Case Study: Identification

CASE STUDY
IDENTIFICATION DATA:-
Patient name --- Mrs. Basantimeena

Age --- 23 year
Sex --- female
Bed No. --- 7
Religion --- hindu
DOA --- 29/3/19
Education --- 6th pass
Occupation --- Housewife
Marital status --- married
LMP --- 12/8/18
EDD --- 19/5/19
Obstetrical --- G3P2L2A0
Provisional diagnosis --- Anaemia(severe)
Final diagnosis --- High risk pregnancy
HISTORY OF ILLNESS:-
 Present history:- My client Basantimeena is third gravida women and 23 year on date
of admission she is having nausea, lower extrimities pain, weakness and suffer from anaemia,
Chief complaints:- Mrs Basanti having complaint of weakness, lower extrimities, lower eye
sightedness fainting occur
 Past history:- she had no history of T.B, HTN,Diabetes mellitus, other medical
complaints.
[A] Medical history- H/O HTN -- NO

H/O ASTHMA-- NO
H/O DIABETES -- NO
H/O TUBERCULOSIS -- NO
H/O ALLERGY-- NO
[B] Surgical history- No any surgical history
PAST OBSTETRICAL HISTORY:-

SNO YEAR FULL PRE- ABORTIO TYPE OF BABY
TERM TERM N DELIVER ALIV SEX
Y E
1 2015 PRESENT --- ---- NVD NO F
2 2017 PRESENT --- ---- NVD NO M
PRESENT PREGNANCY:-
Admission notes
Admitted on date of 29/3/19 at 2:40 am
Height of fundus : 32 cm
Presentation : cephalic
Engaged : not engaged
FHR: present
Bladder : empty
Bowel: empty
FAMILY HISTORY:-
Name of head of family:-Mithameena

Type of family:- joint family
S. NAME RELATION AGE SEX EDUCATION OCCUPATIO REMARK
N. N
1 Mithameen Father in law 49 y M 2nd pass farmer No any
a other
medical
history
2 Lalibai Mother in 45 y F illiterate housewife anaemia
law
3 Papumeena father 25 y M 6th pass driver No other
medical
history
4 Basantimee mother 23y F 6th pass housewife anaemia
na
SOCIOECONOMIC HISTORY:- Client live in joint family

House — pacca
Water supply --- properly supply
Electricity supply --- properly supply
Sanitation --- properly disposal
MENSTRUAL HISTORY
The age of menarchy started is 11 years interval is 28 days. Duration is 6 days. Before pregnancy
she is having regular menstrual cycle and normal flow.
PHYSICAL EXAMINATION
VITAL SIGNS PATIENT VALUE NORMAL VALUE
Temperature 96.9F 96.8-97.2F
Pulse 92 beats/min 80-86 beats/min
B.P 110/70mmof hg 120/80mm of hg
Respiration 22breath/min 20 breath/min
Physical findings mirror the underlying disease process and the duration from the onset. Patients
with chronic anemia usually do not manifest typical physical findings associated with acute
anemia.
The usefulness of skin pallor as a sign is limited by the color of the skin, the Hgb concentration,
and the fluctuation of blood flow to the skin. The color of the palmar creases is a better indicator.
If they are as pale as the surrounding skin, Hgb is usually less than 7 g/dL. Patients also may
exhibit purpura, petechiae, and jaundice.
Ocular findings may include the following:
 Pale conjunctiva
Cardiovascular findings may include the following:

 Tachycardia
 Orthostatic hypotension
Pulmonary findings may include the following:
 Tachypnea
Abdominal findings may include the following:

 Hepatomegaly and/or splenomegaly
 pain
 Positive result on Hemoccult test
Neurologic findings may include the following:
 Mental status changes
DISEASE DESCRIPTION
DEFINITION:-
Anemia, also spelled anaemia, is usually defined as a decrease in the total amount of red blood
cells (RBCs) or hemoglobin in the blood. It can also be defined as a lowered ability of the blood
to carry oxygen.
CLASSIFICATION:
IMPAIRED RED CELL PRODUCTION
A.
INADEQUATE SUPPLY OF NUTRIENTS ESSENTIAL FOR ERYTHROPOIESIS.
1.
 IRON DEFECIENCY
 VITAMIN B-12 DEFECIENCY
 FOLIC ACID DEFECIENCY
 PROTEIN-CALORI MALNUTRITION
 OTHER LESS COMMON DEFECIENCIES
ANAEMIA DUE TO REPLACEMENT OF THE BONE MARROW BY

2.
LEUKEMIA
o
LYMPHOMA
o
MYELOPROLIFERATIVE DISORDER
o
POLYCYTHEMIA
o
ESSENTIAL THROMBOCYTHEMIA
o
CHRONIC MYELOID LEUKEMIA
o
MYELOFIBROSIS
o
MYELOMA
o
MYELODYSPLASTIC DISORDERS
o
ANAEMIA DUE TO INHERITED DISORDERS
B.
THALASSAEMIA
A.
CAUSES:-
BOOK PICTURE PATIENT PICTURE
Faulty dietic habit present
Faulty absorption mechanism absent
Iron loss due to typhoid present
GI bleeding absent
Increased demands of iron present
Diminished intake of iron present
Diminished absorption absent
SIGN & SYMPTOMS:-
BOOK PICTURE PATIENT PICTURE

1.Easy fatigue and loss of energy Present
2.Unusual rapid heart beat, particularly with exercise Present
3.shortness of breath Present
4.dizziness Present
5.pale skin Present
6.leg cramps Present
7.insomnia Absent
8.beittle hairs Absent
9. glossitis absent
DIAGNOSTIC EVALUATION:-
S.N NAME OF PATIENT'S VALUE REFERENCE REMARK

INVESTIGATION VALUE
COMPLETE BLOOD
COUNT
1 HB 4.5gm% 13-15 gm % low
2 RBC 2.09 4.2-6.0 low
3 MCV 92.3[FL] 70-99 normal
4 MCH 27.8[Pg] 24-35 normal
5 MCHC 30.1[g/dl] 32-35 low
6 WBC 2.67 4.0-11.0 low
7 IRON,SERUM 358.18ug/dl 33.0-193.0 normal
8 FERRITTIN 117.10ng/ml 10.00-291.00 normal
MANAGEMENT:-
SURGICAL MANAGEMENT:-no surgical history
NURSING MANAGEMENT:- DOROTHEA OREM’S THEORY

Dorothea Orem;sTeory earned her bachelor of science nursing education in 1939 and Master of
science in nursing in 1945.During her professional carrier, she worked as a staff nurse, private
duty nurse, nurse educator and administratior and nurse consultant .
Orem worked for the division of hospital and institutional services of the indian state board of
health. Her goal was to upgrade the quality of nursing in general hospitals thoroughout the state.
Nursing process:
Orem approach to the nursing process presents a method to determine the self care deficit and
then defines the roles of person or nurse to meet the self care demands.
 Assessment
 Nursing diagnosis
 Plans with scientific rationale
 Implementation
 evaluation
NURSING DIAGNOSIS:-
1.Inability to maintain the ideal nutrition related to inadequate imtake of essential nutrients.
2.Ineffective pain control in lower extrimities to lack of utilization of pain relief measures.
3.Imbalanced nutrition less than body requirements,related to inadequate intake of essentials
nutrients.
4.Ineffective tissue perfussion related to inadequate blood volume.
5.Knowledge deficit related to management and treatment of anaemia.
ASSESS NURSING GOAL INTERVENTIONS RATIONALE EVALUATIO
MENT DIAGNOSIS N
Acc to Inability to To avhieve Assist the patient Assisted Achieving
orem’s maintain the optimal prioritize and to prioritize and optimal level of
theory ideal nutrition level of establish a balance to establish nutrition.
Subjectiv related to nutrition between activity and between
e data; intake of rest activity and
Headach essential rest.
e,weakne nutrients Providing iron Provided iron
ss,faintin supplements supplements.
g Restrict the activities Restricted the
Objective which affect activities affect
data; thehealth of a client the health a
Fatigue, client.
weakness Maintain some Maintained
, nausea, physical activity to some physical
loss of prevent the results activity to
appetite from inactivity prevent the
results from
inactivity
HEALTH EDUCATION:-
1.Dietary education
 Advised to eat food,containing more iron like drum stick, juggery and green leafy
vegetables .
 Eat food at regular interval
2.Maintain personal hygiene
3.Advice for daily bath, mouth care, hair care.
4.Advice her to take all medicine regularly and come for routine check up according doctor’s
order
5.Famiy planning methods – advised her to use temporary family planning methods.
BIBILIOGRAPHY:-
1.Dutta DC ‘’textbook of obstetrics’’ 8th edition, 2015 , New central book agency publication ,
Calcutta, page no 300-305
2. Jacob Anamma“ A comprehensive textbook of Midwifery edition 2005,jaypee medical
publication.’Newdelhi,page no 164-172

Case Study: Identification

Uploaded by

Copyright:

Available Formats

Case Study: Identification

Uploaded by

Document Information

Original Title

Copyright

Available Formats

Share this document

Share or Embed Document

Sharing Options

Did you find this document useful?

Is this content inappropriate?

Copyright:

Available Formats

Case Study: Identification

Uploaded by

Copyright:

Available Formats

CASE STUDY

Patient name --- Mrs. Basantimeena

[A] Medical history- H/O HTN -- NO

[B] Surgical history- No any surgical history

PAST OBSTETRICAL HISTORY:-

Name of head of family:-Mithameena

SOCIOECONOMIC HISTORY:- Client live in joint family

Cardiovascular findings may include the following:

Abdominal findings may include the following:

 Mental status changes

 VITAMIN B-12 DEFECIENCY

 FOLIC ACID DEFECIENCY

 OTHER LESS COMMON DEFECIENCIES

ANAEMIA DUE TO REPLACEMENT OF THE BONE MARROW BY

SIGN & SYMPTOMS:-

BOOK PICTURE PATIENT PICTURE

S.N NAME OF PATIENT'S VALUE REFERENCE REMARK

SURGICAL MANAGEMENT:-no surgical history

NURSING MANAGEMENT:- DOROTHEA OREM’S THEORY

You might also like