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West Visayas State University

COLLEGE OF NURSING
La Paz, Iloilo City

OBSTETRICAL ASSESSMENT

I. VITAL INFORMATION

Name: EMA

Age: 23 yrs. old

Religious Affiliation: Roman Catholic

Date and Time of Delivery: July 22, 2014; 9:16 am

Educational Attainment: College Graduate

Civil Status: Married

Date and time Admitted: July 22, 2014; 6:50 am

Physicians Initials: Dr. JM

Chief Complaint: indi ko na maagwantahan ang kasakit sang akon tiyan as


verbalize by the patient

Impression/ Diagnosis: G1P1 (1001) pregnancy uterine delivered to a live term


baby boy via assisted vaginal delivery (outlet forceps extraction)

Number of days of post-op (if CS):

Date and time of Interview: July 25, 2014; 11:10 am

Informant: patient herself

II. OBSTETRICAL HISTORY

G1P1T1P0A0L1

LMP: Oct. 24, 2013 EDD: July 31, 2014 AOG: 38 5/7 weeks

Pad counts: 2- 3 pads per day Duration of Menses: 2-3 days

Discomforts: Mood Swings

Type of Delivery: NSVD

Others (specify): assisted vaginal delivery (outlet forceps extraction)

Episiotomy: Yes ___ No ___

Type of Incision:

Mediolateral Right ___ Left ___

Median

Previous Hospitalization: Yes ___ No ___


Date of last consultation while pregnant: July 18, 2014 at West Visayas State

University Medical Center

Did she have access to inform regarding childbirth? Yes

If yes, how?

___TV Programs ___Attendance to health classes

___reading magazines ___family members (mother)

___friends/neighbors ___others (pre natal check-up and pamphlets)

Any complications during this pregnancy / previous pregnancies: None

Medications taken during this pregnancy (include dosage, frequency and


compliance)

Multivitamins + Iron - OD, (started 4th month of pregnancy until before delivery)

Calvit- OD, 600mg (started 4th month of pregnancy until before delivery)

FAMILY PLANNING

Practicing: Yes ___ No ___

If yes, what method of contraceptive used:

If none, does she signify willingness to practice family planning?

Yes ___ No ___

If yes, what method? Natural Method

NURSING HISTORY

1. History of Present Illness


a. Usual Health Status

E.M.A expressed that she is healthy. She performs activities of daily living
without difficulty such being a cashier of a pharmacy.

b. Chronologic Story
It was 2 in the morning of June 22 when the patient first experienced
intermittent labor pains at their residence in Mandurriao, Iloilo City. This lasted
for a few minutes. At first, she thought it was just a normal scenario in the
span of her pregnancy and that would not bother her on the possibility that
she may be able to deliver her baby that day. Also, she had eaten a fresh slice
of pineapple fruit the day before which also gave her the idea that it was the
reason of such pain. Patient rated the pain as 5 out of 10 in the pain rating
scale. She had not performed any activity that would relieve the pain because
it had disappeared earlier.
At around 4am, the pain became severe. The interval of pain from the
previous one was almost 1 hour. It was felt in the hypogastric region of the
stomach. Patient rated it as 10 out of 10 in the pain rating scale. She cant
tolerate the pain for it seemed to be excruciating already. While in the comfort
room, she have had observed bloody show and reported it to her grandmother.
She was not able to perform any activity that would relieve the pain. Her
grandmother then prompt her to go to West Visayas State University Medical
Center. Since the woman is primigravida, she have already assumed that she
will be delivering her newborn anytime that day because of the presence labor
pains and bloody show.
The patient together with her father-in-law and older sibling rushed to
WVSU-MC riding a private automobile. Although, there is a hospital nearer
their home, she still preferred to be admitted in WVSU-MC because she
believes that such offers good quality care. Mas nami diri nga daan kuno kay
matutukan ka gid nila (referring to the health care providers). she verbalized.
They reached the hospital gates past 4 in the morning. The physician then
performed vaginal examination and revealed to be in 4cm cervical dilation.
After that, she was advised to stay in the hospital premises until the time of
her delivery.
While waiting, almost 7am when the bag of water erupted. Upon checking,
patient revealed to be in 8cm cervical dilation and have been referred in the
delivery room already.
The delivery took almost 2 hours. Patient delivered a baby boy via assisted
vaginal delivery (outlet forceps extraction) at exactly 9:16am of June 22.
2. Past Health Problems/Status

a. Childhood Illness
Chickenpox (+)
Mumps (+)

b. Immunization
Patient cannot recall
BCG scar noted on right deltoid
c. Allergies
Food, Drugs, Medications, Dust, Pet Dander (-)

d. Accidents and Injuries


Motorcycle accident (2013)

e. Hospitalization for serious illnesses


None

f. Medications (all currently used prescriptions and OTCs)


Co-amoxiclav; 625mg/tab, 1 tab BID for 7 days
Mefenamic acid; 500mg/tab, 1 tab Q6H PRN for pain
Multivitamins + Iron; 1 tab OD
Vit. A, C, E + zinc (Conzace); 1 tab OD
Amlodipine; 5mg/tab, 1 tab OD

3. Family History of Illness


Hypertension (Both maternal and paternal side)

4. Patients Expectation
a. What does she expect to occur during this hospitalization?
Maatipan ako sang maayo, indi ako pag pabay-an kag maka gwa kami
insigida sang akon bata.

b. To the nurses, doctors and staffs?


Indi sila suplada kag palaakig, mabuot kag maayo mag-atindir.

III. PATTERNS OF FUNCTIONING

A. BREATHING PATTERN
Respiratory Problems: None
Usual Remedy: None
Manner of Breathing: Effortless

B. CIRCULATION
Usual Blood Pressure: 120/80
Any history of chest pain, palpitations, coldness of extremities, etc.: None

C. SLEEPING PATTERN
Usual Bedtime: 10 11 PM up to 8-9 AM
Number of pillows: 3; placed on the head, feet, and side
Bedtime rituals: taking a bath
Problems regarding sleep: None
Usual Remedy: None

D. DRINKING PATTERN
Kinds of Fluid Taken in 24 hours and amount in mL:

Type Amount Time


Water 1000 1200 mL Every after eating
Soda (Coke) 600-800 mL after lunch, dinner
and snacks
Milk 200 mL-300ml 8:00-9:00 AM

E. EATING PATTERNS

Usual Food Taken Time


Breakfast 1 cup of rice, egg 9:00 10:00 AM
Lunch cup of rice, 1 fried fish, 1 12:00 1:00 PM
bowl of vegetables
Dinner 1 cup rice, fried pork chop 7:00 - 8:00 PM
Snacks Bread 3:00 3:30 PM

Food Preferences: none in particular

F. ELIMINATION PATTERNS
1. Bowel Movement
Frequency: Twice a week
Problems or difficulties: occasional constipation
Usual remedy: increase fluid intake

2. Urination
Frequency: 3-4 times a day
Problems: None
Usual remedy: None

G. EXERCISE, REST, AND ACTIVITIES


Activities and rest period during the duration of pregnancy: The activity that EMA
did during pregnancy is brisk walking. She verbalized that most of the time she
sleeps during the day.

Exercise done on

1st Trimester: Brisk walking 4-5 times a week for 5-10 minutes @ 9AM for approx.
25 meters

2nd Trimester: : Brisk walking 2-3 times a week for 5-10 minutes @ 9AM for
approx. 25 meters

3rd Trimester: Brisk walking once a week for 5-10 minutes @ 9AM for approx. 25
meters
H. PERSONAL HYGIENE
1. Bath
Type: Full bath
Frequency: Once or twice per day
Time of day: Morning/ Afternoon

2. Oral Care
Frequency: once
Care of Dentures (if any): None

3. Shaving
Frequency: None

4. Use of cosmetics and toiletries


Uses Powder, Lip shiner, and Tawas

I. RECREATION
Surfing the internet

J. Health Supervision
Patient is reactive, seeking healthcare only when ill.
IV. CLINICAL INSPECTION

1. Vital Signs
T= 36.6 C
RR= 19 bpm
PR= 68 bpm BP= 130/80 mmHg
2. Measurements
Height= 53
Weight=127 lbs.

3. Physical Assessment

General Appearance

Patient awake and conscious lying on bed in semi-fowlers position, wearing pink
floral tube-dress, without jewelries, body build is mesomorph, hair unkempt, untrimmed
fingers and toenails, age was appropriate to her appearance, no breath and body odor,
attentive and cooperative.

A. Neurological System

Cranial Nerve Function How Elicited Clients Response

Occlude the nostril


while the patient Intact nostrils, patient
contributes in the
closes eyes; let the able to distinguish
I. Olfactory sense of smell in
patient smell the scent of coffee and
the client
scent. Repeat with orange fruit.
other nostril.
Ask the patient
about a certain
transforms letter in the
II. Optic information about Snellens chart at Not assessed
vision to the brain twenty feet testing
for her visual
acuity.
superiorly
Assess papillary
uplifting eyelid,
response to light
superiorly
and
rotating eyeball,
accommodation by Patients papillary
construction of
III. Oculomotor instructing patient response is present.
pupil on the
to look straight as PERRLA
exposure to light
penlight is shining
and operating
through each pupil.
several eye
PERRLA
muscles
Place penlight in
front of the patient
Patient able to follow
and ask her to
handling the eye penlight with both
follow it with her
IV. Trochlear muscles and eyes through six
eyes only as it
turning the eye cardinal fields of
moves through the
gaze.
6 cardinal fields of
gaze,
Ask patient to
clench teeth while Patients
Sensory functions the nurse palpates temporomandibular
related to nose, her temporal and joints and masseter
eyes, tongue and masseter muscles muscles contact
teeth. It basically for contractions, bilaterally, was able
is further divided use cotton balls to to identify light
V. Trigeminal
in three branches stroke forehead, touches on forehead,
that are cheeks and chin cheeks and chin.
ophthalmic, and ash patient if
maxillary and she is able to feel Automatically blinks
mandibular nerve the touch, and test bilaterally when
for the corneal corneas are touched.
reflex.
Place penlight in
front of the patient
Patient able to follow
and ask her to
function of penlight with both
follow it with her
VI. Abducens turning eye eyes through six
eyes only as it
laterally cardinal fields of
moves through the
gaze.
6 cardinal fields of
gaze.
Instruct patient to Intact skin, patient
responsible for smile, frown, able to smile, frowns,
VII. Facial different types of elevate and lower puff cheeks, elevates
facial expressions down eyebrows and lowers down
and puff cheeks. eyebrows.
providing
Occlude ear and Patient able to repeat
information
intermittently and and hear whispered
VIII. related to balance
ask client to repeat words nurse at the
Vestibulocochclear of head and
whispered words at left ear and hi at
sense of sound or
two feet distance. the right ear.
hearing
Gag reflex is present,
for taste, helping Using tongue
IX. patient able to
in swallowing depressor, tests for
Glossopharyngeal swallow without
food. gag reflex
difficulty
Instruct the patient
it contributes in to close her eyes, Patient able to
X. Vagus the tasting ability let the patient distinguish the taste
of the client taste the of sugar and salt.
condiments.
Tests for muscle
strength, turn the
Patient is able to
Tests for muscle head to one side
move head, muscle
strength, against the
strength of 4/5
XI. Spinal provides muscle resistance of a
against resistance,
Accessory movement of the hand on each sides
able to shrug
shoulders and and shrugs
shoulders against
surrounding neck shoulders against
resistance.
resistance of the
hands.
Tongue movement
and strength using
motor nerve that the tongue Intact, able to move
deals with the depressor put and push tongue
XII. Hypoglossal
muscles of resistance on the depressor with 4/5
tongue tongue and muscle strength.
observe the
strength.

B. Cardiovascular System
BP -130/80, Radial Pulse-68bpm, jugular veins not distended, (-) Homans sign as
evidenced by no pain after dorsiflexion of the foot, varicosities have regressed.

C. Respiratory System
Nose: Uniform in color, symmetric, midline, nares patent, no discharges
Nasal Mucosa: pink, no swelling, no discharges, no lesions
Chest: brown, uniform in color, no masses, no lesions, no tenderness, and no
adventitious sounds heard
Effortless breathing characterized by deep inhalation and shallow respiration,
thorax and chest rises in unison, shoulder and scapulae of the same height.

D. Gastrointestinal System
Lips: dry, pink, no lumps
Oral mucosa: pink, smooth, moist Gums: pink, moist and intact, no inflammation
Teeth: Tooth filling present in central incisors
Tongue: midline, no lesions

E. Genito-Urinary System
Voids 3-4 times a day, no difficulty in voiding, no history of kidney stones or
kidney disease
Hair distribution shaped like inverse triangle, dry smooth walled vagina, no
pain, redness and swelling, right mediolateral episiotomy present, perineum is
smooth and slightly darkened.

F. Reproductive System
Breast symmetrical, areola dark brown, approximately 4.5cm, Nipples are
inverted, feels pain on both breast upon palpation with 5 as the rate of pain ( 1-
10 pain rating scale ), fundus is firm and descends 3cm. Presence of lochia rubra
for 3 days with 3-5 pads use each day.

G. Lymphatic System

Tonsils: symmetrical grade +1, no lesions, no swelling, no exudates noted; Lymph


nodes: non-palpable and non tender.

H. Endocrine System

Thyroid gland at midline, rises upon swallowing, non-palpable, non-tender; able to


tolerate hot and cold; good appetite; good skin turgor; no excessive sweating.
I. Hematopoeitic System

Nail beds: pale pink on both upper and lower extremities, capillary refill of 2 seconds;
palpebral conjunctivae: pale pink, no lesions noted; Lips: pinkish in color, moist;
Tongue: pinkish in color, no ulcerations, no lesions and no masses present. No pallor
and no bruises noted.

J. Musculoskeletal System

Head: normocephalic, no tenderness, no masses noted; neck: symmetrical, midline, no


masses, no tenderness, no nodules noted, full ROM with 4/5 muscle strength;Upper
extremities: able to shrug shoulder with muscle strength of 4/5, smooth, coordinated
movements, equal on both sides of body; elbow and hands muscle strength of 4/5
bilaterally, no contractures, no deformities, no tenderness or swelling noted, no edema
noted; Lower extremities: 3/5 muscle strength, can be flex and extend.

K. Integumentary System

Hair: black, short, soft, fine and evenly distributed; no infestations noted; scalp is
smooth and firm, no dandruff, no masses and no lesions noted.

Skin is brown with uniform color except sun-exposed areas; good skin turgor and
temperature is within normal limit; BCG mark on the right deltoid muscle; scars noted
on the face about 2.5 cm in diameter, left elbow about 4.5 cm long and 2.5 cm wide
and on the left leg about 5.5 cm in diameter

Fingernails and toenails are untrimmed; both nails have a 160 angle of curvature,
smooth, intact surrounding skin tissues; translucent nail plate and pale pink nail beds.
Presence of linea nigra.

V. LABORATORY and DIAGNOSTIC RESULTS

Name of Examination: Urinalysis

Definition: An analysis of the volume and physical, chemical, and microscopic


properties of urine

Preparation:

1. Instruct patient to collect the first void of the day in a specimen container upon
awakening.

2. Have patient clean labia and meatus from front to back.

3. Upon voiding, have patient collect urine from the midstream void.

4. Cover container tightly and clean the outside portion.

5. Send the specimen with name, date, and time of voiding to the laboratory as soon
as possible.

Purpose: to check for complications

Date: July 24, 2014

Properties Normal Values result Significance


Color Yellow to amber Straw The sample urine
in color is within the
normal range of
color of urine.
Color is due to
urochrome and
urobilin.

Transparency Hazy Hazy Sample urine is


within normal
range of turbidity
of urine. Freshly
voided urine is
transparent, but
becomes cloudy
upon standing.

Reaction(pH) 4.6 to 8.0 7.0 Sample urine is


within normal
range of acidity or
urine. Acidity of
urine varies due to
diet.

Specific 1.001 to 1.035 1.015 Sample urine is


gravity within normal
range of specific
gravity of urine.
Specific gravity is
the ratio of the
weight of a
volume of a
substance to the
weight of an equal
volume of distilled
water

Chemical Test

Sugar Negative No traces of Sample urine must


sugar should be not contain traces
found of sugar.
Otherwise, it could
be an indication
for diabetes
mellitus. But
sometimes, small
traces are found
because the
patient is stressed
which increases
excessive amount
of epinephrine.
Albumin trace Small traces of Sample urine
albumin contains small
amount of
albumin. It is only
little because
albumin is too
large to pass
through capillary
tenistations.

Microscopic
Findings

Pus cells <5/hpf 30-40/hpf Sample urine


contains pus cells
beyond the normal
value. If sample
urine has an
abnormal amount
of pus cells, it is
an indication for
urinary tract
infection or acute
glomerulophrenitis

Red Blood <5/hpf 50-70/hpf Sample urine


Cells contains RBCs
beyond normal
value. If sample
urine is has an
abnormal amount
of RBCs, it could
be an indication
for urinary tract
infection, tumors
in the urinary
tract, acute
tubular necrosis,
kidney stones,
and/or kidney
trauma.

Casts and
Crystals

Amorphous No significant Few It is very common


Phosphates value in the urine to
have amorphous
phosphate
crystals. The
presence of
amorphous
crystals are not
usually indication
for diseases.

Squamous None Many Sample urine has


Epithelial many squamous.
Cells This indicates that
the urine sample
haas been
contaminated by
the skin flora.

Round Few Many This could be an


Epithelial indication for
Cells tubular necrosis
and/or exposure to
nephrotoxic agent

Name of Procedure: Hematology

Name of Examination: Complete Blood Count

Date: July 24, 2014

Definition:

The CBC and differential count are a series of tests of the peripheral blood
that provide a tremendous amount of information about the hematologic system and
many other organ systems.

It includes:

Hemoglobin concentration: a measure of the total amount of hemoglobin in the


peripheral blood, which reflects the number of RBCs in the blood

Red blood cell count: a count of the number of circulating red blood cells in 1
mm3 of peripheral venous blood.

Red blood cell indices: provide information on about the size (MCV and RDW),
weight (MCH), and Hgb concentration (MCHC) of RBCs

WBC count: count of the total n umber of WBCs (leukocytes) in 1 mm3 of


peripheral venous blood; differential count, measures the percentage of each
type of leukocyte present in the same specimen.

Platelet count: count of the number of platelets (thrombocytes) per cubic milliliter
of blood.

Enumeration of the cellular elements of the blood

Evaluation of RBC indices


Determination of cell morphology by means of stained smears. Counting is
performed by automated electronic devices capable of rapid analysis of
blood samples with a measurement error of less than 2 percent.

Purpose:

Because the CBC provides much information about the overall health of the
individual, it is an essential component of a complete physical examination,
especially when performed on admission to a health-care facility or before
surgery. Other indications for a CBC are as follows:

Suspected hematologic disorder, neoplasm, or immunologic abnormality

History of hereditary hematologic abnormality

Suspected infection(local or systemic, acute or chronic)

Monitoring effects of physical or emotional stress

Monitoring desired responses to drug therapy and undesired reactions to


drugs that may cause blood dyscrasias

Monitoring progression of non-hematologic disorders such as chronic


obstructive pulmonary disease, malabsorption syndromes, malignancies,
and renal disease

Preparation:

No special preparations are needed. Tell the patient the purpose of the test and
explain the procedure.

Source: Kee,J.L., A Look at Laboratory and Diagnostic Tests, 7th edition, 2006 Pagana,
K.D., Pagana, T., Mosbys Diagnostics and Laboratory Test Reference, 8th edition,
2007
CBC 7/24/14 Unit Normal Significance
Value
Hemoglobin 118g/L g/L 120-160 Decreased
Hematocrit 0.34L/L L/L 0.37-
0.47 Hemoglobin
RBC 10^12/L 3.88 10^12/L 4.2-5.4 is the oxygen
carrying
component
of the blood
which is
found in RBC,
thus the
decrease in
RBC
decreases
also the
number of
hemoglobin
in blood.

Hematocrit
and
hemoglobin
is directly
proportional
to RBC.

Decrease in
hemoglobin,
RBC and
hematocrit is
very
common and
is present in
almost 8o%
of pregnant
women.
Because
volume of
blood
increases
during
pregnancy
(hemodilutio
n), a
moderate
decrease in
the
concentratio
n of red
blood cells
and
hemoglobin
is normal
WBC 16.09 10^9/L 4.5-11 Increased
10^9/L
White blood
cell (WBC)
counts,
especially
neutrophils,
increase
naturally
during
pregnancy.
During active
VI. DESCRIPTION/DISCUSSION OF THE TYPE OF DELIVERY
VII. DRUG STUDY
VIII. LIST OF NURSING PROBLEMS IDENTIFIED (according to priority)

1. Pain related to breast engorgement


2. Constipation related to slowed peristalsis and inadequate fiber intake
3. Pain related to episiotomy
4. Health seeking behaviors related to lack of knowledge about lactation and
breastfeeding techniques
5. Deficient knowledge of infant care related to lack of experience

IX. NURSING CARE PLAN