INTRODUCTION The actual beginning of life dates back nine months before the occasion when the father

and the mother are happily unuted in the sacrament of marriage. Marriage is taught to have the highest bliss and the weightiest responsibilities that can devolve upon man and woman here in mortality. True man and woman The divine impulse within every man and woman that impulse for a holy purpose not to be satisfied as a mere biological urge or as a lust of the flesh in promiscuous associations,but to be reserved as an expression of true love in holy wedlock making available the sex cells. The two cells unite to form a sinlge cell producing a life. This as they combined provided the biological elements from which a new human life is formed. From conception onward to the time of birth, the mother‟s relationship to the child is very important for it is the time when the life within her body is being developed. The passing of life from parent to child is one of the greatest privileges that come to man and woman. Seeing one‟s children grow ang develop is th life‟s greatest satisfaction. A parent delights in the observation that her child is like himself. Home must not only be sanctuaries but also place of preparation fron which each child can go forth confidently to lead and to face a turbulent world. What has learned in home has amazing persistence. With the priviledges pf parenthood comes responsibity for the child‟s welfare. A parent‟s care for the child‟s intellect and character will be.

The decision of the young couple to begin a happy family is a happy event, with the over tones of great responsibility of the parents to be. Although parenthood does bring fulfillment, happiness and great reward, it can also bring anxiety and great responsibility; therefore the decision to have a child should not be made lightly. Before increasing the family unit and thereby complicating it, the husband and wife should have strong and good foundation ready to face challenges. The family is generally recognized as an element of a broader kinship network that links ancestors and descendants of a person. Most published statistics on the family are based on census or household survey questions and responses. In the United States (and, for the most part, 1

throughout the world), the "family" is defined in censuses and surveys as two or more persons related by blood, marriage, or adoption CHAPTER I ORGANIZATION AND GENERAL FUNCTION ANTEPARTUM MALE REPRODUCTIVE ORGAN

EXTERNAL REPRODUCTIVE ORGAN A. PENIS-composed of three cylindrical masses of erectile tissue, two termed corpus cavernosa and a third, corpus spongiosum contained in the shalft b. Scrotum- is rugated skin covered muscular pouch suspended from the perineum.It contains the testes, epidedymis, and the lower portion of the spermatic cord. Its function is to support the testes and help regulate temp of the sperm through contractions. c.Testes-two ovoid glands containing number of lobules, which contains Leydig cells. These cells are responsible for thr production of testosterone.

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INTERNAL REPRODUCTIVE ORGAN A.Epididymis-responsible for conducting sperms from the testes to the vas deferens b. Vas deferens-it carries sperm from the epididymis through the original canal into the abdominal cavity where it ends at the seminal vesicle and the ejaculatory ducts c.Seminal Vesicle-they secretes a viscous portion of the semen, which has a high content of basic sugar, protein and prostaglandin and it alkalinic in nature. d. Ejaculatory Ducts-they pass through the prostate gland and join seminal vesicles in the urethra. e. Prostate Gland-secretes thin alkaline fluid, when added to the secretion from the seminal vesicles and the accompanying sperm from the epididymis, this fluid will further protect the scounteractperm from being immobilized by low ph level of the urethra. f. Bulbourethral Gland-secretes an alkaline fluid that helps counteract the secretions of the urethra and ensure the safe passage of the spermatozoa g. Urethra- a hallow tube leading from the base of the bladder which after passing through the prostate gland continuous to the outside through the shaft the glands of the penis.

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Urethral Meatus-external opening of the urethra VII. VI.external opening of the vagina VIII. Mons pubis or Mons Veneris-pad of flat which lies over the symphypis pubis.FEMALE REPRODUCTIVE ORGAN EXTERNAL REPRODUCTIVE ORGAN I. Glans Clitoris –small erectile tissue structure at the anterior junction of the labia minora extremely sensitive to sexual manipulation V. form an upper fold encircling the clitoris which is highly sensitive to manipulation and trauma that is why it is often torn during delivery IV. Perineum. Labia Majora-two folds of skin with flat underneath.contains the bartholin glands III. Labia Minora-two thin folds of delicate tissues. II.area from the lower border of the vagina orifice to the anus. Contains the muscle that supports the pelvic organs 4 . Vestibule-narrow space seen when the labia minora is separated.Vaginal Orifice. which protect the surrounding delicate tissues from trauma.

Consist implantation. The perimetrium.a 3-6 inches longitudinal canal located between the bladder and the rectum.isthmus.and nourishment of the product of conception. 5 . B. receives the penis during coitus.Fallopian tube.4 inches long form each side of the fundus.Produces mature and expel ova nd manufacture estrogen and of three parts:corpus or the body.Consist of three parts:corpus or the body.Uterus.almond shape dull white sex glands.INTERNAL REPRODUCTIVE ORGAN A.32 inches wide. Composed of three muscular layers.isthmus.endometrium and myometrium.Responsible for the transport of the mature ovary to the uterus.hallow pear shaped fibro muscular organ 3 inches long.Uterus.1 inch thick. The perimetrium. and the cervix which is the site of progesterone. and forms part of birth canal.32inches wide. D.endometrium and myometrium. C.1 inch thick. Composed of three muscular layers.passageway of menstrual discharges.hallow pear shaped fibro muscular organ 3 inches long.retainment. and the cervix whic B.Ovaries.Vagina.

PELVIS A.Two OS COXAC made up of: Illium-upper extended part Ischium-upper part Pubis-front part 2.lowest part of the spine 6 .STRUCTURE 1.Coccyx.Sacrum.wedged shaped forms the back part of the pelvis 3.

The stimulated follicle grows in size. the follicles grow further. This phase is characterised by the presence of menstrual cycle. in females the reproductive phase only lasts till the age of 45-50years. CYCLES OF MENSTRATION Menstrual Phase.MENSTRATION MENSTRATION.It lasts for the first 3-4 days. Follicular Phase-In this phase. This causes bleeding and is called menstruation. The first occurrence of mensuration is termed menarche.defined as episodic uterine bleeding in response to cyclic hormonal changes. The FSH stimulates one of the follicles. Ovulatory Phase-When the follicle is mature. During this phase the inner lining of the uterus is shed which causes the blood vessels to rupture. the pituitary gland secretes another hormone called luteinizing hormone (LH). the ovaries of females are stimulated by the follicle stimulating hormone (FSH) of the pituitary. This is called the onset of puberty and is accompanied by release of hormones oestrogen and progesterone. At about the age of 10 to 13 years. Unlike males where sperms can be produced through out the life of man. It stops by the age of 45-50 years and is called menopause. LH stimulates the follicle to rupture and release the egg. The release of egg is called ovulation and occurs between the 10th and the 16th day 7 . These hormones control the production of ova or eggs and appearance of secondary sexual characteristics.

the Graafian follicle reaggregates to form corpus luteum. Once the egg is released. The corpus luteum secretes two hormones-estrogen and progesterone. 8 .Luteal Phase-This phase lasts between the 16th and the 28th day.

This entrance creates an 'activation' in the egg and it too begins to enlarge. fertilisation may occur. During intercourse the man will ejaculate and sperm will be passed from the testicles via the penis into the woman's vagina. Once one sperm is successful and penetrates the egg it will lose it's tail and it's head will increase in size. The cells are called a zygote.PROCESS OF CONCEPTION Conception is the process of becoming pregnant. If the egg has been fertilised (the process of the sperm fusing with the egg) it will move to the uterus and attach itself to the uterine lining. If a sperm meets the egg. a process called implantation. The cells will begin to divide which will lead to the development of an embryo and hopefully produce a baby in nine months time! 9 . The egg can be impregnated for approximately 24 hours from when it leaves the follicle.

Milestone Of Growth and Development ONE LUNAR MONTH Does not appear human Heart appears as bulge on anterior surface SECOND LUNAR MONTH Organogenesis is complete Heart is beating Facial features are descernible External genitalia present but not distiunguisable THIRD LUNAR MONTH Ossification centers forming at the bones and tooth buds Male and female distinguishable FOURTH LUNAR MONTH FHT can be heard Lanugo is forming FIFTH LUNAR MONTH Quickening occurs SIX LUNAR MONTH Passive antibody transfer occurs Vernix caseosa forms Production of surfactant SEVENTH LUNAR MONTH Surfactant found in amniotic fluid EIGHT LUNAR MONTH Subaceous begins to deposit Assumes delivery position Brown fats present NINETH LUNAR MONTH Testes descend 10 .

LEOPOLD’S MANEUVER PROCEDURE FIRST MANEUVER (Fundal Grip) Using both hands feel fot the fetalbpart lying in the fundus SECOND MANEUVER (Umbilical Grip) One hand is used to steady the uterus on one side of the abdomen while the other hands moves slightly on a circular motion from top to the lower segment of the uterus to feel for the fetal back and small fetal parts . and mobility To identify location of the fetal back To determine position To determine engagement of the presenting part 11 . press in slightly and RATIONALE To determine fetal part lying in the fundus. grasp the lower portion of the abdomen above symphypis pubis. THIRD MANEUVER (Pawlik‟s Grip) Using thumb and finger. shape. its consistency.Use gentle but deep pressure.

palpate the fetal head pressing downward about 2 inches above the inguinal ligaments. Use both hands To determine degree of flexion 12 .make gentle movements from side to side. FOURTH MANEUVER ( Pelvic Grip) Facing foot part of the woman.

PLACENTAL CIRCULATION 13 .

it often means that your cervix is opening faster (about 1 centimeter per hour). One centimeter is a little less than half an inch. Contractions may go away if you change activity. drink clear fluids. your cervix will widen to about 10 centimeters. As your labor progresses. eat light meals if you want to. you can expect your contractions to speed up. and keep track of your contractions. During this stage. Relax. Try to keep doing your usual activities. Active labor Your cervix opens from 4 to 7 centimeters. After the bag of waters breaks. Transition to second stage Your cervix opens from 7 to 10 centimeters. You will probably spend most of early labor at home. how strong. your bag of waters may break. This first stage of labor usually lasts about 12 to 13 The first stage of labor has three parts: 1. For most women. This is when you should head to the hospital. and when you can no longer talk during a contraction. this is the hardest or most painful part of labor. rest. As your cervix dilates. contractions help your cervix to thin and begin to open. This is called effacement and dilation. When you have contractions every 3 to 4 minutes and they each last about 60 seconds. but over time they'll get stronger. and how long your contractions are. Early labor Your cervix opens to 4 centimeters. 3. You may not want to talk as you become more involved in dealing with your contractions.B. you are probably moving into active labor. your health care provider will measure the opening in centimeters. causing a gush of fluid. When you notice a clear change in how frequent. 2.INTRAPARTUM STAGES OF LABOR FIRST STAGE OF LABOR Thinning (effacement) and opening (dilation) of the cervix During the first stage of labor. This is when your cervix opens to its fullest. Contractions last about 60 to 90 seconds and come every 2 to 3 minute 14 .

and ends with the birth of your baby. THIRD STAGE OG LABOR After the birth of your baby. the placenta has delivered. FOURTH STAGE OF LABOR Recovery Your baby is born. relief. Your health care provider may ask you to push with each contraction. The length of the second stage depends on whether or not you've given birth before and how many times. your uterus continues to contract to push out the placenta (afterbirth).SECOND STAGES OF LABOR Your baby moves through the birth canal The second stage of labor begins when the cervix is completely dilated (open). similar to an urge to have a bowel movement. The placenta usually delivers about 5 to 15 minutes after the baby arrives. Nursing right after birth will help your uterus to contract and will decrease the amount of bleeding. If you are planning to breastfeed. 15 . we strongly encourage you to try to nurse as soon as possible after your baby is born. and you may feel intense pressure. and the position and size of the baby. Contractions push the baby down the birth canal. but they may spread out a bit and give you time to rest. and fatigue. Most babies are ready to nurse within a short period after birth. The contractions continue to be strong. Others wait a little longer. and you and your partner will probably feel joy.

In some cases. the fetal head flexes so that the fetal chin is touching the fetal chest.external. Descent occurs because of contraction.The pressure of the fetus on the sacral nerves causes the mother to ezperience a pushing sensation. INTERNAL ROTATION With further descent. the occiput rotates anteriorly and the fetal head assumes an oblique orientation. FLEXION While descending through the pelvis.MECHANISMS OF LABOR Passage of the fetus through birth canal involves a number of different position changes to keep the smallest diameter of the fetal (in cephalic presentations)always presenting to the smallest diameter of the birth canal. EXTENSION 16 .Full descent occurs when the fetal head extrudes beyond dilated cervix and touches the posterior vaginal floor. the occipital (posterior) fontanel slides into the center of the birth canal and the anterior fontanel becomes more remote and difficult to feel.flexion. Flexion is aided by abdominal muscle contraction during pushing. The fetal position remains occiput transverse. These position changes we termed „‟Cardinal Movements of labor‟‟ :descent. As descent occurs.internal rotation. pressure from the pelvic floor causes the fetal head to bend forward unto the chest. The smallest anteroposterior diameter(the suboccipito-bregmatic diameter )is the one presented to the birth canal in this flexed position. When flexion occurs. This functionally creates a smaller structure to pass through the maternal pelvis. and expulsion. the head may rotate completely to the occiput anterior position. DESCENT It is downward movement of the biparietal diameter of the fetal head to within the pelvic inlet.extension.

involution of the uterus and the vagina PROGRESSIVE.the rest of the body easily and smoothly because of its smaller size. EXPULSION Once the shoulders are born.production of milk for lactation. Known as the 5th stages labor.prone to thrombus formation. Hyperfibrinogenia. Involution– return of reproductive organ to its non pregnant state.early ambulationPhysiologic changes: Two typses of physiologic changes occur during the postpartum period RETROGRESSIVE.The curve of the hollow of the sacrum favors extension of the fetal head as further descent occurs. This encourages the fetal head to return to its transverse position.Many physiologic and psychological changes occur in the mother during this time. or puerperium.the restoration of menstrual cycle and beginning of parental role. STAGES OF PUERPERIUM TAKING-IN PHASE -time of reflection of women -she is largely passive and prefers the nurse to do everything and make decisions for ther 17 . Nursing careshould focus on helping the mother and her family adjust to these changes and on easing the transition to the parenting role. This is also known as restitution. This is expulsion and is the end if the pelvic division of labor C. refers to the 6-to-8week period after deliveryduring which themother‟s body returns to its prepregnant state.POSTPARTUM The postpartum period. Some people refer to this period as thefourth trimester of pregnancy. This means that the fetal chin is no longer touching the fetal chest EXTERNAL ROTATION The shoulders rotate into an oblique or frankly anteriorposterior orientation with further descent.

COMPLETE-implies that the mother and the child are together 24 hours a day 2. TWO TYPES OF ROOMING-IN 1. -she begin to show strong interest in her baby -actions show independence yet still feel insecure about her ability to care for the newborn -praise her in the things she does well.infants stay in the room with the mother rather than in nursery -more time with the mother the faster the mother and the child is likely to develop .she gives up the fantatsize image of her child and accepts the real one -she gives up her role of being a childless or a mother of one or two ROOMING-IN . LETTING –GO PHASE -finally redefines her role .INCOMPLETE-infant remains in the womans room in a specific time only 18 .more aquainted with the baby and feels confidence in her ability to care for nb.-this is due to physical uncertainty in caring for nb and partly from exhaustion in childbirth -time of reflection and pondering her new role -a time when she wants to talk about her labor and delivery -holds her child with a sense of wonder -regain physical strength and for calming her swirling thoughts -2-3 days TAKING-HOLD PHASE -begin to initiate action herself -she prefer to work and decide on her own -woman who have not receive anesthesia may reach this second stage in a matter of hours following from birth.

warm. safe place close to the mother. If this is not possible. the baby should be kept in a clean. The umbilical cord should be clamped using a sterile. Clamp and cut the umbilical cord . alerts other personnel in case any help is needed. The baby should be delivered on to a warm clean towel and kept on the mother's chest. clean and dry towel or cloth on a warm dry surface 3. Call out the time of birth RATIONALE It is important to tell loudly the time of birth this helps in accurate recording of the time and more importantly.IMMEDIATE CARE OF THE NEWBORN PROCEDURE 1. disposable clamp or a sterile tie and cut using a sterile blade about 23 cm (1-inch) away from the skin 19 2. Receive the baby on to a warm.

the baby's breathing should be assessed. Blood or meconium on the baby's skin should be wiped away. wipe the eyes 5. At the time of drying itself. the white greasy substance covering the baby's body (vernix) should not be wiped off.4. Assess the baby's breathing while drying The baby should be thoroughly dried to prevent from getting cold (this would be explained in the module on 'Thermal protection'). A normal newborn should be crying vigorously or breathing regularly at a rate of 40-60 20 . Because this vernix helps to protect the baby's skin and gets reabsorbed very quickly. however. Immediately dry the baby with a warm clean towel or piece of cloth.

Clean the eyes using sterile gauze/cotton. Wipe from the medial side (inner canthus) to the lateral side (outer canthus) Once the cord is cut. Place an identity label on the baby 9. If the baby is not breathing well. Cover the baby's head with a cap. Wipe both the eyes with sterile gauze 7. The label should be placed on the wrist or ankle. This helps in easy identification of the baby.6. Use separate gauze for each eye. breaths per minute. Both the mother and the baby should be 21 . the baby should be placed between the mother's breasts to the normal temperature of the baby as well as in promoting early breastfeeding. avoiding any confusion. Leave the baby between the mother's breasts to start skin-to-skin care 8. then the steps of resuscitation have to be carried out.

Cover the mother and baby with a warm cloth 10. a newborn baby's head should be covered with a cap to prevent loss of heat. especially if the delivery room is cold (temperature less than 25°C). Since head is the major contributor to the surface area of the body. Encourage mother to initiate exclusive breastfeeding covered with a warm cloth. 22 . Breastfeeding should be initiated within half an hour of birth in all babies.

Cagayan Occupation: Housewife B. HISTORY OF PRESENT PREGNANCIES LMP:02-10-2012 EDC:11-08-2012 AOG: 23 . ASSESSMENT I.4lbs Present status Of the Child Normal Normal Male Spontaneous Delivery III. NURSING HISTORY A. Old Duration: 5days Color:Bright red to dark Odor: Fleshy Consistency: Moderate flow Interval between Menses: 28 cycles Dysmennorhea: Sometimes Nursing Measures done: -Rest -Take meds.OBSTETRIC HISTORY Number of Pregnancy 1 AOG on Delivery 38weeks Manner Of Delivery Sex Of the child Weight 6. G Age: 29 Civil Status: Married Educational attainment:High School Graduate Religion: Roman Catholic Nationality: Filipino Address: iguig. PERSONAL DATE Name: E. NURSING PROCESS IN MOTHER AND CHILD MATERNAL DATA BASE A.MENSTRUAL HISTORY Menarche: 10 yrs.(dolfenal) -Take herbal meds (yerba Buena) C.CHAPTER II.

(_)hypertension (_)others:specify (_)none 24 .) Medications taken during pregnancy (_)multivitamins (\)iron (_)others: specify (_)none IV. PAST HEALTH HISTORY (_)Respiratory Dse.) Prenatal Check up: (_) (\) When: Where: Rural health Unit By Whom: Midwife Frequency: B. (_)Gynecological (_)Cardiac Dse.A.

She wakes up at 6 in the morning. IV. To augment her interrupted sleeps.HEALTH PERCEPTION. II. VI.BOWEL.estimated 50-75cc per urination. She canfeed herself alone and no problem in n taking any food supplements. She takes good care of herself well. III.COGNITIVE-PERCEPTUAL PATTERN She can react and write well.but she experience frequent urination. She defecates with a brownish yellow stool everyday particularly in the morning when she wakes up. she takes her nap in the afternoon when she has nothing todo.and time.SLEEP-REST PATTERN She admitted that she sleeps 8-10 hours a day. The odor of her urine is aromatic.ACTIVITY-EXERCISE PATTERN She wakes up at around 6 in the morning to cook for their breakfast and attend to needs of her husband . According to her. V. She usually urinates with an average of 8-10 times a day since she got pregnant.She has no sensory perception deficit and she doesn‟t use any king of prosthesis. She does household chores.place. She is oriented to person.ELIMINATION PATTERN The mother has no problem in defecating.she doesn‟t have any problem in her ability to eat. She had also mentioned that she doesn‟t use any maedications ti keep her go to sleep.She can swallow solid and liquids and chew her food well.HEALTH MANAGEMENT PATTERN She is very much aware and understands the physiological and psychological changes of her pregnancy She eats nutritious foods and sometimes she drinks milk every morning for the growing fetus in her womb. NUTRITIONAL-METABOLIC PATTERN She eats balanced diet because she is aware that the fetus in her womb depends on her. She has no problem in sleeping at night. She has no problem in urinating. She has normal appetite and loves to eat vegetables. She takes a bath everyday because she wants to keep herself fresh the wholeday.GORDON’S 11 FUNCTIONAL PATTERN I. 25 .

She tries to communicate with her husband on some important issues and major decisions in life. they have harmonious relationship. wife should be expressive enough to problems and fears to her husband.and itawes clearly. tagalong. she turns to God for streght and guidance. X. 26 .SEXUALITY-REPRODUCTION PATTERN She had menstruation at the age of 10.VALUE-BELIEF SYSTEM She is roman catholic and a chuch goer. She does not forget to pray and ask God‟s blessings and guidance. She experiences occasional pain-dysmennorhea The mother stated that she is not comfortable and not interested in using some of the contraceptives. VIII.because she wants to look fresh and clean the whole day. VII. Every time if she is under stressed. XI. She can express herself verbally. IX. As a couple.She can speak Ilocano. She is concerned about her delivery and wise to be bear a healthy child.COPING-STRESS PATTERN She is anxious about the outcome of her pregnancy. They live in their own house. And they face it with courage. Sexual intercourse was diminished simce the secong trimester because she was uncomfortable.She is mentally equipped and healthy. According to her she attends mass every Sunday. She takes a bath twice a day.SELF-PERCEPTION PATTERN The pregnant is well groomed.ROLE-RELATIONSHIP PATTERN For her.

GENERAL PHYSICAL EXAMINATION Date performed: 09-23-2012 Vital signs Bp:110/80 Pr:77bpm RR:19cpm Temp:37celsius Area assessed General appearance Overall apparent settle Apparent state of comfort or distress Consciousness state of awareness Mood .manner. Presence of chloasma No indications of illnesssuch as pallor Dark pigmentation Normal 27 .relationship To surroundings Facial expression Speech Head Symmetry Wounds /lessions Contour Foreign Hair Lice and nuts Texture Distribution Face Method used Normal findings Actual Findings analysis Inspection inspection Inspection Inspection Inspection Healthy Comfortable Alert Cooperative Relaxed Relaxed Normal normal normal normal normal Inspection Inspection Palpation Inspection Inspection Palpation inspection Symmetrical body to sized None Smooth contour None None thick Equally distributed Normocephalic skull size None normal normal normal normal None none Equally distributed Color Pigmentation Inspection Inspection Healthy.

midline Patent.midline.pink soft Firmly in place Symmetrical Normal Normal Normal Normal Without lessions Palate symmetrical Not imflammed Normal Normal Normal Normal Neck Symmetry Lessions Chest Respiratory movement Imspection Inspection Inspection Symmetrical to body size None Chest expands at 28 .near/far without the aid of spectacles Movement of the eyelids is equal and closes completely Equal White in color Adequate response to normal sounds Symmetrical .neck none Normal Symmetry Reaction to light Sclera Ears Auditory Auricle Discharges Mastoid process Nose External nose Vestibule Septum Nasal Canal Mouth and lip Lips Tongue Palate Teeth Tonsils Inspection Inspection Inspection Inspection Inspection Inspection inspection Normal Normal firm Normal Inspection Inspection Inspection Inspection Inspection Inspection Inspection Inspection Inspection No lesions Clear and no No discharges discharges Straight.No deformities none No tenderness on face .Scars Eyes Visual acuity Inspection Inspection None Able to see during night and day.unobstructed Symmetrical moist without lession Moist.pink White hard.

shape and appearance Protruded and no discharges None Normal Normal Normal normal none Inspection Inspection Inspection Inspection Enlarged due to gravid fetus Linea nigra and striae gravidum None Enlarged due to gravid fetus Inspection Equally distributed pubic hair.Chest excursion Vibration Breathing rate Hearth Rate and rhythm Heart sounds Heart beat Heart murmurs Breast Symmetry Skin Areola Nipples Mass and Nodules Abdomen Shape Scars Bowel sounds Masses Genitalia External the same time with breathing Inspection Thumbs are equidistant away from the spinal cord area Inspection.dubb) 86 beats per minute none Normal rate Normal Normal Normal Normal Inspection Inspection Inspection Inspection Inspection Symmetric bilaterally Countour is snooth and intact Equally bilaterally in size.no odor.clear minimal discharges 29 .auscultation Normal pitch Auscultation Regular and normal rate Inspection and auscultation Auscultation Auscultation Auscultation Steady and rhythmical Normal sound(lubb.

Upper and lower extremeties Symmetry Skin color Varicosities Neurological Level of consciousness Memory Motor function Skin Color Pigmentation Inspection Inspection Inspection Inspection Inspection Proportioned Fairly brown Short trimmed None Alert .slightly rough Normal Pain is complained after a long standing None Normal Lesions Hair distribution Inspection and palpation Inspection None Equally distributed 30 .and cooperative Able to recall past .present experiences Able to do household chores Brown in complexion Equally pigmented with slight chloasma on the face Elastic and mobile Smooth Warm and soft Bipedal edema Normal Normal Normal None Normal Inspection Inspection Can relate immediately Normal Inspection Inspection Brown Normal Normal Turgor and motility Texture Temperature and moistness Edema Inspectionand palpation Inspection and palpation Inspection and palpation inspection Normal .coherent.

client experienced her breast enlarged.DIAGNOSIS The diagnosis of pregnancy marks a major life milestone.positive signs Presumptive signs: Amenorrhea-client experienced 10 days elapsed since the expected menstrual flow Easy fatigability Breast changes-started at the fourth week of her pregnancy. like a resistant surface 31 . hard.probable sign.hicks contractions-painless palpable contractions Fetal outline-palpable at 24 weks Positive Signs: Fetal heart tones-can be detected by Doppler at 12 weeks Funic Suffle-a swishing sound synchronous at 20 weeks Fetal movement-can be felt by examiner at 2o weeks Ultrasonography evidenced of pregnancy: -abdomonal cramping -small white gestational ring can be detected after six weeks -fetal brain and heart action is demonstrated by eight weeks using Doppler -Fetal head and thorax can be identified by 14 weeks.Pregnancy is officially diagnosed on the basis of the symptoms reported by the woman and the signs elicited by the healthcare provider.and skin changes like presence of striae gravidum and chloasma Probable signs experienced by the client: Hegars sign.These signs and symtoms are traditionally divided into classifications: presumptive sign. Findings of leopold’s maneuver: First maneuver-fundus feels not firm.feels tender and heavy Urinary frequency.shaped s less well defined -moves in conjuction with the body Second Maneuver--Small fetal parts (knees and elbows) feel nodular with numerous angular nodulations-Fetal back feels smooth.softening of the lower uterine segment Uterine Growth-the uterus doubles in size Ballottement-refers to the rebound that occurs when the examiner‟s fingers tap the floating fetus within the uterus Goodles sign-softening of the cervix Brxton.

No obstruction Other diagnostic exam that confirms pregnancy: -detecting Hcg-tset performed by radio immunoassay(RIA) -home pregnancy test-for this test the woman dips a reagent strip into her stream of urine. it is engaged.presenting part moves.descended deeply.Third maneuver. only a small portion of the fetal head palpated. Fourth Maneuver.knoblike part. balottable and easily displaced it is notyet engaged. round. If the presenting part is not movable felts as relatively fixed.when a color change it denotes pregnancy 32 .

DIAGNOSIS Altered Nutrition:Less than body requirements r/t nausea and vomiting brought about by pregnancy.Client was able to demonstrate understanding on how maintain adequate nutritional intake during pregnancy. IMPLEMENTATION -advised client to increased glucose intake -advised client to eat crakers before rising up from bed -advised client to eat small frequent meals -advised client to get out of bed slowly EVALUATION Goal met. client will be able to demonstrate understanding of nutritional needs during pregnancy. PLANNING After 30 mins of nursing intervention.PLANNING NURSING CARE PLAN .of ANTEPARTAL ASSESSMENT S: „‟palagi akong naduduwal‟‟as vervalized by the patient. 33 .

Assessing S: “madali lng akong mapagod” by the as verbalized the client.client was able to demonstrate desired activities without undue fatigue. Implementation  Encouraged client to take atleast 8 hours of sleep  Encouraged client to take a rest period during the day  Encouraged a client to eat well balanced evaluation Goal met. Planning 2 days after the home visit client will be able to report improved sense of energy without fatigue. Diagnosis Fatigue r/t increased physiologic needs for sleep and rest during pregnancy. 34 .

Assessment S: “ihi ako ng ihi lalo pag gabi”as verbalized by the client Diagnosis Sleep pattern disturbance r/t frequent need to urinate during night time Planning After 30mins of nursing intervion the client will be able to understand that urinating frequently is normal so that she can cope within the situations and practice ways of coping Implementation Encouraged client to limit fluid intake before meals at night Instructed client to kegel‟s exercise at night. Client was able to understand that requnet urination is normal.and demonstrate ways of copin 35 . evaluation Goal partially met.

Time Frame 9:30am11:00am Resources visual aids ballpen paper pentlepen books manuals Person(s) responsible Student Family members Pregnant mother Evaluation Goal met. newborns and their Families.expectant mothers in labour and thepostnatal period to gain a deeper understanding of such care for women. VENUE: Iguig cagayan PARTICIPANT(S): ANTEPARTUM Learning objectives Content Methodology Home visit Interaction with the pregnant women and family members This activity aims to Prenatal allow those who care visits for women in pregnancy.After the nursing intervion the family and the expectant mother was able to understand the importance of prenatal check ups. 36 .SESSION DESIGN TOPIC: PRENATAL CARE GOAL:To promote awareness of the social and psychological components of childbearing and their influences on the family and to monitor the progress of pregnancy to ensure the health and wellbeing of mother and fetus.

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MATERNAL AND CHILD HEALTH NURSING .

With each chapter it provides us a clear understanding of how man was miraculously form from just a single cell. Prenatal care and guidelines are essential to the health of the woman and the fetus and to the family‟s emotional preparation for childbearing.PREFACE The care of childbearing and child rearing families is a major focus on nursing practice.it is important to promote the health of the childbearing woman and her family from the time before children are born until they reach adulthood. keeping the familyat the center of care delivery is an essential goal. This book features the cycle of pregnancy from conception of man and woman up to fertilization until pregnancy and birth. . To have a healthy children. In all settings and types of care . This book helps us to understand deeply the miracle of life on how man exist in the womb of mother for a couple of months.As part of the health care team we are the one‟s who could meet the needs of our clients most especially during the time that they are at the peak of needing help and care.

Organization And General A. Title page II.Preface III.Introduction Chapter I.TABLE OF CONTENTS I.Antepartum .Table of Contents IV.

Diagnosis Manifestations of pregnancy Leopolds maneuver Laboratory Works Other Diagnostic Exam C. Implementation Health Teaching Antepartum Prenatal Care Danger signs of pregnancy Discomforts of pregnany Nutrition Travel Sexual Activity . NURSING PROCESS IN MOTHER AND CHILD A.Planning Nursing Care Plan D. Assessment Maternal Data Base -Demographic Profile -Gynecologic history -Obstetric history Health History -Past health history -Present health history -Social health history -Family health history Gordon‟s 11 Functional Health Pattern Physical Examination -Cephalocaudal Psychosocial ExaM B.Intrapartum Stages of Labor Mechanisms of Labor C.Anatomy and physiology of Male and Female Reproductive System Menstration Process of conception Fetal development Leopolds maneuver Placental Development B.Postpartum Stages of puerperium Immediate NewBorn Care CHAPTER II.

Immunization Prenatal Exercise Rest and sleep Prenatal Check up Labor Preparation Intrapartum Birthing methods Stages Of Labor Breathing techniques and exercise Post Partum -Stages of Puerperium -Maternal Changes -Fetal Changes -Brestfeeding -Nutrition(mother and child) -Immediate Newborn care -Family Planning Evaluation Summary follow – up of prenatal checkup Appendices Documentation References Acknowledgement Dedication Approval Sheet Other supporting Materials -Assessment -tables -Consent INTRODUCTION The actual beginning of life dates back nine months before the occasion when the father and the mother are happily .

Marriage is taught to have the highest bliss and the weightiest responsibilities that can devolve upon man and woman here in mortality. With the priviledges pf parenthood comes responsibity for the child‟s welfare. for the most part. A parent‟s care for the child‟s intellect and character will be. the "family" is defined in censuses and surveys as two or more persons related by blood. The two cells unite to form a sinlge cell producing a life. the mother‟s relationship to the child is very important for it is the time when the life within her body is being developed. with the over tones of great responsibility of the parents to be.unuted in the sacrament of marriage. A parent delights in the observation that her child is like himself. the husband and wife should have strong and good foundation ready to face challenges. Seeing one‟s children grow ang develop is th life‟s greatest satisfaction. What has learned in home has amazing persistence. throughout the world). The passing of life from parent to child is one of the greatest privileges that come to man and woman. In the United States (and. or adoption. it can also bring anxiety and great responsibility.but to be reserved as an expression of true love in holy wedlock making available the sex cells. This as they combined provided the biological elements from which a new human life is formed. marriage. The decision of the young couple to begin a happy family is a happy event. Although parenthood does bring fulfillment. The family is generally recognized as an element of a broader kinship network that links ancestors and descendants of a person. Home must not only be sanctuaries but also place of preparation fron which each child can go forth confidently to lead and to face a turbulent world.happiness and great reward. From conception onward to the time of birth. Before increasing the family unit and thereby complicating it. True man and woman The divine impulse within every man and woman that impulse for a holy purpose not to be satisfied as a mere biological urge or as a lust of the flesh in promiscuous associations. Most published statistics on the family are based on census or household survey questions and responses. therefore the decision to have a child should not be made lightly. .

CHAPTER I ORGANIZATION AND GENERAL FUNCTION ANTEPARTUM MALE REPRODUCTIVE ORGAN .

It contains the testes. and the lower portion of the spermatic cord. Vas deferens-it carries sperm from the epididymis through the original canal into the abdominal cavity where it ends at the seminal vesicle and the ejaculatory ducts c.Epididymis-responsible for conducting sperms from the testes to the vas deferens b.Seminal Vesicle-they secretes a viscous portion of the semen. which contains Leydig cells. Scrotum. two termed corpus cavernosa and a third.EXTERNAL REPRODUCTIVE ORGAN A.Testes-two ovoid glands containing number of lobules. . corpus spongiosum contained in the shalft b. These cells are responsible for thr production of testosterone. which has a high content of basic sugar. Its function is to support the testes and help regulate temp of the sperm through contractions. INTERNAL REPRODUCTIVE ORGAN A. PENIS-composed of three cylindrical masses of erectile tissue.is rugated skin covered muscular pouch suspended from the perineum. c. epidedymis. protein and prostaglandin and it alkalinic in nature.

a hallow tube leading from the base of the bladder which after passing through the prostate gland continuous to the outside through the shaft the glands of the penis. Mons pubis or Mons Veneris-pad of flat which lies over the symphypis pubis. Urethra. II. when added to the secretion from the seminal vesicles and the accompanying sperm from the epididymis. Labia Minora-two thin folds of delicate tissues. which protect the surrounding delicate tissues from trauma.contains the bartholin glands III. this fluid will further protect the scounteractperm from being immobilized by low ph level of the urethra. FEMALE REPRODUCTIVE ORGAN EXTERNAL REPRODUCTIVE ORGAN I. Bulbourethral Gland-secretes an alkaline fluid that helps counteract the secretions of the urethra and ensure the safe passage of the spermatozoa g. e. Labia Majora-two folds of skin with flat underneath. Ejaculatory Ducts-they pass through the prostate gland and join seminal vesicles in the urethra. Prostate Gland-secretes thin alkaline fluid. form an upper fold encircling the clitoris which is highly sensitive to manipulation and trauma that is why it is often torn during delivery .d. f.

Glans Clitoris –small erectile tissue structure at the anterior junction of the labia minora extremely sensitive to sexual manipulation V. Composed of three muscular layers.area from the lower border of the vagina orifice to the anus. The perimetrium.and nourishment of the product of conception. .endometrium and myometrium.Uterus.Uterus. and forms part of birth canal. VI.retainment.Consist implantation.external opening of the vagina VIII. Urethral Meatus-external opening of the urethra VII. Composed of three muscular layers.32 inches wide. B. receives the penis during coitus.1 inch thick. Contains the muscle that supports the pelvic organs INTERNAL REPRODUCTIVE ORGAN A. The perimetrium.a 3-6 inches longitudinal canal located between the bladder and the rectum.32inches wide.1 inch thick.Vagina. Perineum.Vaginal Orifice.passageway of menstrual discharges. Vestibule-narrow space seen when the labia minora is separated.hallow pear shaped fibro muscular organ 3 inches long.endometrium and myometrium.isthmus.Consist of three parts:corpus or the body.IV.hallow pear shaped fibro muscular organ 3 inches long. and the cervix whic B.

almond shape dull white sex glands.Two OS COXAC made up of: Illium-upper extended part Ischium-upper part Pubis-front part 2.defined as episodic uterine bleeding in response to cyclic hormonal changes. This is called the onset of puberty and is accompanied by release of hormones oestrogen and progesterone.STRUCTURE 1. the ovaries of females are stimulated by the follicle stimulating hormone (FSH) of the pituitary. and the cervix which is the site of progesterone. PELVIS A.wedged shaped forms the back part of the pelvis 3.Sacrum.Responsible for the transport of the mature ovary to the uterus. Unlike males where sperms can be produced through out the life of man. D. These hormones control the production of ova or eggs and appearance of secondary sexual characteristics.Ovaries.4 inches long form each side of the fundus. At about the age of 10 to 13 years. in females the reproductive phase only lasts till the age of 45-50years. .Coccyx.Fallopian tube. This phase is characterised by the presence of menstrual cycle.isthmus.lowest part of the spine MENSTRATION MENSTRATION.Produces mature and expel ova nd manufacture estrogen and of three parts:corpus or the body.C.

If a sperm meets the egg. The stimulated follicle grows in size. the follicles grow further. The FSH stimulates one of the follicles. This entrance creates an 'activation' in the . Follicular Phase-In this phase. the Graafian follicle reaggregates to form corpus luteum. LH stimulates the follicle to rupture and release the egg.It lasts for the first 3-4 days. Ovulatory Phase-When the follicle is mature. It stops by the age of 45-50 years and is called menopause. During intercourse the man will ejaculate and sperm will be passed from the testicles via the penis into the woman's vagina. The corpus luteum secretes two pregnancy hormones . PROCESS OF CONCEPTION Conception is the process of becoming pregnant. fertilisation may occur. The degenerating corpus luteum is called corpus albicans. the pituitary gland secretes another hormone called luteinizing hormone (LH). The first occurrence of mensuration is termed menarche. Once the egg is released.progesterone and relaxin. During this phase the inner lining of the uterus is shed which causes the blood vessels to rupture. The release of egg is called ovulation and occurs between the 10th and the 16th day Luteal Phase-This phase lasts between the 16th and the 28th day. This causes bleeding and is called menstruation.CYCLES OF MENSTRATION Menstrual Phase. The egg can be impregnated for approximately 24 hours from when it leaves the follicle. Once one sperm is successful and penetrates the egg it will lose it's tail and it's head will increase in size.

The cells will begin to divide which will lead to the development of an embryo and hopefully produce a baby in nine months time! Milestone Of Growth and Development ONE LUNAR MONTH Does not appear human Heart appears as bulge on anterior surface SECOND LUNAR MONTH Organogenesis is complete Heart is beating Facial features are descernible . If the egg has been fertilised (the process of the sperm fusing with the egg) it will move to the uterus and attach itself to the uterine lining.egg and it too begins to enlarge. The cells are called a zygote. a process called implantation.

shape.External genitalia present but not distiunguisable THIRD LUNAR MONTH Ossification centers forming at the bones and tooth buds Male and female distinguishable FOURTH LUNAR MONTH FHT can be heard Lanugo is forming FIFTH LUNAR MONTH Quickening occurs SIX LUNAR MONTH Passive antibody transfer occurs Vernix caseosa forms Production of surfactant SEVENTH LUNAR MONTH Surfactant found in amniotic fluid EIGHT LUNAR MONTH Subaceous begins to deposit Assumes delivery position Brown fats present NINETH LUNAR MONTH Testes descend LEOPOLD’S MANEUVER PROCEDURE FIRST MANEUVER (Fundal Grip) Using both hands feel fot the fetalbpart lying in the RATIONALE To determine fetal part lying in the fundus. and mobility . its consistency.

Use gentle but deep pressure. grasp the lower portion of the abdomen above symphypis pubis.fundus SECOND MANEUVER (Umbilical Grip) One hand is used to steady the uterus on one side of the abdomen while the other hands moves slightly on a circular motion from top to the lower segment of the uterus to feel for the fetal back and small fetal parts . THIRD MANEUVER (Pawlik‟s Grip) Using thumb and finger. To identify location of the fetal back To determine position To determine engagement of the presenting part FOURTH MANEUVER ( Pelvic Grip) Facing foot part of the woman. palpate the To determine degree of flexion . press in slightly and make gentle movements from side to side.

fetal head pressing downward about 2 inches above the inguinal ligaments. Use both hands PLACENTAL CIRCULATION .

B.INTRAPARTUM .

drink clear fluids. you can expect your contractions to speed up.STAGES OF LABOR FIRST STAGE OF LABOR Thinning (effacement) and opening (dilation) of the cervix During the first stage of labor. After the bag of waters breaks. You may not want to talk as you become more involved in dealing with your contractions. Contractions may go away if you change activity. Relax. This is when your cervix opens to its fullest. rest. this is the hardest or most painful part of labor. your health care provider will measure the opening in centimeters. and keep track of your contractions. This is when you should head to the hospital. This is called effacement and dilation. Transition to second stage Your cervix opens from 7 to 10 centimeters. When you have contractions every 3 to 4 minutes and they each last about 60 seconds. your cervix will widen to about 10 centimeters. and when you can no longer talk during a contraction. 3. For most women. Active labor Your cervix opens from 4 to 7 centimeters. how strong. Early labor Your cervix opens to 4 centimeters. eat light meals if you want to. As your cervix dilates. Try to keep doing your usual activities. it often means that your cervix is opening faster (about 1 centimeter per hour). 2. When you notice a clear change in how frequent. but over time they'll get stronger. and how long your contractions are. As your labor progresses. This first stage of labor usually lasts about 12 to 13 The first stage of labor has three parts: 1. One centimeter is a little less than half an inch. your bag of waters may break. causing a gush of fluid. you are probably moving into active labor. You will probably spend most of early labor at home. During this stage. contractions help your cervix to thin and begin to open. Contractions last about 60 to 90 seconds and come every 2 to 3 minute SECOND STAGES OF LABOR Your baby moves through the birth canal .

and fatigue. and the position and size of the baby. If you are planning to breastfeed. and you and your partner will probably feel joy. The length of the second stage depends on whether or not you've given birth before and how many times. Nursing right after birth will help your uterus to contract and will decrease the amount of bleeding. we strongly encourage you to try to nurse as soon as possible after your baby is born. Others wait a little longer. but they may spread out a bit and give you time to rest. similar to an urge to have a bowel movement. and you may feel intense pressure. Most babies are ready to nurse within a short period after birth. Contractions push the baby down the birth canal.The second stage of labor begins when the cervix is completely dilated (open). the placenta has delivered. Your health care provider may ask you to push with each contraction. The placenta usually delivers about 5 to 15 minutes after the baby arrives. The contractions continue to be strong. and ends with the birth of your baby. MECHANISMS OF LABOR . FOURTH STAGE OF LABOR Recovery Your baby is born. THIRD STAGE OG LABOR After the birth of your baby. relief. your uterus continues to contract to push out the placenta (afterbirth).

DESCENT It is downward movement of the biparietal diameter of the fetal head to within the pelvic inlet. In some cases. INTERNAL ROTATION With further descent. the head may rotate completely to the occiput anterior position.flexion. These position changes we termed „‟Cardinal Movements of labor‟‟ :descent.Full descent occurs when the fetal head extrudes beyond dilated cervix and touches the posterior vaginal floor. pressure from the pelvic floor causes the fetal head to bend forward unto the chest. The smallest anteroposterior diameter(the suboccipito-bregmatic diameter )is the one presented to the birth canal in this flexed position.The pressure of the fetus on the sacral nerves causes the mother to ezperience a pushing sensation.extension. FLEXION While descending through the pelvis.Passage of the fetus through birth canal involves a number of different position changes to keep the smallest diameter of the fetal (in cephalic presentations)always presenting to the smallest diameter of the birth canal. This means that the fetal chin is no longer touching the fetal chest EXTERNAL ROTATION . Descent occurs because of contraction. When flexion occurs.internal rotation. Flexion is aided by abdominal muscle contraction during pushing. As descent occurs. the fetal head flexes so that the fetal chin is touching the fetal chest. The fetal position remains occiput transverse. This functionally creates a smaller structure to pass through the maternal pelvis.external. the occipital (posterior) fontanel slides into the center of the birth canal and the anterior fontanel becomes more remote and difficult to feel. EXTENSION The curve of the hollow of the sacrum favors extension of the fetal head as further descent occurs. and expulsion. the occiput rotates anteriorly and the fetal head assumes an oblique orientation.

This is expulsion and is the end if the pelvic division of labor C.the rest of the body easily and smoothly because of its smaller size.the restoration of menstrual cycle and beginning of parental role.POSTPARTUM The postpartum period. Nursing careshould focus on helping the mother and her family adjust to these changes and on easing the transition to the parenting role.early ambulationPhysiologic changes: Two typses of physiologic changes occur during the postpartum period RETROGRESSIVE. or puerperium.Many physiologic and psychological changes occur in the mother during this time. Involution– return of reproductive organ to its non pregnant state. Known as the 5th stages labor. EXPULSION Once the shoulders are born.production of milk for lactation. This is also known as restitution. refers to the 6-to-8week period after deliveryduring which themother‟s body returns to its prepregnant state. Hyperfibrinogenia.The shoulders rotate into an oblique or frankly anteriorposterior orientation with further descent.prone to thrombus formation.involution of the uterus and the vagina PROGRESSIVE. STAGES OF PUERPERIUM TAKING-IN PHASE -time of reflection of women -she is largely passive and prefers the nurse to do everything and make decisions for ther -this is due to physical uncertainty in caring for nb and partly from exhaustion in childbirth -time of reflection and pondering her new role -a time when she wants to talk about her labor and delivery -holds her child with a sense of wonder . Some people refer to this period as thefourth trimester of pregnancy. This encourages the fetal head to return to its transverse position.

LETTING –GO PHASE -finally redefines her role .INCOMPLETE-infant remains in the womans room in a specific time only IMMEDIATE CARE OF THE NEWBORN .more aquainted with the baby and feels confidence in her ability to care for nb.COMPLETE-implies that the mother and the child are together 24 hours a day 2.she gives up the fantatsize image of her child and accepts the real one -she gives up her role of being a childless or a mother of one or two ROOMING-IN . TWO TYPES OF ROOMING-IN 1.-regain physical strength and for calming her swirling thoughts -2-3 days TAKING-HOLD PHASE -begin to initiate action herself -she prefer to work and decide on her own -woman who have not receive anesthesia may reach this second stage in a matter of hours following from birth. -she begin to show strong interest in her baby -actions show independence yet still feel insecure about her ability to care for the newborn -praise her in the things she does well.infants stay in the room with the mother rather than in nursery -more time with the mother the faster the mother and the child is likely to develop .

Call out the time of birth 2. Receive the baby on to a warm. disposable clamp or a sterile tie and cut using a sterile blade about 23 cm (1-inch) away from the skin The baby should be thoroughly dried to . safe place close to the mother. Clamp and cut the umbilical cord 4. The baby should be delivered on to a warm clean towel and kept on the mother's chest. the baby should be kept in a clean. If this is not possible. clean and dry towel or cloth on a warm dry surface 3.PROCEDURE 1. The umbilical cord should be clamped using a sterile. Immediately dry the baby with a warm clean towel or RATIONALE It is important to tell loudly the time of birth this helps in accurate recording of the time and more importantly. warm. alerts other personnel in case any help is needed.

If the baby is not breathing . however. the white greasy substance covering the baby's body (vernix) should not be wiped off.piece of cloth. A normal newborn should be crying vigorously or breathing regularly at a rate of 40-60 breaths per minute. Assess the baby's breathing while drying prevent from getting cold (this would be explained in the module on 'Thermal protection'). Blood or meconium on the baby's skin should be wiped away. At the time of drying itself. the baby's breathing should be assessed. wipe the eyes 5. Because this vernix helps to protect the baby's skin and gets reabsorbed very quickly.

Leave the baby between the mother's breasts to start skin-to-skin care 8. This helps in easy identification of the baby.6. Place an identity label on the baby 9. especially if the delivery . The label should be placed on the wrist or ankle. Wipe both the eyes with sterile gauze 7. then the steps of resuscitation have to be carried out. Use separate gauze for each eye. the baby should be placed between the mother's breasts to the normal temperature of the baby as well as in promoting early breastfeeding. avoiding any confusion. Both the mother and the baby should be covered with a warm cloth. Wipe from the medial side (inner canthus) to the lateral side (outer canthus) Once the cord is cut. Clean the eyes using sterile gauze/cotton. Cover the baby's head with a cap. Cover the mother and baby with a warm cloth well.

Encourage mother to initiate exclusive breastfeeding room is cold (temperature less than 25°C).MENSTRUAL HISTORY Menarche: 10 yrs. NURSING PROCESS IN MOTHER AND CHILD MATERNAL DATA BASE A. G Age: 29 Civil Status: Married Educational attainment:High School Graduate Religion: Roman Catholic Nationality: Filipino Address: Penablanca Cagayan Occupation: Housewife B. a newborn baby's head should be covered with a cap to prevent loss of heat.10. Since head is the major contributor to the surface area of the body. Old Duration: 5days Color:Bright red to dark Odor: Fleshy Consistency: Moderate flow . ASSESSMENT I. NURSING HISTORY A. Breastfeeding should be initiated within half an hour of birth in all babies. PERSONAL DATE Name: E. CHAPTER II.

OBSTETRIC HISTORY Number of Pregnancy 1 AOG on Delivery 38weeks Manner Of Delivery Sex Of the child Weight 6.4lbs Present status Of the Child Normal Normal Male Spontaneous Delivery III. PAST HEALTH HISTORY (_)Respiratory Dse.(dolfenal) -Take herbal meds (yerba Buena) C.) Prenatal Check up: (_) (\) When: Where: Rural health Unit By Whom: Midwife Frequency: B. HISTORY OF PRESENT PREGNANCIES LMP:02-10-2012 EDC:11-08-2012 AOG: A. (_)Gynecological (_)Cardiac Dse.) Medications taken during pregnancy (_)multivitamins (\)iron (_)others: specify (_)none IV.Interval between Menses: 28 cycles Dysmennorhea: Sometimes Nursing Measures done: -Rest -Take meds. (_)hypertension (_)others:specify (_)none .

She wakes up at 6 in the morning. She is oriented to person. IV.GORDON’S 11 FUNCTIONAL PATTERN I. VI. She canfeed herself alone and no problem in n taking any food supplements.HEALTH PERCEPTION. She takes good care of herself well. She does household chores.she doesn‟t have any problem in her ability to eat.but she experience frequent urination.She can swallow solid and liquids and chew her food well. She had also mentioned that she doesn‟t use any maedications ti keep her go to sleep. She has no problem in urinating.place. She has no problem in sleeping at night. .She has no sensory perception deficit and she doesn‟t use any king of prosthesis.estimated 50-75cc per urination.SLEEP-REST PATTERN She admitted that she sleeps 8-10 hours a day. She is mentally equipped and healthy.ACTIVITY-EXERCISE PATTERN She wakes up at around 6 in the morning to cook for their breakfast and attend to needs of her husband . To augment her interrupted sleeps. II.COGNITIVE-PERCEPTUAL PATTERN She can react and write well.HEALTH MANAGEMENT PATTERN She is very much aware and understands the physiological and psychological changes of her pregnancy She eats nutritious foods and sometimes she drinks milk every morning for the growing fetus in her womb.and time. She defecates with a brownish yellow stool everyday particularly in the morning when she wakes up. V. NUTRITIONAL-METABOLIC PATTERN She eats balanced diet because she is aware that the fetus in her womb depends on her. She has normal appetite and loves to eat vegetables. III. According to her.ELIMINATION PATTERN The mother has no problem in defecating. The odor of her urine is aromatic. She usually urinates with an average of 8-10 times a day since she got pregnant. She takes a bath everyday because she wants to keep herself fresh the wholeday.BOWEL. she takes her nap in the afternoon when she has nothing todo.

X. She does not forget to pray and ask God‟s blessings and guidance. According to her she attends mass every Sunday.SEXUALITY-REPRODUCTION PATTERN She had menstruation at the age of 10. VIII. As a couple.COPING-STRESS PATTERN She is anxious about the outcome of her pregnancy. They live in their own house. IX. XI. she turns to God for streght and guidance. She tries to communicate with her husband on some important issues and major decisions in life. GENERAL PHYSICAL EXAMINATION .because she wants to look fresh and clean the whole day.She can speak Ilocano.ROLE-RELATIONSHIP PATTERN For her.VII. And they face it with courage. Sexual intercourse was diminished simce the secong trimester because she was uncomfortable.SELF-PERCEPTION PATTERN The pregnant is well groomed.and itawes clearly. She is concerned about her delivery and wise to be bear a healthy child. wife should be expressive enough to problems and fears to her husband. She can express herself verbally.VALUE-BELIEF SYSTEM She is roman catholic and a chuch goer. She experiences occasional pain-dysmennorhea The mother stated that she is not comfortable and not interested in using some of the contraceptives. She takes a bath twice a day. they have harmonious relationship. tagalong. Every time if she is under stressed.

Date performed: 09-23-2012 Vital signs Bp:110/80 Pr:77bpm RR:19cpm Temp:37celsius Area assessed General appearance Overall apparent settle Apparent state of comfort or distress Consciousness state of awareness Mood .manner. Presence of chloasma None Scars Eyes Inspection No indications of illnesssuch as pallor Dark pigmentation on face .neck none Normal .relationship To surroundings Facial expression Speech Head Symmetry Wounds /lessions contour Foreign Hair Lice and nuts Texture Distribution Face 21 Color Pigmentation Method used Normal findings Actual Findings analysis Inspection inspection Inspection Inspection Inspection Healthy Comfortable Alert Cooperative Relaxed Relaxed Normal normal normal normal normal Inspection Inspection Palpation Inspection Inspection Palpation inspection Symmetrical body to sized None Smooth contour None None thick Equally distributed Normocephalic skull size None normal normal normal normal None none Equally distributed Inspection Inspection Healthy.

No deformities none No tenderness Normal Normal Normal firm Normal Inspection Inspection Inspection Inspection Inspection Inspection Inspection Inspection Inspection No lesions Clear and no No discharges discharges Straight.midline Patent.pink soft Firmly in place Symmetrical Normal Normal Normal Normal Without lessions Palate symmetrical Not imflammed Normal Normal Normal Normal Neck Symmetry Lessions Chest Respiratory movement Chest excursion Imspection Inspection Inspection Symmetrical to body size None Inspection Chest expands at the same time with breathing Thumbs are equidistant away .midline.pink White hard.near/far without the aid of spectacles Movement of the eyelids is equal and closes completely Equal White in color Adequate response to normal sounds Symmetrical .unobstructed Symmetrical moist without lession Moist.Visual acuity Inspection Symmetry Inspection Reaction to light Sclera Ears Auditory Auricle Discharges Mastoid process nose External nose Vestibule Septum Nasal Canal Mouth and lip Lips Tongue Palate Teeth Tonsils Inspection Inspection Inspection Inspection Inspection inspection Able to see during night and day.

no odor.Vibration Breathing rate Hearth Rate and rhythm Heart sounds Heart beat Heart murmurs Breast Symmetry Skin Areola from the spinal cord area Inspection.dubb) 86 beats per minute none Normal rate Normal Normal Normal Normal Inspection Inspection Inspection Nipples Mass and Nodules Abdomen Shape Inspection Inspection Symmetric bilaterally Countour is snooth and intact Equally bilaterally in size.clear minimal discharges Upper and lower extremeties .auscultation Normal pitch Auscultation Regular and normal rate Inspection and auscultation Auscultation Auscultation Auscultation Steady and rhythmical Normal sound(lubb.shape and appearance Protruded and no discharges None Normal Normal Normal normal none Inspection Enlarged due to gravid fetus Linea nigra and striae gravidum None Enlarged due to gravid fetus Scars Bowel sounds Masses Genitalia External Inspection inspection Inspection Inspection Equally distributed pubic hair.

coherent.and cooperative Able to recall past .present experiences Able to do household chores Brown in complexion Equally pigmented with slight chloasma on the face Elastic and mobile Smooth Warm and soft Bipedal edema Normal Normal Normal None Normal Can relate immediately Normal Motor function Skin Color Pigmentation Inspection Inspection Inspection Brown Normal Normal Turgor and motility Texture Temperature and moistness edema Inspectionand palpation Inspection and palpation Inspection and palpation inspection Normal .slightly rough Normal Pain is complained after a long standing None Normal Lesions Hair distribution Inspection and palpation Inspection None Equally distributed .Symmetry Skin color Varicosities Neurological Level of consciousness Memory Inspection Inspection Inspection Inspection Inspection Inspection Proportioned Fairly brown Short trimmed None Alert .