ANTE NATAL CASE STUDY

PATIENT IDENTIFICATION
Name : Mrs Ruhi Banu
Age : 19 years
Ward : Ante natal ward
Religion : Muslim
Obstetrical score : G1P0L0A0
Date of examination : 6/9/2011

INTRODUCTION
During my posting in St. Mary’s Hospital I was posted in antenatal ward. And I
took Mrs. Ruhi Banu, an antenatal mother for my ante natal case study. I introduce
myself to her and explained how I will be helping her cope with antenatal problem.

FAMILY HISTORY
Mrs.Ruhi Banu’s family has no history of diabetes mellitus, hypertension,
multiple pregnancy, cardiac problem, communicable diseases and psychiatry problems.

SOCIO-ECONOMIC STATUS
She belongs to middle class family. They live in house of their own with all
minimum basic requirements such as electricity, water supply, and good sanitation. Her
husband is the bread winner of her family. He is a driver.

PERSONAL HISTORY
Diet: She is taking mixed diet
Hygiene: She maintained good personal hygiene
Sleep: She used to sleep 8 hours at night and 1 hour in day time. She has no sleeping
disturbance
Bowel and bladder: No history of bowel and bladder pattern disturbance.
Habits: No alcoholism and smoking

MENSTRUAL HISTORY
She attained menarche at the age of 14 years. She is having regular menstrual
cycle of 28 days with moderate flow. Her menstrual cycle lasts for 4-5 days.

MARITAL HISTORY
She got married at the age of 18 years. Her married life is for 1 years and her marriage
is non –consanguineous marriage.

PAST MEDICAL HISTORY

Mrs. Ruhi Banu has no significant past medical history.
PAST SURGICAL HISTORY
Mrs. Ruhi Banu has no significant past surgical history.

OBSTETRICAL HISTORY

Past obstetrical history:

No Year Full Premature Abortion Nature Nature of Child

term of puerperium Alive Weight Sex
delivery
Primi mother

Present obstetrical history

Obstetrical score : G1P0L0A0
LMP : 24/12/2010
EDD : 14/10/2011
Gestational age : 34 weeks+3 days

Ist trimester II nd trimester IIIrd trimester

 She had ante  Had ante natal  Had ante natal

natal visit at St visit. visits.
Mary’s hospital  Taken iron folic  Taken iron
 Taken folic acid acid and folic acid and
tablets. calcium tablets. calcium tablets.
 No exposure to  Fetal  Inj. T.T taken
radiations. movements was  Fetal
 She had felt. movements
vomiting for 4th  Inj.T.T taken. was good
week to 6th  Body  Body
week . weight:48kg weight:54kg
 Body  Haemoglobin:  Haemoglobin :
weight:46kg 10.6gms% 10.6gms%
 Haemoglobin:  Had no  No complications
11.gm% complications like bleeding
 Had no  Quickening
complications started at 19th
week

ANTE NATAL EXAMINATION

Vital signs
Temp : 98.60 F
Pulse : 82b/m
Respiration : 24br/m
BP : 120/70mmHg
Weight : 54kg
Height : 160cm
General appearance : Moderately built
Mood : Cheerful
 HEAD TO FOOT EXAMINATION
Head : Healthy hair, clean scalp, no dandruff or lesions.
Face : No edema or puffiness, chloasma present
Eyes : Conjunctiva pale in colour, normal vision
Ear : Hearing capacity is normal, no abnormal discharge
Nose : No septal deviation , no abnormal discharge
Mouth : Lips and tongue are dry
Teeth : No dental carries
Neck : No thyroid and lymph node enlargement
Chest : Expansion of the chest is normal
CVS : S1and S2 heard
Breast : soft, nipple erect, secondary areola present.
Abdomen
Inspection
Shape : Round
Size : Appropriate to gestational age
Contour : Convex
Umbilicus : Flat
Flanks : Empty
Fetal movements : Visible fetal movements present
Lenia nigra : Present
Stria gravid : Present
Scar : No scar marks
Palpation
Abdominal girth : 110 cm
Fundal height : 34cm
Gestational weeks : 34 weeks +4 days
Fundal palpation : Soft and irregular mass felt assumed as fetal
buttocks
Lateral palpation :
Right: Multiple irregular, soft nodules felt assumed as fetal limbs
Left: Continuous curved surface felt assumed as back of fetus
Pelvic grip 1 : Hard round mass felt hands are converging
Pelvic grip 2 : Ballottement present
: Attitude - good flexion
: Presentation - cephalic
Auscultation
FHR : 148 b/minute
Final findings
Lie : Longitudinal
Position : Left occipito anterior position
Presentation : Cephalic
Attitude : Good flexion
FHR : 148 b/ minute
Genitalia : secretions normal, no abnormal white discharge
Extremities : normal range of motion, have first degree of pedal
edema
INVESTIGATIONS

Date Name of Patient Normal Remark

investigation value value
6/9/2011 Blood A+ ve
grouping
6/9/2011 Hb% 10.6gm/dl 13-14mg/dl She is
having
mild
anaemia
6/9/2011 RBS 94mg/dl 80-120 She is not
mg/dl a diabetic
patient
6/9/2011 VDRL Negative Negative
6/9/2011 HIV Negative Negative

Before Nursing Process

PROBLEMS IDENTIFIED

 Back pain
 Constipation
 Anxiety.
 Knowledge deficit regarding breast feeding techniques.
 Knowledge deficit regarding labour process
NURSING DIAGNOSIS
1. Back pain related to compression by hormonal changes in the body
2. Constipation related to compression of gravid uterus.
3. Anxiety related to the outcome of pregnancy.
4. Knowledge deficit due to lack of information related to breast feeding techniques.
5. knowledge deficit due to lack of information related to labour process
Sl no Drug name Route Doze Action Side effects Nurses responsibility
1 Ferrous sulphate Oral 200 mg Iron supplementation Dizziness Advise patient to take medicine as prescribed.
•N&V • Instruct patient to avoid concurrent use of alcohol
• Nasal Congestion • Advise patient to consult physician if irregular
• Dyspnoea heartbeat, dyspnoea, swelling of hands and feet and
• Hypotension hypotension occurs.
• CHF • Encourage patient to comply with additional
• MI intervention for hypertension like proper diet,
• Muscle cramps regular exercise, lifestyle changes and stress
• Flushing management.

◦Hypotension ◦Assess blood pressure, ECG readings, renal

2 Calcium sulphate Oral 500mg Calcium supplementation ◦Flushing function, magnesium, phosphate, and potassium
◦Warmth concentrations.
◦Nausea ◦Take tablets with full glass of water 30 minutes to
◦Vomiting 1 hour after meals.
◦Pain ◦Give syrup diluted in juice or water.
◦Chew chewable tablets well before swallowing.
◦Monitor blood pressure, ECG,

ANTENATAL FIRST VISIT AND SUBSEQUENT VISIT

Date Weight BP Gestational week Height of Oedema Laboratory finding Signature

fundus Blood (Hb) Urine stool
12/2/11 46 110/70 6 week - Nil 11 gms/dl Nil Nil
17/4/11 48 110/70 15week 16cm Nil 10.6 gms/dl - -
24/5/11 51 120/80 20 week 22cm Nil - - -
29/7/11 54 110/70 28week 28cm Pedal 10.4 gms/dl Nil -
edema
ASSESSME NURSING EXPECTED INTERVENTION RATIONALE IMPLIMENTATI EVALUATION
NT DIAGNOSIS OUTCOME ON

Subjective Back pain Mother Provide hot compress Heat penetrates painful Taught and Mother
tissues, increases
data: related to experience on back provided hot experienced less
circulation, and brings
She says physiological back pain additional oxygen. This compress. back pain within
gives pain relief.
that she is changes during within three three days as
having back pregnancy. days Provide back massage It gives relaxation and Provided and evidenced by
pain. loosens the back muscle. taught back verbalization
massage.
Objective Teach her about To reduce strain over the Taught about
data: proper diet proper vertebral column proper postures
She is 34 postures during during pregnancy.
weeks pregnancy.
pregnant. Educated about
Advise her to take rest It help to decrease the need for taking rest
She is not in between activities muscle spasm in between
maintaining activities
proper Advice to lie in lateral To reduce compression by
postures position while gravid uterus Advised to sleep
sleeping and lie down in
lateral positions
SUMMARY
I took Mrs. Ruhi Banu , an ante natal mother during my clinical posting in St.
Mary’s hospital, as a part of my clinical requirement. She was 34weeks pregnant. I collected
her health history and performed antenatal examination. She was having problems like back
pain, Oedema, fatigue, anxiety and lack of knowledge regarding labour and breast feeding. I
tried to solve her problems by giving health educations and advising her about necessary
interventions. Some of her problems like anxiety and knowledge deficit reduced by my
interventions and she became aware about the interventions to reduce other problems like
back pain and oedema.
CONCLUSION
I took Mrs.Ruhi Banu,a 19 years old antenatal mother with gestational age of 34
weeks for antenatal case study. She was very co-operative and I was able study her problems
and to compare it with the normal antenatal physiological changes and to give her proper care
through interventions and education.

REFERENCE