankari barman

LIVING MALE

LIVING FEMALE

e. MENSTRUAL HISTORY
● Age of menarche- at 13 years
● Regularity- Regular
● Cycle- 26 土 2 days
● Duration- 3-4 days
● Flow- average blood flow (4-5 pads daily)
● LMP- 28.03.2024
f. MARITAL HISTORY
● Age of marriage- Client got married 2 year back at the age of 21
● Years of married life- 2 Years.

g. OBSTETRICAL HISTORY
Obstetrical score: - G1P1L0A1
EDD – 04.1.2025
Gestational Period(LMP)- 15 weeks
h. PERSONAL HISTORY
 Hobbies- Watching TV
 Likes/dislikes- Client likes to cook.
 Veg/Non-veg- Non-vegetarian
 Alcoholic/ smoker- Client is non-smoker and non-alcoholic.
 Sleeping pattern- 6-7 hours in a day.
 Any allergy- Nothing Significant
 Food Habit – Non Vegetarian

i. SOCIO-ECONOMIC STATUS
● Type of house- Patient lives in a pucca house.
● No. of rooms- There are a total 4 rooms in the client's house.
● Electricity facility- There is a proper electricity facility in the client's house e.g. tubes and
bulbs.
● Drainage facility- There is a closed drainage system

5. PHYSICAL EXAMINATION
a) General examination:
Date: 18.07.24
Time: 10:00 am
Height- 5.1 feet
Weight- 41 kg.
BMI- 20.7 Kg/m2
Age- 23 years.
Sex- Female
Body movements- Mother was having normal body movements and there were no tics or
tremors.
Hygiene and grooming- Patient maintains personal hygiene.
 Mood and affect- Mother was having an appropriate mood and no in association of affect
found .
Speech- Client was having normal speech and there was no slurring or stammering of
speech.
Mental status- Client was conscious and oriented to time, place and person.

b) Vital signs :
Temperature- 98.6⁰F
Pulse- 90 beats/ min.
Respiration- 20 breaths / min.
Blood pressure- 110/70 mm of hg

c) Head to Foot Examination:

Integumentary System:
Skin- Patient was having dark complexion with no rash or redness present.
Nails- Patient was having pinkish nails with no clubbing and normal nail capillary refill.
Hair and scalp- Patient was having black hair with rough texture with normal distribution of
hair and there was no pediculosis but dandruff present.

Head: head was normal in shape and size.

Face: Patient was having an oval shaped face and no puffiness or scar mark was present.
Eyes:
Vision- Patient is having normal vision, and there is no history of double vision or blurring of
vision.
Eyelids- Eyelids are symmetrical, and meet completely when eyes are closed. No ptosis is
present in eyelids.
Conjunctiva-In palpebral conjunctivae mild pallor seen (anaemia) and bulbar conjunctiva no
icterus seen (jaundice). Conjunctiva is moist.
Sclera- Sclera is white in colour and there is no yellowish discoloration of the sclera.
Pupils- Pupils are round, equal and reactive to light and accommodation.
Eyebrows and eyelashes- The eyebrows and eyelashes are symmetrical with normal hair
distribution.

Ears: Ears are normal in shape and size, and hearing is normal and there is no discharge, pain
or redness.
Nose: Nose is normal in shape and size, nasal mucosa is moist and no discharge or deviated
nasal septum present.
Mouth and Pharynx:
Buccal Mucosa- Buccal mucosa is reddish pink in colour and is moist. Gums are healthy and
no bleeding is present .
Teeth- Teeth are white in colour and hygiene is maintained, no discoloration present.
Lips- Reddish pink and dry in texture.
Dentures- Mother is not having any dentures.
Halitosis- not present
Neck:
Range of Motion- Normal range of motion present as client is able to move her neck.
Position of Trachea- Trachea is centrally located.

Thyroid gland - Thyroid glands are normal in shape and size and there is no enlargement or
tenderness of thyroid or lymph node is present.
Genitalia: Normal in shape and size, the mucosal membrane is moist. Vulval edema or
infection was not present. Any wart or mole is also not present. Active bleeding was present
before getting controlled by medication.
Rectum and Anus- The rectum and anus are normal and no haemorrhoid was present.
Extremities: Extremities are normal in shape and size and symmetrical and range of motion is
present.
Motor System- Motor system is normal and no abnormal findings present.
Sensory System- Sensory system is normal as the patient is able to feel all the sensations like
touch, and differentiate between cold and hot temperature.

6. INVESTIGATION

SL NO DATE INVESTIGATIO NORMAL PATIENT REMARKS

N VALUE VALUE
1. 14.07.24 Hemoglobin >/ 11 g/dl 9.2 gm/dl Mild Anemia
2. 14.07.24 HBSAg - NR Normal
3. 14.07.24 HIV - NR Normal
4. 14.07.24 Blood Group - 0 +ve -
5. 14.07.24 Radiological USG shows Suggesting
Investigations single intrauterine Incomplete
USG fetus of about 7 Abortion
weeks 06 days
without any
demonstrable
cardiac activity.

7. TREATMENT
Medication:
SL NO DRUG CHEMICAL DOSE ROUTE FREQUENCY
NAME NAME
1. Injection Inj 1gm Intravenous BD
Xone Ceftriaxone
2. Infusion Injection 500 mg Intravenous TDS
Metrogyl Metronidazole
3. Injection Injection 40 mg Intravenous ODAC
Pan Pantoprazole
4. Injection Injection 4 mg Intravenous TDS
Ondem Ondensetron
5. Infusion Injection 1 gm Intravenous TDS
PCM Paracetamol
6. Injection Injection 500 mg Intravenous TDS
Pause Tranaexamic
Acid
7. IVF NS Intravenous 500 ml Intravenous QDS
Fluid Normal
Saline

8. NURSING DIAGNOSIS

A. Acute Pain in lower abdomen related to mass expel from the uterus as evidenced by Painful
Facial Expression and Verbalization.
B. Ineffective Tissue Perfusion related to profuse blood loss as evidenced by Decreased
haemoglobin level, Pallor and Weakness.
C.Self care deficit related to pain and weakness as evidence by poor personal hygiene
D.Imbalance nutrition less than body requirement related to less diet intake as evidence by
weakness
E. Altered sleeping pattern related to pain and grief as evidenced by restlessness & fatigue.
F. Knowledge deficit related to diet, personal hygiene and treatment procedure as evidenced
by frequent questioning and agitation.
G. Vulnerability to life threatening injury related to helplessness, hopelessness secondary to
recent miscarriage
H.Risk for infection related to incomplete abortion and EVA procedure.
Assessment goal Nursing Planning Intervention Evaluation
diagnosis

Subjective To Acute Pain  Level, intensity  Level ,intensity Pain reduced

data: reduce in lower and duration of and duration of to some extent
pain abdomen pain should be pain assessed.
Patient verbalized related to assesse.
“ I am having mass expel
pain at abdominal from the  Give Comfortable  Patient is given
site ” position . fowler position
uterus as
evidenced
 Method of  Method of
by Painful breathing and breathing and
Facial relaxation relaxation
Expression technique to be technique
Objective and taught. taught.
data : Verbalizatio
Patients’ Painful n.  Reassurance to be
given  Reassurance for
Facial
possibility of
Expression. next pregnancy

 Divertional  Patient is
Therapy to be introduced with
given same group
patients having
miscarriage

 Injection
Analgesic to be Paracetamol
administered as per 1gm IV TDS
advice. given as per
advice.
Subjective To Ineffective  Assess the tissue  Assessed the
data: maintain Tissue perfusion level of tissue perfusion
normal Perfusion patient level of patient
Patient verbalized tissue
related to  Advise mother to  Advised
“ I am having perfusio
profuse take more of fluid mother to take
blood loss ” n blood loss more of fluid
as evidenced
by  Provide
Decreased comfortable  Provided
Objective haemoglobi position to mother comfortable
n level, position to
data :
Pallor and mother
Patients looks Weakness  Advise mother to
weak and dull. take high calorie ,
less fat diet  Advised mother
to take high
calorie , less fat
 Advise mother to diet
take medicine
properly
 Advised mother
to take
medicine
properly

Subjective To Self care  Assess for  Assessed for Personal

improve deficit weakness and weakness and hygiene of
data : self care related to level of level of mother is
patient verbalized activity pain and immobility immobility maintained
weakness as
“I can’t able to
evidence by
take care of
poor  Assist her to do  Assisted her to
myself properly”.
personal perineal care do perineal care
hygiene

 Apply sterile  Applied sterile

Objective vulval pad vulval pad
data:
Patients look  Advise to take  Advised to take
untidy. daily bath. daily sponging
 Assist patient
family member to
 Assist patient
keep the patient
family member
surrounding clean
to keep the
and tide.
patient
surrounding
clean and tidy .

To Imbalance  Assess the  Assessed the Patient

maintain nutrition nutritional status nutritional maintained
Subjective adequate less than and deficiencies of status and balance
data : nutrition body mother deficiencies of nutritional
requirement mother diet .
patient verbalized related to
“I can’t able to less diet  Assess the level of
take proper food” intake as weakness  Assessed the
evidence by level of
weakness weakness
 Provid small
Objective frequent , soft ,
data : easily digestible  Provided small
diet frequent , soft ,
Patient looks dull easily digestible
diet
 Advise to take

normal balance
diet such as fish ,  Advised to take
milk , vegetables , normal balance
fruits diet such as fish
, milk ,
vegetables ,
 Advise to increase fruits
the amount of food
than previous as
extra calorie as  Advised to
needed during post increase the
- natal period amount of food
than previous as
extra calorie as
 Advise to drink needed during
adequate amount post - natal
of water period

 Advised to
drink adequate
amount of water

 .
Sub: Obstetrics & Gynaecological
Nursing
ASSIGNMENT
On
HIGH RISK
PREGNANCY SCORING

Submitted to, Submitted by,

Ms. Subhra Sarkar Bishakha Maity
Senior Lecturer MSc Nursing Part I
CON,NBMC&H CON,NBMC&H