INTRODUCTION

NAME : Ms. Nehakumari V. Patel

CLASS : First Year M.Sc. Nursing

SUBJECT : Obstetrics and Gynecological Nursing

TOPIC : Post Partum Hemorrhage

As a part of our clinical experience in Advance Nursing Practice, we were posted in

postnatal ward, CHC Chikhli. There I get chance to give care to the patient with PPH.
 DEMOGRAPHIC INFORMATION:
 Name : Mrs. Jitina Vadavi
 Age : 26 years
 Sex : Female
 Address : Khergam
 Religion : Hindu
 Marital status : Married
 Occupation : Housewife
 Income : 15,000 /- per month
 Ward : post-natal ward
 Obstetrical score : G1 P1 L1 A0 D0
 Diagnosis :PNC mother with atonic PPH

PRESENT HEALTH HISTORY

1. CHIEF COMPLAINTS ( ON THE DAY OF ADMISION)
Patient was admitted with the complaint of the per vaginal bleeding referred from
PHC, Khergam for the management of atonic uterus and PPH in CHC, Chikhli With the
complains of,
 Back pain
 Pain in perineal region
 weakness
 vaginal bleeding
 abdominal cramp
2. PRESENT MEDICAL HISTORY
Patient was admitted in postnatal ward with the reference from PHC. She was
apparently not well because of sever bleeding from vagina, she had started labour pain
and membrane was ruptured , baby was delivered by normal vaginal delivery , she
complained abdominal pain and heavy vaginal bleeding. Then diagnosed with the PPH.
After that mother was referred from nearest PHC for management of atonic PPH.

Examination finding:
Temperature- 98.6 F
BP-90/60 mm of hg
Pulse-88 beats/min
Respiration - 24 beats /min

 DAY 1 :

Patient compliant medical intervention

 Vaginal bleeding Give inj. Methergine as per dr. Prescribe
 Loss of appetite Give sanitary pad to minimize the infection
 Impaired sleeping Give nutritive diet provide in hospital
 Discomfort Give comfortable bed for rest and sleep
Give health education about personal
hygiene and iron reach diet

 DAY 2 :
Patient complain medical intervention
 Pallor with weakness same treatment as previous day
 Impaired sleeping
 Mild discomfort
  DAY 3 :
 Pallor with weakness same treatment as previous day
 Disturbed sleeping
 Mild discomfort

3. PRESENT SURGICAL HISTORY

No any major and minor surgery have been done in the present.

PAST HEALTH HISTORY:

1) PAST MEDICAL HISTORY
Patient has no any major or minor disease in the past.
2) PAST SURGICAL HISTORY
Patient has no any major or minor surgery in the past.

FAMILY HISTORY:

Sr.n Name of the age Gender Occupation Education Relation Health

o. family status
members

1 Jitina 26 Female House wife Illiterate Self PPH

2 Bharat 28 Male Labor worker 10th pass Husband Healthy
3 Baby boy 3 days Male - Son Malnouri
shed

She belongs to the middle-class family. In her family patient’s husband has no any major
disease in present , but other family member also has no any type of communicable disease and
all are healthy
 FAMILY TREE :

Bharat (25 year) Jitina (20yrs)

baby boy (2 days)

PSYCHOSOCIAL AND ECONOMIC HISTORY:

Patient was housewife and her husband is bread winner of the family, total family
monthly income is about 15,000/-
Economic history : She belongs to middle class family and live in own home
Mother tongue : Marathi
Language known : Hindi , Marathi
Cultural group : Friends and Family
Mood : Social and cooperative

ENVIRONMENTAL HISTORY:
 She lives with her family in own house, her native place is in Maharashtra.
 In her House has two rooms and a kitchen.
 They use toilet for defecation and getting water from the municipal water supply.
 She has adequate electricity supply.

PERSONAL HISTORY
a) PERSONAL HABIT
Patient has no any bad habit of smoking , alcoholism , drinking and tobacco chewing
b) NUTRITIONAL HISTORY:
Type of food : Nonvegetarian
Likes/ dislikes : like spicy food , dislike sweet food
Allergies : no any allergy
Because of surgery and discomfort there is a loss of appetite.

c) ELIMINATION PATTERN:
Bowel - one time per day.
Bladder - 7-8 times per day

d) MENSTRUATION HISTORY:
Puberty attained on : 15 years
Duration of cycle : 5-6 days
Amount of flow : normal
Any abnormality : absent

e) OBSTETRICAL HISTORY
G1P1L1A0

 ANTENATAL HISTORY
Mild anemia present
Immunization: both TT dose taken
 INTRANATAL HISTORY
 No any perineal tear. No vaginal laceration
 No bleeding from episiotomy site
 Small perimetral tear present at right side bleeding present at that side.
 delivery of male child.
 POSTNATAL HISTORY
PPH present
 PHYSICAL EXAMINATION:

1) GENERAL OBSERVATION
 Constitution : Poor nourished
 Stature : Normal
 Personal appearance : conscious , oriented
 Posture : steady
 Emotional stage : Restlessness
 Skin : Dry, cracked
 Cooperativeness : cooperative
 Mood : Sad and anxious
 Activity : Dull

2) VITAL SIGNS
 Temperature : 98.6 F
 Pulse : 88bpm
 Respiration : 24bpm
 Blood pressure : 90/60 mm of Hg

3) HEIGHT : 152 Cm
4) WEIGHT :47 Kg
weight (kg) 47
BMI= = = 18.72
height (N2 ) (1.52)2

5) SKIN AND MUCUS MEMBRANE:

 Color of the skin : pallor in color
 Edema : absent
 Turgor : Dry
 Texture : pallor
6) HEAD
 Skull : Normal
 Hair : Black in color and equally distributed
 Movements of the head : normal
 Forehead : Normal
 Face : conscious, no any scar

7) EYES
 Eyebrows : Equal
 Eyelids : Normal, no lesions
 Lacrimation : Clear fluid
 Conjunctiva : Pale in color
 Sclera : White in color, Normal
 Cornea : Clear
 Iris : Normal
 Edema : absent
 Pupils : PERRLA ,3mm size

8) EARS
 Appears : Both symmetrical
 Discharge : No any discharge
 Hearing : Normal
 Lesions : Absent

9) NOSE
 Appearance : Normal
 Discharge : No any discharge
 Patency : Both nostrils are patent
 Sense of smell : Good
 Septal deviation : Absent
10) MOUTH AND THROAT
 Lips : Dry
 Tongue : Moist
 Teeth : Intact in upper and lower jaw
 Gums : Pink
 Buccal mucosa : Clean, moist, no lesions
 Tonsil : No any enlargement
 Speech : slow speech

11) NECK
 General appearance : Normal
 Trachea : Normal in position
 Lymph node : No enlargement
 Thyroid gland : Feel smooth and firm
 Cyst and tumor : Absent
 Range of motion : painful

12) BREAST
 Symmetry : Symmetrical
 Shape : Normal
 Size : Normal
 Nipple : erect
 Discharge : milk secretion present
 Auxiliary Node : Absent
 Lesion : Absent
 Areola : primary and secondary areola differentiate
 Montgomery tubercle : evident
 Visible vein : not present
13) RESPIRATORY SYSTEM
 Inspection : chest expansion equal in both side, respiration rate 30bpm
 Palpation : No any lesion and mass
 Percussion : No abnormal sound in both lungs
 Auscultation : Normal breath sound and vesicular sound present

14) CARDIO VASCULAR SYSTEM

 Inspection : No enlargement of jugular vein
 Palpation : Peripheral pulse normal
 Percussion : No any abnormal sound
 Auscultation : S1 and S2 heart sound appear

15) ABDOMEN
POSTNATAL EXAMINATION
 Inspection : Straia albican present
No any previous scar present
 Palpation : Height of uterus : 14 cm
Abdominal girth : 70 cm
 Percussion : Presence of Fluid
 Auscultation : Bowel Sound Heard
 Appetite : Anorexia Present

16) BACK
 Spine and curvature : Normal
 Movements : painful
 Tenderness : absent
 Pain : present
17) GENITELIA
 Hemorrhoids : absent
 Vaginal discharge : present
 Labia majora & minora : redness is present

18) UPPER EXTREMITIES

 Symmetry : symmetrical
 Range of motion : possible
 Oedema : absent
 Cyanosis : absent
 Joints : movable
 Deformity : absent

19) LOWER EXTRIMITIES:-

 Homan sign : negative
 Symmetry : symmetrical
 Range of motion : possible
 Oedema : absent
 Cyanosis : absent
 Joints : movable
 Deformity : absent
 INVESTIGATION
Sr Investigations Patient’s Normal Inference
no value value
1 CBC:
Hemoglobin 9.6 g/dl 11-16 g/dl Decreased
Leukocyte count 22200/cmm 4000- Increased
11000/cmm

2 WBC differential count:

Neutrophils 85% 30-70% Increase
Lymphocytes 11% 20-40% Decrease
Eosinophils 02% 1-6% -
Monocytes 02% 1-8% -
Basophils 00% < 2% -
Platelets count: 478.00 150-450 -
thousand thousand
/cmm /cmm
3 Renal function test
Urea 14.2 mg/dl 10-50 mg/dl Normal
S.creatinine 0.8 mg/dl 0.6-1.2mg/dl Normal
S. uric acid 2.0 mg /dl 2.6-6.0mg/dl Normal
4 Electrolytes:-
Serum sodium 142 mEq/l 135-147mEq/l Normal
Serum potassium 4.5 mEq/l 3.5-5.5 mEq/l Normal
Serum chloride 96 mEql 96-10mEq/l Normal
ULTRASONOGRAPHY OF ABDOMEN & PELVIS

Liver : no focal mass . normal size , contour and parenchymal echotexture

Gall bladder : shows physiological distension

Pancreas , spleen , portal vein , kidneys , pelvis : normal

Uterus: normal in size , Both ovaries are normal.

IMPRESSION :No any mass or lesion found..

 DRUG STUDY

Sr. Drug Dose Route Action Side effect Nurses

no Responsibility
1. Inj. 1gm IV stat Inhibits bacterial cell -seizure -do not break
Cefotaxime
wall synthesis, -bleeding ,chrush or chew
rendering cell wall -diarrhea tab
osmotically unstable, -leukopenia -check bowel
leading to cell death -protenuria pattern

2. Inj. 40 IV Suppresses gastric -pnemonea -assess vit b12

Pantoprazole mg secrition by inhibiting -hypergly deficiency
hydrogen/potassium cemia -may take without
ATPase enzyme system -rash food
in gastric cells, known -abdominal -diabetic patient
as gastric acid pump pain should know
inhibitor -insomnia hyperglycemia
-headache may occur
3. Inj. Emeset 4 mg IV Prophylaxis of post Warm Check the
(ondasetron) operative nausea , feeling, hydration level of
vomiting associated head ache, patient
with radiation constipation
4. Tab. Folic acid 800 Oral Folic acid helps the Fever Check the any
mcg body to produce and general allergic reaction
weakness or
maintain new cells, and discomfort Stored at the room
also helps prevent reddened temperature
changes to DNA that skin Assess the 10 right
may lead to cancer. As shortness of of the patient
breath
a medication, folic before administer
skin rash or
acid is used to itching drug
 treat folicacid deficienc
y and certain types of
anemia (lack of red
blood cells) caused
by folicacid deficiency.
5. Metrogyl 20mg IV Directed again Leucopenia Check the renal
elistolytical T- vaginal Pruritis function test ,
antibiotic.,actively Urticaria, dosage and
against variety of Headache frequency of drug
organisms.
6. Methergin 80 Iv act directly on the Headache Check pt
mymetrium. It excites
mg Nausea conscious level
uterine contractions
which come so Vomiting
frequently one after the
Cardiac
other with increaseing
intensing that the uterus problems
passes in to a state of
spasm without any
relaxation.

7. Iron sucrose 200m Iv Iron sucrose , the Muscels

complex of Check the any
g cramp allergic reaction
polyneuclesr iron(lll)-
dilute hydroxide in sucrose is Nausea Stored at the room
dissociated in to iron temperature
d in Vomiting
and sucrose by the
100m reticuloendothelial Dizziness Assess the 10 right
system of the patient
l NS constipation
before administer
drug
 THEORY APPLICATION
IMOGENE KING GOAL ATTAINMENT THEORY:

INTRODUCTION

 Theorist : Imogene King - born in 1923.

 Bachelor in science of nursing from St. Louis University in 1948
 Master of science in nursing from St. Louis University in 1957
 Doctorate from Teacher’s college, Columbia University.
 Theory describes a dynamic, interpersonal relationship in which a person grows and
develops to attain certain life goals.
 Factors which affects the attainment of goal are: roles, stress, space & time

BASIC ASSUMPTIONS

 Nursing focus is the care of human being

 Nursing goal is the health care of individuals & groups
 Human beings: are open systems interacting constantly with their environment.
 Basic assumption of goal attainment theory is that nurse and client communicate
information, set goal mutually and then act to attain those goals, is also the basic
assumption of nursing process
 “Each human being perceives the world as a total person in making transactions with
individuals and things in environment”
 “Transaction represents a life situation in which perceiver & thing perceived are
encountered and in which person enters the situation as an active participant and each is
changed in the process of these experiences”
 Major Concepts

 Interacting systems:
o personal system
o Interpersonal system
o Social system
 Concepts are given for each system

CONCEPTS FOR PERSONAL SYSTEM

 Perception
 Self
 Growth & development
 Body image
 Space
 Time

CONCEPTS FOR INTERPERSONAL SYSTEM

 Interaction
 Communication
 Transaction
 Role
 Stress

Concepts for Social System

 Organization
 Authority
 Power
 Status
 Decision making
PROPOSITIONS OF KING’S THEORY

 If perceptual interaction accuracy is present in nurse-client interactions, transaction will

occur
 If nurse and client make transaction, goal will be attained
 If goal are attained, satisfaction will occur
 If transactions are made in nurse-client interactions, growth & development will be
enhanced
 If role expectations and role performance as perceived by nurse & client are congruent,
transaction will occur
 If role conflict is experienced by nurse or client or both, stress in nurse-client interaction
will occur
 If nurse with special knowledge skill communicate appropriate information to client,
mutual goal setting and goal attainment will occur.

NURSING PARADIGMS

1. Human being /person

 Human being or person refers to social being who are rational and sentient.
 Person has ability to :

 perceive
 think
 feel
 choose
 set goals
 select means to achieve goals and
 to make decision
  Human being has three fundamental needs:

1. The need for the health information that is unable at the time when it is needed
and can be used
2. The need for care that seek to prevent illness, and
3. The need for care when human beings are unable to help themselves.

2. Health

 Health involves dynamic life experiences of a human being, which implies continuous
adjustment to stressors in the internal and external environment through optimum use of
one’s resources to achieve maximum potential for daily living.

3. Environment

 Environment is the background for human interactions.

 It involves:
1. Internal environment: transforms energy to enable person to adjust to continuous
external environmental changes.
2. External environment: involves formal and informal organizations. Nurse is a part
of the patient’s environment.

4. Nursing

 Definition: “A process of action, reaction and interaction by which nurse and client share
information about their perception in nursing situation.” and “ a process of human
interactions between nurse and client whereby each perceives the other and the situation,
and through communication, they set goals, explore means, and agree on means to
achieve goals.”
 Action: is defined as a sequence of behaviors involving mental and physical action.
 Reaction: which is considered as included in the sequence of behaviors described in
action.
  In addition, king discussed:

 (a) goal
 (b) domain and
 (c) functions of professional nurse

 Goal of nurse: “To help individuals to maintain their health so they can function in their
roles.”
 Domain of nurse: “includes promoting, maintaining, and restoring health, and caring for
the sick, injured and dying.
 Function of professional nurse: “To interpret information in nursing process to plan,
implement and evaluate nursing care..

Theory of Goal Attainment and Nursing Process

Assessment

 Assessment occur during interaction.

 The nurse brings special knowledge and skills whereas client brings knowledge of self
and perception of problems of concern, to this interaction.
 During assessment nurse collects data regarding client (his/her growth & development,
perception of self and current health status, roles etc.)
 Perception is the base for collection and interpretation of data.
 Communication is required to verify accuracy of perception, for interaction and
transaction.

Nursing diagnosis

 The data collected by assessment are used to make nursing diagnosis in nursing process.
 In process of attaining goal the nurse identifies the problems, concerns and disturbances
about which person seek help.
Planning

 After diagnosis, planning for interventions to solve those problems is done.

 In goal attainment planning is represented by setting goals and making decisions about
and being agreed on the means to achieve goals.
 This part of transaction and client’s participation is encouraged in making decision on the
means to achieve the goals.

Implementations

 In nursing process implementation involves the actual activities to achieve the goals.
 In goal attainment it is the continuation of transaction.

Evaluation

 It involves to finding out whether goals are achieved or not.

 In king description evaluation speaks about attainment of goal and effectiveness of
nursing care.

NURSING PROCESS AND THEORY OF GOAL ATTAINMENT

Nursing process method Nursing process theory

A system of oriented actions A system of oriented concepts
Perception, communication and interaction of
Assessment
nurse and client
Planning Decision making about the goals
Be agree on the means to attain the goals
Implementation Transaction made
Evaluation Goal attained
 IMOGENE KING THEORY

ASSESSMENT THROUGHPUT OUTPUT

PERSONAL SYSTEM 
Acute abdominal pain Assess the bledding Reduce
NURS PERCEPTION flow bledding
Bleeding from vagina
Atonic uterus JUDGEMENT  Provide pain relieve medication
Assess the level of anxiety
Encourage for non pharmacological method
- Client is a whole  Maintain urine out put chart & record Providing medication as per order
INTERRELATIONAL SYSTEM Providing care to client Reduce level of
Provide
Difficulty in urine pass because of uterine prolapsed. Providing need base quality care Practice evidence base anxiety
nursing care.
 psychological support to client
Anxiety related to disease condition
Difficulty in sleeping
Acute abdominal pain due to uterine prolapsed
 GOAL
ATTINMENT
Maintain normal urine
output
PERCEPTIONL & 
JUDGEMENR

-Nurse is a care taker
SOCIAL SYSTEM of her Improve sleeping
-Patient fully depend on nurse pattern.

- Belongs from the lower -Cooperative behavior with her.Involve family
cast family CLIENT member in take care SATISFACTI
- Family monthly income 18000/-
ON & EFFECTIVE NUR
CARE

FEEDBACK
 THEORY APPLICATION

DOROTHY E. JOHNSON’S BEHAVIORAL SYSTEM MODEL

DESCRIPTION
Johnson’s theory defined Nursing as “an external regulatory force which acts to preserve
the organization and integration of the patients behaviors at an optimum level under those
conditions in which the behavior constitutes a threat to the physical or social health, or in
which illness is found.”
It also states that “each individual has patterned, purposeful, repetitive ways of acting that
comprises a behavioral system specific to that individual.”

GOALS
Johnson began her work on the model with the premise that nursing was a profession that
made a distinctive contribution to the welfare of society. Thus, nursing had an explicit goal
of action in patient welfare.
The goals of nursing are fourfold, according to the Behavior System Model:
(1) To assist the patient whose behavior is proportional to social demands.
(2) To assist the patient who is able to modify his behavior in ways that it supports
biological imperatives.
(3) To assist the patient who is able to benefit to the fullest extent during illness from the
physician’s knowledge and skill. And
(4) To assist the patient whose behavior does not give evidence of unnecessary trauma as a
consequence of illness.

ASSUMPTIONS
The assumptions made by Johnson’s theory are in three categories: assumptions about
system, assumptions about structure, and assumptions about functions.
Johnson identified several assumptions that are critical to understanding the nature and
operation of the person as a behavioral system:
(1) There is “organization, interaction, interdependency and integration of the parts and
elements of behaviors that go to make up the system.”
(2) A system “tends to achieve a balance among the various forces operating within and
upon it, and that man strive continually to maintain a behavioral system balance and steady
state by more or less automatic adjustments and adaptations to the natural forces occurring
on him.”
(3) A behavioral system, which requires and results in some degree of regularity and
constancy in behavior, is essential to man. It is functionally significant because it serves a
useful purpose in social life as well as for the individual. And
(4) “System balance reflects adjustments and adaptations that are successful in some way
and to some degree.”
The four assumptions about structure and function are that: (1) “From the form the
behavior takes and the consequences it achieves can be inferred what ‘drive’ has been
stimulated or what ‘goal’ is being sought.” (2) Each individual person has a “predisposition
to act with reference to the goal, in certain ways rather than the other ways.” This
predisposition is called a “set.” (3) Each subsystem has a repertoire of choices called a
“scope of action.” And (4) The individual patient’s behavior produces an outcome that can
be observed.
And lastly, there are three functional requirements for the subsystems.: (1) The system
must be protected from toxic influences with which the system cannot cope. (2) Each
system has to be nurtured through the input of appropriate supplies from the environment.
And (3) The system must be stimulated for use to enhance growth and prevent stagnation.

MAJOR CONCEPTS
Human Beings
Johnson views human beings as having two major systems: the biological system and the
behavioral system. It is the role of medicine to focus on the biological system, whereas
nursing’s focus is the behavioral system.
The concept of human being was defined as a behavioral system that strives to make
continual adjustments to achieve, maintain, or regain balance to the steady-state that is
adaptation.
Environment
Environment is not directly defined, but it is implied to include all elements of the
surroundings of the human system and includes interior stressors.

Health
Health is seen as the opposite of illness, and Johnson defines it as “some degree of
regularity and constancy in behavior, the behavioral system reflects adjustments and
adaptations that are successful in some way and to some degree… adaptation is
functionally efficient and effective.”
Nursing
Nursing is seen as “an external regulatory force which acts to preserve the organization and
integration of the patient’s behavior at an optimal level under those conditions in which the
behavior constitutes a threat to physical or social health, or in which illness is found.”
Behavioral system
Man is a system that indicates the state of the system through behaviors.
System
That which functions as a whole by virtue of organized independent interaction of its parts.
Subsystem
A mini system maintained in relationship to the entire system when it or the environment is
not disturbed.

SUBCONCEPTS
 Structure
The parts of the system that make up the whole.
 Variables
Factors outside the system that influence the system’s behavior, but which the system
lacks power to change.
 Boundaries
The point that differentiates the interior of the system from the exterior.
 Homeostasis
Process of maintaining stability.
 Stability
Balance or steady-state in maintaining balance of behavior within an acceptable range.
 Stressor
 A stimulus from the internal or external world that results in stress or instability.
 Tension
 The system’s adjustment to demands, change or growth, or to actual disruptions.
 Instability
 State in which the system output of energy depletes the energy needed to maintain
stability.
 Set
 The predisposition to act. It implies that despite having only a few alternatives from
which to select a behavioral response, the individual will rank those options and choose
the option considered most desirable.
 Function
Consequences or purposes of action.

7 SUBSYSTEMS
Johnson identifies seven subsystems in the Behavioral System Model. They are:
 Attachment or affiliative subsystem
Attachment or affiliative subsystem is the “social inclusion intimacy and the formation
and attachment of a strong social bond.” It is probably the most critical because it forms
the basis for all social organization. On a general level, it provides survival and security.
Its consequences are social inclusion, intimacy, and formation and maintenance of a
strong social bond

 Dependency subsystem
Dependency subsystem is the “approval, attention or recognition and physical
assistance.” In the broadest sense, it promotes helping behavior that calls for a nurturing
response. Its consequences are approval, attention or recognition, and physical
assistance. Developmentally, dependency behavior evolves from almost total
dependence on others to a greater degree of dependence on self. A certain amount of
interdependence is essential for the survival of social groups.

 Ingestive subsystem
Ingestive subsystem is the “emphasis on the meaning and structures of the social events
surrounding the occasion when the food is eaten.” It should not be seen as the input and
output mechanisms of the system. All subsystems are distinct subsystems with their
own input and output mechanisms. The ingestive subsystem “has to do with when, how,
what, how much, and under what conditions we eat.”
 Eliminative subsystem
Eliminative subsystem states that “human cultures have defined different socially
acceptable behaviors for excretion of waste, but the existence of such a pattern remains
different from culture to culture.” It addresses “when, how, and under what conditions
we eliminate.” As with the ingestive subsystem, the social and psychological factors
are
 viewed as influencing the biological aspects of this subsystem and may be, at times, in
conflict with the eliminative subsystem.

 Sexual subsystem
Sexual subsystem is both a biological and social factor that affects behavior. It has the
dual functions of procreation and gratification. Including, but not limited to, courting
and mating, this response system begins with the development of gender role identity
and includes the broad range of sex-role behaviors.

 Aggressive subsystem
Aggressive subsystem relates to the behaviors concerning protection and self-
preservation, generating a defense response when there is a threat to life or territory. Its
function is protection and preservation. Society demands that limits be placed on modes
of self-protection and that people and their property be respected and protected.

 Achievement subsystem
Achievement subsystem provokes behavior that tries to control the environment. It
attempts to manipulate the environment. Its function is control or mastery of an aspect
of self or environment to some standard of excellence. Areas of achievement behavior
include intellectual, physical, creative, mechanical, and social skills.

BEHAVIORAL SYSTEM MODEL AND THE NURSING PROCESS

The nursing process of the Behavior System Model of Nursing begins with an assessment
and diagnosis of the patient. Once a diagnosis is made, the nurse and other healthcare
professionals develop a nursing care plan of interventions and setting them in motion. The
process ends with an evaluation, which is based on the balance of the subsystems.
Johnson’s Behavioral System Model is best applied in the evaluation phase, during which
time the nurse can determine whether or not there is balance in the subsystems of the
patient. If a nurse helps a patient maintain an equilibrium of the behavioral system through
an illness in the biological system, he or she has been successful in the role.
STRENGTHS
o Johnson’s theory guides nursing practice, education, and research; generates new
ideas about nursing; and differentiates nursing from other health professions.
 o It has been used in inpatient, outpatient, and community settings as well as in
nursing administration. It has always been useful to nursing education and has been
used in practice in educational institutions in different parts of the world.
o Another advantage of the theory is that Johnson provided a frame of reference for
nurses concerned with specific client behaviors. It can also be generalized across the
lifespan and across cultures.
o The theory also has potential for continued utility in nursing to achieve valued
nursing goals.
WEAKNESSES
o The theory is potentially complex because there are a number of possible
interrelationships among the behavioral system, its subsystems, and the
environment. Potential relationships have been explored, but more empirical work is
needed.
o Johnson’s work has been used extensively with people who are ill or face the threat
of illness. However, its use with families, groups, and communities is limited.
o Though the seven subsystems identified by Johnson are said to be open, linked, and
interrelated, there is a lack of clear definitions for the interrelationships among them
which makes it difficult to view the entire behavioral system as an entity.
o The problem involving the interrelationships among the concepts also creates
o difficulty in following the logic of Johnson’s work.
DYNAMIC ENVIRONMENT

Unhygienic environment Unclean cloth

Not taking proper breast care Poor parenting

Dependency Child is fully

Trusted on mother
achieve normal milestone

Internal environment

Aggressive stage sexual-oral

Sensitive to touch

POSITIVE Digestive / eliminative pattern ( normal)

OUTCOME

Maintaining stable vital sign Encourage For Kangaroo Mother Care Good

Parenting Explain Importance Of Good Parenting

Maintaining Good Personal Hygiene Encourage For Breast Feeding

 ANATOMY AND PHYSIOLOGY

THE BLOOD
• Blood is a fluid connective tissue. It circulates continually around the body, allowing
constant communication between tissues distant from each other.
• Blood makes up about 7% of body weight (about 5.6 liters in a 72 Kg man). This
proportion is less in women, while in children is greater (gradually decreasing until the
adult level is reached).

Normal Situation
Iron Cycle (Hb 14g/dl)

FUNCTIONS OF THE BLOOD

1) The main function of the blood is to maintain intracellular homeostasis by: a). Carries
O2 and nutrients (glucose, amino acids, lipids, and vitamins) to the cells. b). Carries
CO2 and other wastes (nitrates, creatine, nucleic acid) away from the cell.
2) Providing intercellular communication in the body: carryies hormones (secreted by
endocrine glands) to the target organs.
3) Production and defense: it allows cells and immunological proteins to transport from
place to place where need them.
4) Self repair mechanism: clotting cascade.

BLOOD COMPONENTS
 • Blood is composed from 2 fractions:
1. Plasma Non living extracellular matrix composes about 55% of total blood volume.
2. Formed elements (living cells) composes about 45% of total blood volume.
• The two frictions of blood can be separated by spinning.

PLASMA
The constituents of plasma are:
1. Water (90-92%)
2. Plasma proteins: make up about 7% of plasma.
- Albumins (about 60% of total plasma protein) They are responsible for maintain normal
plasma osmotic pressure. Albumins also act as carrier molecules for free fatty acids, some
drugs and steroid hormones.
- Globins their main functions are: as antibodies (immunoglobulins), transportation of
some hormones and mineral salts (e.g. thyroglobulin carries the hormone thyroxin and
transferrin carries the mineral iron.
- Clotting factors. These are responsible for coagulation of blood. And inhibition of some
proteolytic enzymes (e.g. macroglobulin inhibits trypsin) activities)
3. Inorganic salts (electrolytes) like Ca, Na, Po4 which are responsible for muscle
contraction, transmission of nerve impulses, ect.
4. Nutrients: glucose, amino acid, fatty acids and glycerol.
5. Waste products like urea, creatinine and uric acid they are carried in the blood to the
kidney for excretion.
6. Hormones and gases Formed Elements
CELLULAR CONTENT OF BLOOD
• There are three types of blood cell:
1. Erythrocytes (Red Blood Cells =RBC).
2. Platelets (thrombocytes)
3. Leukocytes (white blood cells = WBC) they include monocytes, lymphocytes,
neutrophils, eosinophils, and basophils.
SOURCE OF BLOOD CELLS
• Mature blood cells have a relatively short life spine.
• Blood cells are synthesised mainly in the red bone marrow.
• Some lymphocytes, additionally are produced in lymphoid tissue.
• The organ or system responsible for synthesis blood cells are called hematopoietic
system and the process of blood cell formation is called hematopoiesis.

UTERUS
  The uterus is described as a hollow, muscular, pear-shaped organ.
 It is located at the lower pelvis, which is posterior to the bladder and anterior to
the rectum.
 The uterus has an estimated length of 5 to 7 cm and width of 5 cm. it is 2.5 cm
deep in its widest part.
 For non-pregnant women, it is approximately 60g in weight.

Introduction

LAYERS-The three layers, from innermost to outermost, are as follows:

Endometrium
It is the inner epithelial layer, along with its mucous membrane, of
the mammalian uterus. It has a basal layer and a functional layer; the functional layer
thickens and then is sloughed during the menstural cycle or estrous cycle.
During pregnancy, the glands and blood vessels in the endometrium further increase in
 size and number. Vascular spaces fuse and become interconnected, forming the placenta,
which supplies oxygen and nutrition to the embryo and fetus.
Myometrium
The uterus mostly consists of smooth muscle, known as "myometrium." The
innermost layer of myometrium is known as the junctional zone, which becomes
thickened in adenomyosis.
Perimetrium
Serous layer of visceral peritonium. It covers the outer surface of the uterus.
 Its function is to receive the ovum from the fallopian tube and provide a place for
implantation and nourishment.
 It also gives protection for the growing fetus
 It is divided into three: the body, the isthmus, and the cervix.
 The body forms the bulk of the uterus, being the uppermost part. This is also the
part that expands to accommodate the growing fetus.
 The isthmus is just a short connection between the body and the cervix. This is the
portion that is cut during a cesarean section.
 The cervix lies halfway above the vagina, and the other half extends into the vagina.
It has an internal and external cervical os, which is the opening into the cervical
canal.

PHYSIOLOGY OF UTERUS
A. THE REPRODUCTIVE CYCLE
The female reproductive cycle is the process of producing an ovum and readying
the uterus to receive a fertilized ovum to begin pregnancy. If an ovum is produced but not
fertilized and implanted in the uterine wall, the reproductive cycle resets itself through
menstruation. The entire reproductive cycle takes about 28 days on average, but may be as
short as 24 days or as long as 36 days for some women.
B. OOGENESIS AND OVULATION
…Under the influence of follicle stimulating hormone (FSH), and luteinizing hormone
(LH), the ovaries produce a mature ovum in a process known as ovulation. By about 14
days into the reproductive cycle, an oocyte reaches maturity and is released as an ovum.
Although the ovaries begin to mature many oocytes each month, usually only one ovum
per cycle is released.
C. FERTILIZATION
Once the mature ovum is released from the ovary, the fimbriae catch the egg and direct it
down the fallopian tube to the uterus. It takes about a week for the ovum to travel to the
uterus. If sperm are able to reach and penetrate the ovum, the ovum becomes
a fertilized zygote containing a full complement of DNA. After a two-week period of rapid
cell division known as the germinal period of development, the zygote forms an embryo.
The embryo will then implant itself into the uterine wall and develop there during
pregnancy.
D. MENSTRUATION
While the ovum matures and travels through the fallopian tube, the endometrium grows
and develops in preparation for the embryo. If the ovum is not fertilized in time or if it fails
to implant into the endometrium, the arteries of the uterus constrict to cut off blood flow to
the endometrium. The lack of blood flow causes cell death in the endometrium and the
eventual shedding of tissue in a process known as menstruation. In a normal menstrual
cycle, this shedding begins around day 28 and continues into the first few days of the new
reproductive cycle.
E. PREGNANCY
If the ovum is fertilized by a sperm cell, the fertilized embryo will implant itself into the
endometrium and begin to form an amniotic cavity, umbilical cord, and placenta. For the
first 8 weeks, the embryo will develop almost all of the tissues and organs present in the
adult before entering the fetal period of development during weeks 9 through 38. During
the fetal period, the fetus grows larger and more complex until it is ready to be born.
 DISEASE CONDITION

POSTPARTUM HEMORRHAGE
The amount of blood loss greater than or equal to 500 ml within 24 hours after birth,
while severe PPH is blood loss greater than or equal to 1000 ml within 24 Hours(WHO)
DEFINITION
“Any amount of bleeding from or into the genital tract following birth of the baby
upto the end of the puerperium, which adversely affects the general condition of the patient
evidenced by rise in pulse rate and falling blood pressure is called postpartum hemorrhage”.

CLASSIFICATION OF THE POSTPARTUM HEMORRHAGE

BOOK PICTURE PATIENT PICTURE

 Primary: Hemorrhage occurs within 24 hours following
the birth of the baby. In the majority, hemorrhage occurs
within two hours following delivery.
 Third stage hemorrhage—Bleeding occurs before
expulsion of placenta.
 True postpartum hemorrhage—Bleeding occurs PATIENT HAVE
subsequent to expulsion of placenta (majority). True postpartum
 Secondary: Hemorrhage occurs beyond 24 hours and hemorrhage
within puerperium, also called delayed or latepuerperal
hemorrhage.
 PATHOPHYSIOLOGY OF POSTPARTUM HEMORRHAGE

Tissue destruction
with endometrial
damage

Clotting casecade activation

Intravascular microthrombi

relaxatio
n

Tissue
ischemia Uterine atony
with organ
dysfunction

Hemorrhage
 ETIOLOGY

BOOK PICTURE PATIENT PICTURE

Atonic uterus (80%): Atonicity of the uterus is the
commonest cause of postpartum hemorrhage Present
 Grand multipara
 Overdistension of the uterus
 Malnutrition and anemia (<9.0 g/dL)
 Antepartum hemorrhage (Both placenta previa and
abruption)
 Prolonged labor (>12 hours)
 Anesthesia
 Initiation or augmentation of delivery by oxytocin
 Malformation of the uterus
 Uterine fibroid
 Mismanaged third stage of labor
 Precipitate labor
 Other causes of atonic hemorrhage are: Obesity
(BMI > 35),Previous PPH,Age(>40 yrs), Drugs: Use
of tocolytic drugs (ritodrine), MgSO4, Nifedipine.
Traumatic (20%) Trauma to the genital tract usually
occurs following operative delivery, episiotomy,
cesarean section
Retained tissues: Bits of placenta, blood clots cause
PPH due to imperfect uterine retraction
Combination of atonic and traumatic causes.
 Thrombin: Blood coagulation disorders
 SIGN & SYMPTOMS

BOOK PICTURE PATIENT PICTURE

 Blood pressure low Low blood pressure (90/60 mm of hg )
 Pulse rate increase Pulse rate increased (89/min)
 Signs of shock may present
 Vaginal bleeding around 600ml Present

 Abdominal pain and Abdominal pain Present

tenderness may or may not present

 Pale and cold Anxious, Present

 confused or unconscious
 Urinary output is 30ml/hour or
Present
<30ml/hour
 Anxious

DIAGNOSTIC FINDINGS

BOOK PICTURE PATIENT PICTURE

 History taking Done
 Physical examination Done
 feel abdomen-uterus poorly contracted Done

 Vital sign Done

 Estimation of blood loss Done

 1 tampon fully soaked – 30 ml

 1 sanitary pad fully soaked – 120 ml
 1 sarong fully soaked – 500 ml
Done
 Examine placenta
 Examination of stool
Done
 The urine is examined for the presence of
protein, sugar and pus cells & amount.
 MANAGEMENT

BOOK PICTURE PATIENT PICTURE

 Immediate measures
Call for extra help (involve the obstetric Done
registrar (senior staff ) on call.)
 Put in two large bore (14-gauge)
intravenous cannulas.
 Keep patient flat and warm.
 Send blood for full blood count, group,
cross matching, diagnostic tests (RFT,
LFT), coagulation
 screen including fibrinogen and ask for 2
units (at least) of blood
 Start 20 units of oxytocin in 1 L of
normal saline IV at the rate of 60 drops
per minute. Done
 Transfuseblood as soon as possible.
 One midwife/rotating houseman should
be assigned to monitor the following—
(i) Done
Pulse
(ii) Blood pressure (iii) Temperature (iv)
Respiratory rate and oximeter (v) Type and
amount of fluids (blood, blood products) the
patient has received (vi) Urine output
(continuous catheterization) (vii) Drugs- Done
type, dose and time (viii) Central venous Per vaginal examination was done and
pressure found few membrane’s retained portion,
 Palpate the fundus and massage which was removed.
 Perform Per vaginal examination Start IV Oxytocin 40 unit + RL

Done
 Start crystalloid solution
Given
 Oxytocin
 To catheterize the bladder.
 To give antibiotics
 If shock is suspected immediately begin
treatment
 Place of blood transfusion: 2unit whole blood given
The indication of blood transfusion in
anemia during pregnancy is very much
limited. The indications are :
(1) To correct anemia due to blood loss and Health education given
to combat postpartum hemorrhage.
(2) Patient with severe anemia seen in later
months of pregnancy (beyond 36 weeks)
(3) Refractory anemia: Anemia not
responding to either oral or parenteral
therapy in spite of correct typing.
(4) Associated infection
Exchange transfusion:
 Mechanical management
- Bimanual uterine compression to
stimulate uterus to contract External
Internal
 Surgical management
- Balloon Tamponade
- Haemostatic Brace Suturing – B-
Lynch suture
- Bilateral ligation of uterine arteries
- Hysterotomy
 SCHEME OF MANAGEMENT OF TRUE
PPH Immediate measures
• Call for extra help (communication)
• Commence IV line with two wide bore cannulas
• Send blood for cross matching tests, coagulation screening including fibrinogen level
and ask blood for 2 units (at least)
• Rapidly infuse normal saline/haemaccel 2
liters till blood is available
• To catheterize the bladder
• To monitor pulse, BP, temperature, output, oximeter every 15-30 minutes
To Feel the Uterus by abdominal Palpation

Uterus atonic
Uterus hard and contracted

• Massage the uterus to make it hard Traumatic

• To add oxytocin 10—20 units in 500 mL
of Normal saline, at the rate of 40 drops I
per minute Exploration
• Injection methergine 0.2 mg IV (slowly)
• To examine the expelled placenta Hemostatic sutures on the tear sites
Cemmenly Used Oxytoclcs in the Management of I?
Uterus remains atonic PH
• Exploration of the uterus Drug Dose Route Dose Side Contra-
• Blood transfusion frequency effects indications
• To continue oxytocin drip
Oxytocin 10-40 First line: Continu- • Nausea Not as IV
Uterus atonic units IV;Second ous IV • Water bolus,
in 1 L line: IM intoxi- otherwise
• 15 methyl PGF„ 250 yg IM/intramyometria of (10 cation none
OR crysta- units)
• Misoprostol 1000 pg per rectum Iloid
OR solution
• Carbetocin 100 kg IM I IV Methergine 0.2 mg First line Every * Nausea * Hyperten-
IM/IV; 2 • Vomiting sion
Uterus atonic Second hours • Hyper- •Pre-
line PO tension eclampsia
I
Uterine tamponade
15 0.25 mg First line Every • Nausea •Bronchial
•• Balloon
Bimanualtamponade (Fig.
compression 28.4)
(Fig. 28.3) methyl IM; 15-90 • vomiting asthma
(any PGF2 Second min. • Diarrhea • Active
line intra- (8 doses cardiac,
method) • Tight intrauterine packing under uterine maxi- • Chills renal
anesthesia mum) or
hapatic
disease
Uterus atonic Miso- 6011-1000 First line Single • Fever, None
prostol mcg PR dose • Tachy-
(PGE ) second cardia
Surgical methods
Stepwise uterine devascularization
(any procedure
method)
• B-Lynch compression and multiple square sutures (Fig. 28.6) Bleeding controlled t
• Ligation of uterine artery and utero-ovarian
anastomotic vessels unilateral or bilateral (Fig. 28.5)
• Ligation of anterior division of internal iliac artery Continuous observation
(unilateral or bilateral) in high dependency uniVlCU
• Angiographic arterial embolization with gelatin sponge
t Documentation of procedures
adopted in respect to time
Hysterectomy (rarely)
Guidelines for Management of PPH : RCOG, FIGO and ACOG
 COMPLICATIONS

 Anemia and loss of iron

 Increased risk of venous thrombosis and embolic events
 Hypopituitarism following severe pph (Sheehan syndrome) is due to critical ischemia of
the hypertrophied pituitary.
 Hypovolemic shock.
 Damage to all major organs is possible; respiratory (adult respiratory distress
syndrome) and renal (acute tubular necrosis) damage are the most common but are rare
 Hypovolemia from extreme blood loss
 Infection
 Increased length of postpartum recovery period
 NURSING DIAGNOSIS:

1. Fluid volume deficit related to uterine atony as evidenced by excessive vaginal

blood loss.
2. Ineffective tissue perfusion related to vaginal bleeding as evidenced by fluctuation
of vital signs.
3. Self-care deficit: dressing, toileting related to generalize weakness secondary to
PPH as evidenced by and poor grooming.
4. Anxiety related to knowledge deficit regarding procedures, management and disease
condition as evidenced by patient asks many questions about the disease.
5. Sleeping pattern disturbance related to acute pain as evidenced by verbal report of
difficult falling asleep.
6. Deficit knowledge related to management of postnatal anemia as evidenced by
frequently asking question.
7. Risk for infection related to improper hygiene secondary to lack of knowledge
regarding PPH.
ASSESSMENT NURSING EXPECTED INTERVENTION RATIONAL IMPLIMENTATION EVALUATION
DIAGNOSIS OUTCOME
Subjective data Fluid volume Patient will be -Assess general -To provide -Assessed general patient ‘s
Patient reported Prevented condition of the baseline data for condition of the patient body
deficit related to
that “I have from patient care by physical examination. fluid volume
vaginal bleeding” uterine atony as dysfunctional improved
bleeding and
evidenced by
improve fluid -Advise patients to -With feet -Provided sleep with
excessive vaginal volume. sleep with higher will feet higher, while the
Objective data feet higher, while the increase body remained
blood loss.
Vaginal bleeding body the venous supine
present (by remained supine. return, and
physical allowing
examination) the blood to
Patient changed the brain and
other organs.
5-6 pads - Monitor vital signs -Changes in vital -Monitor vital signs
signs when T-100 f, p-106 beats
bleeding occurs /min,R-30 breath/min
more intense
-Monitor intake and
output -Change the -Monitored intake and
every 15 minutes output is a sign of output
impaired renal every 15 minutes
function
-administered Oxitocin
- Administer drug as -to reduce blood IU with RL
per order loss.
- administered3 unit
-Administer whole - to maintain whole blood cell
blood cell normal hb level
ASSESSMENT NURSING GOAL PLANNING RATIONAL IMPLEMENTATION EVALUATION
DIAGNOSIS
Sub.data:- Self-care deficit: Short Term -evaluate client’s -establish -Reports of dyspnea, Now patient is
Patient reported dressing, patient will be response to activity client’s needs increase weakness and able to do activity
that” I am hving toileting relatedto maintain daily and facilitate change in vital signs and maintain
so much generalize activity and choice of during and after activity personal hygiene
weakness and weakness reduced foul interventions
not able to do secondary to smell from -assist client to -assist client to assume
daily activity” PPH as body assume comfortable -client may be comfortable position for
evidenced by and position for rest take easily breath rest and sleep
poor Long Term
Obj.data:- grooming. patient will be -done the daily -done the daily dressing
Patient is unable maintain dressing -To prevent
to perform daily personal infection
activity hygiene -provide comfort -provide comfort
Poor grooming. measures -client enhance measures e.g. back rubs,
Bad odour. sense of well change of position, quiet
being music or conversation

-instruct and assist -instruct and assist client

client in selfcare -to control of in selfcare activity
activity discomfort
ASSESSMENT NURSING GOAL PLANNING RATIONAL IMPLEMENTATION EVALUATION
DIAGNOSIS
Sub.data:- Sleeping pattern Patient can -- Assess -to determine if an - Assessed general now patient
Patient reported take asleep general infection is present condition of the patient WBC count in
disturbance
without condition of the Patient has dark circle normal and
that” I cannot
related to acute difficulty patient around eyes infection risk
take sleep
pain as evidenced also decrease.
-monitor WBC count -to detect presence
during
by verbal report of infection - monitor WBC count
nighttime” and differential
of difficult falling
results
asleep. -teach patient and -to prevent
family about infection
infection control -teach patient and
Obj.data:-
family about infection
control
measures
Patient’s verbal -instruct patient on
appropriate hand
report
washing techniques -to prevent spread -instruct patient on
Patient look of infection appropriate hand
washing techniques and
tired and dark
-use universal other aseptic techniques
circle are precautions
-to prevent - use universal
present around
infection among precautions and use
eyes health care member aseptic technique to treat
patient
ASSESSMENT NURSING GOAL PLANNING RATIONAL IMPLEMENTATION EVALUATION
DIAGNOSIS
Subjective data Anxiety related to The patient -Assess the patient's -To provide -Assessed the patient's Client said
baseline data for psychological anxiety is
Patient says that knowledge deficit can verbalize psychological
care response to the post- reduced
“I am not well regarding Anxiety and response to the post- childbirth bleeding by
what is procedures, said anxiety is childbirth interview technique.

happened to management and Reduced or bleeding. -Provide emotional -Treat the patient
me” disease condition lost -Treat the patient support calm, empathetic and
supportive
as evidenced by calm, empathetic and -Accurate attitude.
. patient asks many supportive information can
reduce
questions about attitude. the anxiety and
the disease -Provide information fear of the -Provided information
unknown about care and
about care and -The expression treatment.
treatment. can reduce feelings
of anxiety
Objective data -Help clients identify Helped clients identify a
-to divert the mind
Patient’s facial a sense of anxiety. sense of anxiety.
-Advised to watch T.V
expression is -Provide divisional
& talk with family
anxious therapy members
HEALTH EDUCATION:

DIET
 Provide 3-4 smaller meals per
day
 Avoid gas causing foods such as broccoli, cabbage, beans
 Use less salt and spice in the food
 Fruits and fruit juice to be given to the client, that is a good source of fiber
 Law fat diet like milk, yogurt, and cheese to be included in diet.

PREVENTION

 Complete bed rest

 Do not Use alcohol and tobacco.
 Avoid straneous activity
 do not lift the heavy weight
 Avoid travelling during pregnancy
 PSYCHOLOGICAL SUPPORT

 Give psychological support to patient and family

 Describe whole disease condition to family
 Give all the answer of those question which they asking.

REHABILITATIVE ACTIVITY

 Teach regarding high calorie diet

 Teach walking techniques and bending techniques
 Follow up and take all medicine regularly
 NURSES NOTES
 1st day :
Patient had fever, body ache, generalized weakness and pallor with pervaginal
bleeding and with 3rd postpartum day. Patients Temperature:-100 F, Pulse:- 102/
min, Respiratory rate:- 28/min, blood pressure:- 110/70 mm of hg at time of
admission. Patient is conscious then assessed after that diagnosed with severe
postnatal anemia for that investigation done that are ultrasonography , CBC . after
that patient received treatment, Inj- Cefotaxim, Inj- Tramadol, , Inj- Pantoprazole,
inj. Febrinil& 600 ml of whole blood transfusion & I also Provide knowledge
regarding Mouth Care , personal hygiene and postnatal diet.

 2nd day :

patient is conscious and have a complain of discomfort , generalized weakness

,anorexia Temp-99 F, respiration 24/ min, pulse- 88 /min, BP- 110/80 mm of hg,. So ,
Patient received treatment Inj- Cefotaxim., Inj- Pantoprazole .provide health education
to relative regarding postnatal anemia prevention.

 3rd day :

Patient is conscious Temp-98.4 F, respiration-22/min, Pulse- 80/min, Bp-

120/80 mm of hg. Patient received treatment Inj- Cefotaxim, Inj-
Pantoprazole&tab.folic acid and iron, . Provide education regarding prevention and
rehabilitation of postnatal anemiaand how to take medicine in daily routinre.
 SUMMARY
Patient was admitted in post-natal ward at CHC Chikhli with the complain of fever,
body ache , generalized weakness and pallor with per vaginal bleeding and with 3 rd
postpartum day. Then diagnosed with post-partum hemorrhage. For that she was under
treatment. After that mother has good prognosis.
 BIBLIOGRAPHY
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delhi.2008. P.p. 2233-2235

2. AnnamaJacob , “A COMPREHENSIVE TEXTBOOK OF MIDWIFERY AND

GYNECOLOGICAL NURSING” , 3RD edition , published by jaypee brothersmedical
publisher pvt. Ltd , new delhi 2012 , page no.262-264

3. D C Dutta’s “textbook of obstetrics”7th edition , jaypee brother publication (p)

ltd.,newdelhi 2013 ,page no.303-315

4. Mosby’s , “NURSING DRUG REFERANCE”, 24 th edition, Published by

Elsevier, adivison of reed Elsevier india private limited, 2011. P.p-754, 947, 868

5. Lewis’s chintamani, “MEDICAL SURGICAL NURSING”, 1st edition, published by

Elsevier india private limited, 2011,P.p- 630-655

6. http://www.nhlbi.nih.gov/index.html
http://www.wikipedia.com
https://www.slideshare.net/Hishgeeubuns/9-complication-of-postpartum

https://www.slideshare.net/sandeshkamdi/management-of-postpartum- hemorrhage-

pph?next_slideshow=1