IV.

Fourth Visit: September 11, 2019

During the labor and birth of the client, we are not informed that she delivered
the baby already seventeen days before her expected date of confinement (EDC) due to
some miscommunication. She wasn’t able to communicate with us because he changed her
phone number. However, when we visited her last September 11, 2019, that was the time
that we found out she already gave birth to his healthy baby boy. Unfortunately, we weren’t
able to perform any nursing interventions, hence, we asked the mother to verbalize her
situation during her labor and delivery. The client stated that she started her labor by
1:00pm and delivered at 7:00pm in the evening last August 28, 2019 via Normal
Spontaneous Vaginal Delivery at JR Borja General Hospital. The client experienced an
ankle edema on both feet and difficulty of breathing that leads her to be oxygenated.
Despite of the client’s early delivery, the baby’s condition is reassuring with an Apgar
Score of 9 and weigh for about 2.8 kg. On the following day, the client undergone an x-ray
as prescribed by her doctor to examine the causes of her altered breathing pattern. The
client was discharged from the hospital and returns home two days after her delivery as
claimed by the patient.

Actual Nursing Intervention Intrapartum Period:

Ineffective Breathing Pattern

NURSING
CUES DIAGNOS OBJECTI INTERVENTI RATIONAL EVALUATI
IS VES ONS E ON
Subjective: Independent:
“Galisod ko Ineffective At the end - Teach patient - Allows At the end of
ug breathing of 30 to perform patient to 30 minutes of
ginhawa” as pattern minutes of relaxation participate in nursing
verbalized related to nursing techniques maintaining interventions,
by the fatigue interventio health status objectives are
patient. secondary ns, the and improve fully met as
to labor patient ventilation evidenced
process will be by:
able to:
 - Regain - Place patient - A sitting - Regained
normal with proper position normal
rhythmic body alignment permits rhythmic
breathing for maximum maximum breathing
pattern breathing pattern lung pattern
excursion

- Regain - Avail fan - Promoting - Regained

consciousn inside the room air in the consciousnes
ess room helps to s
increase
ventilation

- Absence - Absence of
of pale pale color
color noted

Objective: Dependent:
-Dyspnea Provide Beta-
-Patient respiratory adrenergic
appears to medication as agonist
be prescribed by medication
exhausted the doctor. relaxes the
and muscles of
unconscious the airways,
-Pale which widen
the airways
and result in
easier
breathing
 Administer It increases
oxygen PRN the amount
of oxygen
your lungs
receive and
deliver to
your blood,
thus, helps
resolve
breathing
pattern

PHYSICAL ASSESSMENT

AOG 35 weeks
Fundal Height 41 cm
FHB 125 bpm (RLQ)
Respiration 25 cpm
Blood Pressure 130/90 mmHg
Pulse Rate 110 bpm
Body Temperature 37.3 C
Weight 54 kg
Height 150
cm
Name of patient: Celestina Pido Date: September 11, 2019

NURSING SYSTEM REVIEW CHART

Temp: PR: RR: BP: Height: Weight:
37.3 C 110 bpm 25 cpm 130/90 mmHg 150 cm 55 kg
EENT
[]impaired []blind []pain
vision
[]reddened []drainage []gums Dark Neck
[]hard hearing []deaf []burning Dark Armpit
[]edema []lesion []teeth FHB 125 bpm
(RLQ)
Assess eyes, ears, nose, throat for any
abnormalities [X]no problem AOG 35 weeks
RESPIRATORY Striae gravidarum
and Linea Negra
[]asymmetric []tachypne []apnea Fundal Height 41
a cm
[]rales []cough []barrel chest Cephalic
Presentation
[]bradypnea []shallow []brhonchi
[]sputum []diminish [X]dyspnea
ed Edema (Right & Left
Ankle)
[]orthopnea []labored []wheezing
[]pain []cyanotic
Assess respiration, rate, rhythm, depth,
pattern, breath sounds, comfort []no
problem Back pain
CARDIOVASCULAR
[]arrhythmia []tachypne []numbness
a
[]diminished [X]edema []fatigue
pulses
[]irregular []bradycar []murmur
dia
[]tingling []absent []pain
pulses
Assess heart sound, rate, rhythm, pulse,
blood pressure, circulation, fluid retention,
comfort
-[]no problem
GASTROINTESTINAL TRACT
[]obese []distentio []mass
n
[]dysphagia []rigidity []pain
Assess abdomen, bowel habits, swallowing,
bowel sound, comfort [X]no problem
GENITO-URINARY & GYNE
[]pain []urine []vaginal
color bleeding
[]hematuria []discharg []nocturia
es
Assess urine frequency, control, color, odor,
comfort, gyne bleeding, discharges [X]no
problem
NEURO
[]paralysis []stuporou []unsteady
s
[]seizures [X]lethargi []comatose
c
[]vertigo []tremors []confused
[]vision []grip
Assess motor function, sensation, Loc,
strength, grip, gait, coordination,
orientation, speech []no problem
MUSCULOSKELETAL & SKIN
[]appliance []stiffness []itching
[]petechiae []hot []drainage
[]prosthesis []swelling []lesion
[]poor turgor []cool []deformity
[]wound []rash []skin color
[]flushed []atrophy [X]pain
(back)
[]ecchymosis []diaphoret []moist
ic
Assess mobility, motion, gait, alignment,
joint, function, skin color, texture, turgor,
integrity [] no problem
 NURSING ASSESSMENT II
SUBJECTIVE DATA OBJECTIVE DATA
COMMUNICATI Comments: “Wala []Glasses []Languages
ON may problema sa
[]Hearing Loss akong panan-aw ug []Contact Lens R L []Hearing Aide
[]Visual Changes pandungog” as Pupil size: 3
verbalized by the mm []Speech difficulties
[X] Denied patient. Reaction: PERRLA
Pupil Equally Round and Reactive to Light
Accommodation
OXYGENATION Comments: “Wala Respiration []Regular [X]Irregular
[X]Dyspnea man ko gi ubo Describe: Respiratory pattern of client is
[]Smoking History karun, dili sab ko irregular and experiencing difficulty of
gapanigarilyo pero breathing
[]Cough lisod iginhawa
[]Sputum ma’am” as R Abnormal breathing pattern
[]Denied verbalized by the L Abnormal breathing pattern
patient.
CIRCULATION Comments: “Dili Heart Rhythm [] Regular [X]Irregular
[]Chest Pain man sakit ako tiil Ankle Edema [X]
ug dughan, pero Pulse Car Rad AP Fem*
[X]Numbness of nanghupong ako R 125
extremities mga tiil” as bpm
verbalized by the L 125
patient. bpm
[X] Denied Comments
NUTRITION Comments: “Wala []Dentures [X]None
Diet: DAT man sab ko nag Complete Incomplete
[]N[]V lisud ug tulon, dili
[]Recent change in sab ko gaka lipong Upper [] []
weight and ug ga suka” as Lower [] []
appetite verbalized by the
[]Swallowing patient.
Difficulty
[X] Denied
ELIMINATION Urinary frequency Comments: “Ok rman Bowel Sounds:
Usual bowel 12 times a day sab ako pag libang ug Normal
pattern ihi, dili sab ko
2 times a day []Urgency constipated” as Abdominal Distention
Constipation []Dysuria verbalized by the []Yes [X]No
Remedy patient.
[]Hematuria Urine (color,
Date of last BM []Incontinence consistency, odor)
September 11, []Polyuria Yellow
2017 @8:30 am
Diarrhea Character []Foley in place
[X]Denied

MANAGEMENT OF HEALTH AND

ILLNESS
[]Alcohol [X]Denied Briefly describe the patient’s ability to follow
“Dili ko ga inom ug alcoholic” as treatments, for chronic health problems.
verbalized by the patient. The patient is able to follow treatments and
medications.
[]SBE Last Pap Smear No chronic health problems.
LMP: December 08, 2019

SUBJECTIVE DATA OBJECTIVE DATA

SKIN INTEGRITY Comments: “Dili []Dry []Cold Pale
[]Dry katol akong panit” as []Flushed [X]Warm
[]Itching verbalized by the []Moist []Cyanotic
[X]Denied patient Rashes, ulcers, decubitus (describe size,
location, drainage, color, odor

ACTIVITY & Comments: “ ok LOC & Orientation

SLEEP rako karun maam”
[]Convulsion as verbalized by the
[]Dizziness patient. Gait: []Walker []Cane
[]Limited Motion of [X]Steady []Unsteady
Joints []Sensory & motor losses in face and
Limitation in ability extremities None
to
[]Ambulate
[]Bathe self ROM Limitations: None
[X]Denied
COMFORT/SLEEP/AWAKE []Facial Grimace
[]Pain (location, Comments: “usahay []Guarding
frequency & remedy maam lisudan ko []Other signs of pain: None
matulog balik ig
makamata nako” as
[]Nocturia verbalized by the
[X]Sleep Difficulty patient.”
[]Denied
COPING Observed non-verbal behavior:
Occupation Cooperative, smiling and approachable.
Members of household: 4 (husband and my Person and phone number that can be
children) reached at any time: None
Most supportive person: Husband

OBSERVATIONS AND IMPLICATIONS

During our fourth visit last September 11, 2019, we greeted the whole family
a ‘good afternoon’ and proceeded eventually to the assessment routine. Upon the
assessment, we ask first the mother if how is she doing, is there any presence of illnesses,
or is there any unusual feelings she is experiencing lately and followed by getting her TPR,
BP, and the developments of her pregnancy.

For the implication of health teachings, the group advised the client to take her
medication religiously, perform exercises to relieve backache, not to skip her follow up
check-up, encouraged the mother to breastfeed her baby for a minimum of six months and
introduced the advantages of breastfeeding for herself and to her baby. When it comes to
her diet, we advised her to try some lactation-boosting foods such as oats that contains a
lot of iron that aid milk production, and plenty of vegetables like carrots and dark leafy
greens (e.g.. malunggay, kangkong, alugbati) that not just boost lactation but provide a lot
of other health benefits.