TABLE OF CONTENTS

I. Table of Contents………………………………………………………………………….1

II. List of Figures……………...……………………………………………………………...2

III. Acknowledgement…………………………………………………………………...……3

IV. Introduction....................................................................................................................…..4

V. Significance of the Study……………………….…………..………………………..........5

VI. Objectives……………………………………………………………………………........6

VII. The Female Reproductive Anatomy and Physiology……….……….……………………7

VIII. Nursing Process……………………………………………..……...…….……………...28

IX. Physical assessment……...…………………………………….………………………...33

X. Diagnostic test…………………...………………………………...……………………..41

XI. Hematology and coagulation………………………………………..…………………...41

XII. Urinalysis results…………………………………………..…..…………………………44

XIII. Laboratory results……………………………………...……………….………………..45

XIV. Clinical Chemistry Result…………………..…………………..…………………..……45

XV. Hematology and Coagulation…………………..…………………..…………………....47

XVI. Urinalysis results…………………………………………………………..…..…………50

XVII. Drug study…………………………………………………………………………..……52

XVIII. Nursing Care Plan……………………...…………………………………………..…….65

XIX. Discharge Plan………………………………………………...…………………………72

XX. Evaluation…………………………………………………...…………………………...74

XXI. Recommendation…...………………………………...………………………………….75

XXII. Bibliography.………...…………..…………………...………………………………….76

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 LIST OF FIGURES

The female reproductive organs…………………………………………………………………...7

External reproductive organs……………………………………………………………………...7
Normal vagina………………………………………………………………………..……………7
Internal vagina……………………………………………………………………..…………….10
Uterine wall…………………………………………………………………………….………...12
Corpus………………………………………………………………………………….………...13
Ovaries ……………………………………………………………………………….………….14
Breast………………………………………………………………………….…………………14
The menstrual Cycle…………………………………………………………..……...………….16
The Ovarian Cycle……………………………………………………………..…..…………….18
Day of Menstrual Cycle………………………………………………….………...………….....20
Genes of Twins………………………………………………………….………..……………...24
Formation of Twins……………………………………………………..……………...………...25
Episiotomy…………………………………………………………………………….…………27
The Vulva……………………………………………………………….………………………..38
The Placenta…………………………………………………..………………………………….38
Lochia……………………………………………………………………………………………40

2
 ACKNOWLEDGEMENT

The group recognizes that this case study would not have had to come to completion with

only efforts of the group members. Several people played vital roles in this case study. The group

would like to express our sincerest gratitude and appreciation on support and assistance of the

following who made this case study possible.

To the panelist faculty; College of Nursing in the Ateneo de Zamboanga University for

their intellectual interaction for the refinement of this study.

To Mrs. Teen, our patient and her family, for the complete cooperation they have given

the group from the time of her hospitalization to be interviewed and assessed. Without them, this

case study would not have been possible at all.

To the Hospital, nurse supervisor, head nurse and staff of Ward 1 for giving the

opportunity to take care of the patient and the information they provided us for the completion of

this study.

To Mrs. Darwina Halbi, R.N., MAN, the group’s case adviser for her patience,

understanding and assistance in the preparation of this case study. Her clinical advice, guidance

and support are of greater help in this study. The group would like to thank her for always

encouraging us to do our best and never give up.

To the Jellycitea Café & Speedy Pizzaria, the group would like to thank them for being

kind and hospitable enough to offer to the group as a safe venue for making our case study.

To the parents and beloved family of the group’s members, the group would like to thank

them for the understanding and patience they have shown us all throughout the course this case

study, and for their emotional and financial support. Thank you for believing in the group’s

facilities, and for boosting our self-confidence whenever we needed it.

Above all, we owe this to God for the gift of wisdom and source of strength. With the

success of this study, the group is pleased to express their sincerest gratitude to all who have

contributed in completing the case study.

3
 Ateneo de Zamboanga University

College of Nursing

I. INTRODUCTION

It was the first week of duty in tertiary government hospital that the researchers

encountered and handled a teenage patient that gave birth to a twin by normal spontaneous

vaginal delivery. The team decided to choose this topic for their case study as they want to

broaden their knowledge as a student nurse about normal vaginal delivery by obtaining sufficient

information which could serve as a guide to enhance skills and attitude in the application of

nursing process and management of post-partum care for normal delivery patient. This is also to

help determine the condition of both mother and babies and be able to set attainable goals in

order to render appropriate health care to the patient.

Giving birth to twins are more likely to be born early, often before 38 weeks, so it’s

important to understand birth options. Less than half of all twin pregnancies last beyond 37

weeks. A normal spontaneous vaginal delivery (NSVD) occurs when a pregnant female goes into

labor without the use of drugs or techniques to induce labor, and delivers her baby in the normal

manner, without forceps, vacuum extraction, or a cesarean section. A vaginal delivery is the

recommended method of childbirth for women whose babies have reached full term. However,

vaginal deliveries are not recommended for women who have had cesarean deliveries before, or

who have infections that can be transferred to their baby through vaginal delivery.

Vaginal delivery is the method of childbirth most health experts recommend for women

whose babies have reached full term, or at least 41 weeks. Compared to other methods of

childbirth, such as a cesarean delivery and induced labor, it’s the simplest kind of delivery

process.

Mrs. Teen is an 18 years old teenager who gave birth to a identical twin by normal

spontaneous vaginal delivery. The teenager caught our attention that is why we chose this as our

case study topic.

4
Significance of the Study

This study aims to give awareness and information to the society and to the readers. Also,

for the researchers, which will help them in the many researches that they weren’t able to

explore. Therefore, we conducted this study that is beneficial to the following:

In nursing education, case study is an evidence-based issue which make researchers

understand fully the content and to create a solution in a given problem. It is utilized as an

educational tool in order to build up the instruments important to contemplate an issue. These

urge students to comprehend thinking strategies, and enhance critical thinking.

In nursing practice, case study may help the researchers to learn up-to-date ideas about a

several sickness condition, its management and prevention. It might also enable the researchers

to expand their knowledge and skills in dealing with a client. These are beneficial in the clinical

setting to enhance the utilization of past information.

In nursing research, case study provides evidence used to support nursing practices that

promote quality health outcomes for individuals, families, communities, and health care systems.

This study will help in finding ways and help improved nursing practice and patient care through

creative studies initiating and evaluating change and taking action to make new knowledge

useful in nursing.

Objectives

General Objectives

To conduct an in-depth study to develop the nursing care necessary to a primigravid

teenage mother who delivered via normal spontaneous vaginal delivery to an alive twin full-term

baby and determine the different physiologic, psychologic changes and discomfort in the

postpartum stage to be able to give appropriate interventions to regain health to a pre pregnancy

state.

Specific Objectives:

5
At the end of the 24 hours of the case study, the students will be able to:

1. Discuss the anatomy and physiology of the reproductive system

2. Discuss teenage pregnancy, and physiology of identical twin pregnancy
3. Enumerate physiological and emotional responses (Psychological changes) during the

puerperium state.
4. Identifies predisposing factors and possible discomfort that a woman can manifest after

delivery
5. Relates the present, past, family and Woman’s OB history comprehensively
6. Utilize the eleven functional health patterns of the patient briefly
7. Conduct a cephalocaudal Assessment to the patient thoroughly
8. Observe the surroundings and to identify the probable health threats present in the

environments
9. Conduct a drug study on the different medications that the patient is taking while confine

and home medications after discharge comprehensively

10. Familiarizes with the different diagnostic and laboratory examination necessary before,

during and after delivery

11. Formulates a Nursing Care plan to identified patient problems systematically
12. Assists the patient to perform activities of daily living independently.
13. Impart health teachings to postpartum mothers with regards to infant care, selfcare,

advocacy in breastfeeding to teach clients the importance of preventing complications

14. Utilizes critical thinking in implementing interventions to help mothers regain health.
15. Evaluate performance regarding how far we are able to extend help to the patient and

family honestly.
16. At the same time, we look forward to gain additional knowledge and the opportunity to

apply this learning in future challenges that we may encounter in any setting

Anatomy & Physiology

The Female Reproductive Anatomy and Physiology

The female reproductive system is composed of both external and internal reproductive

organs

Figure 1: Figure 2:

The Female Reproductive Organ External Female Reproductive Organ

6
Figure 1. The Female Reproductive Organ. Boundless. (n.d.). Boundless Figure 2. The External Female Reproductive Organ. Greedyfellow. (n.d.). Female
Anatomy and Physiology. Retrieved from Reproductive System. Retrieved from
https://courses.lumenlearning.com/boundless-ap/chapter/the-female- https://apniduniyas.blogspot.com/2018/01/human-reproductive-system.html.
reproductive-system/.

External Female Reproductive Organs

The external female reproductive organs collectively are called the vulva (which means

“covering” in Latin). The vulva serves to protect the

urethral and vaginal openings and is highly sensitive to

touch to increase the female’s pleasure during sexual

arousal (Coad & Dunstall,2005). The structures that

make up the vulva include the mons pubis, the labia

majora and minora, the clitoris, the structures within the

Figure 3. Normal Vagina. Shockey, G. (n.d.). Vulva, Illustration. Retrieved
vestibule, and the perineum. from https://www.sciencesource.com/archive/Vulva--Illustration-
SS2689297.html.

Mons Pubis

The mons pubis is the elevated, rounded fleshy prominence over the symphysis pubis.

This fatty tissue and skin are covered with pubic hair after puberty. It protects the symphysis

pubis during sexual intercourse (Telfer, N., & McWeeney, C., 2019).

Labia

The labia majora (large lips), which are relatively large and fleshy, are comparable to the

scrotum in males. The labia majora contain sweat and sebaceous (oil-secreting) glands; after

puberty, they are covered with hair. Their function is to protect the vaginal opening. The labia

minora (small lips) are the delicate hairless inner folds of skin; they can be very small or up to 2

inches wide. They lie just inside the labia majora and surround the openings to the vagina and

urethra. The labia minora grow down from the anterior inner part of the labia majora on each

side. They are highly vascular and abundant in nerve supply (Telfer, N., & McWeeney, C., 2019).

Clitoris and Prepuce

7
 The clitoris is a small, cylindrical mass of erectile tissue and nerves. It is located at the

anterior junction of the labia minora. There are folds above and below the clitoris. The joining of

the folds above the clitoris forms the prepuce, a hood-like covering over the clitoris; the junction

below the clitoris forms the frenulum. A rich supply of blood vessels gives the clitoris a pink

color. Like the penis, the clitoris is very sensitive to touch, stimulation, and temperature and can

become erect. For its small size, it has a generous blood and nerve supply ( Telfer, N., &

McWeeney, C., 2019).

There are more free nerve endings of sensory reception located on the clitoris than on any

other part of the body, and it is, unsurprisingly, the most erotically sensitive part of the genitalia

for most females. Its function is sexual stimulation (Katz, 2007).

Vestibule

The vestibule is an oval area enclosed by the labia minora laterally. It is inside the labia

minora and outside of the hymen and is perforated by six openings. Opening into the vestibule

are the urethra from the urinary bladder, the vagina, and two sets of glands. The opening to the

vagina is called the introitus, and the half-moon–shaped area behind the opening is called the

fourchette. Through tiny ducts beside the introitus, Bartholin’s glands, when stimulated, secrete

mucus that supplies lubrication for intercourse. Skene’s glands are located on either side of the

opening to the urethra. They secrete a small amount of mucus to keep the opening moist and

lubricated for the passage of urine (Schuiling & Likis, 2006).

The vaginal opening is surrounded by the hymen (maidenhead). The hymen is a tough,

elastic, perforated, mucosa-covered tissue across the vaginal introitus. In a virgin, the hymen

may completely cover the opening, but it usually encircles the opening like a tight ring. Because

the degree of tightness varies among women, the hymen may tear at the first attempt at

intercourse, or it may be so soft and pliable that no tearing occurs. In a woman who is not a

virgin, the hymen usually appears as small tags of tissue surrounding the vaginal opening, but the

presence or absence of the hymen can neither confirm nor rule out sexual experience (Mattson &

Smith, 2004).

8
Perineum

The perineum is the most posterior part of the external female reproductive organs. This

external region is located between the vulva and the anus. It is made up of skin, muscle, and

fascia. The perineum can become lacerated or incised during childbirth and may need to be

repaired with sutures. Incising the perineum area to provide more space for the presenting part is

called an episiotomy. Although still a common obstetric procedure, the use of episiotomy has

decreased over the past 25 years. The procedure should be applied selectively rather than

routinely. An episiotomy can add to postpartum discomfort and perineal trauma and can lead to

fecal incontinence (Cunningham et al., 2005).

Internal Female Reproductive Organs

The internal female reproductive organs consist of the vagina, uterus, fallopian tubes, and

ovaries. These structures develop and function according to the specific hormone influences that

affect fertility and childbearing.

Figure 4: The Female Reproductive System

Figure 4. The Female Reproductive System. Agfotografia74. (2019, March 27). Female
Reproductive System. Internal View Of The Uterus With Cross Section Stock Illustration -
Illustration of medical, healthy: 143005765. Retrieved from
https://www.dreamstime.com/female-reproductive-system-internal-view-uterus-cross-
section-d-rendering-image143005765.

Vagina

9
 The vagina is a highly distensible musculomembranous canal situated in front of the

rectum and behind the bladder. It is a tubular, fibromuscular organ lined with mucous membrane

that lies in a series of transverse folds called rugae. The rugae allow for extreme dilatation of the

canal during labor and birth. The vagina is a canal that connects the external genitals to the

uterus. It receives the penis and the sperm ejaculated during sexual intercourse, and it serves as

an exit passageway for menstrual blood and for the fetus during childbirth. The front and back

walls normally touch each other so that there is no space in the vagina except when it is opened

(e.g., during a pelvic examination or intercourse). In the adult, the vaginal cavity is 3 to 4 inches

long. Muscles that control its diameter surround the lower third of the vagina. The upper two

thirds of the vagina lies above these muscles and can be stretched easily. During a woman’s

reproductive years, the mucosal lining of the vagina has a corrugated appearance and is resistant

to bacterial colonization. Before puberty and after menopause (if the woman is not taking

estrogen), the mucosa is smooth due to lower levels of estrogen (Dorland, 2007).

The vagina has an acidic environment, which protects it against ascending infections.

Antibiotic therapy, douching, perineal hygiene sprays, and deodorants upset the acid balance

within the vaginal environment and can predispose women to infections.

Uterus

The uterus is a pear-shaped muscular organ at the top of the vagina. It lies behind the

bladder and in front of the rectum and is anchored in position by eight ligaments, although it is

not firmly attached or adherent to any part of the skeleton. A full bladder tilts the uterus

backward; a distended rectum tilts it forward. The uterus alters its position by gravity or with

change of posture, and is the size and shape of an inverted pear. It is the site of menstruation,

implantation of a fertilized ovum, development of the fetus during pregnancy, and labor. Before

the first pregnancy, it measures approximately 3 inches long, 2 inches wide, and 1 inch thick.

After a pregnancy, the uterus remains larger than before the pregnancy. After menopause, it

becomes smaller and atrophies.

The uterine wall is relatively thick and composed of three layers: the endometrium

(innermost layer), the myometrium (muscular middle layer), and the perimetrium (outer serosal
10
 layer that covers the body of the uterus). The endometrium is the mucosal layer that lines the

uterine cavity in nonpregnant women. It varies in thickness from 0.5 mm to 5 mm and has an

abundant supply of glands and blood vessels (Cunningham et al., 2005).

The myometrium makes up the major portion of the uterus and is composed of smooth

muscle linked by connective tissue with numerous elastic fibers.

Figure 5: The Uterine Wall

During pregnancy, the upper

myometrium undergoes marked hypertrophy,

but there is limited change in the cervical

muscle content. Anatomic subdivisions of the

uterus include the convex portion above the

Figure 5. The Uterine Wall. What are the three layers of the uterine
wall from the inside out?: Socratic. (2016, February 18). Retrieved uterine tubes (the fundus); the central portion
from https://socratic.org/questions/what-are-the-three-layers-of-the-
uterine-wall-from-the-inside-out.
(the corpus or body) between the fundus and the cervix; and the cervix, or neck, which

opens into the vagina.

Cervix

The cervix, the lower part of the uterus, opens into the vagina and has a channel that

allows sperm to enter the uterus and menstrual discharge to exit. It is composed of fibrous

connective tissue. During a pelvic examination, the part of the cervix that protrudes into the

upper end of the vagina can be visualized. Like the vagina, this part of the cervix is covered by

mucosa, which is smooth, firm, and doughnut-shaped, with a visible central opening called the

external os. Before childbirth, the external cervical os is a small, regular, oval opening. After

childbirth, the opening is converted into a transverse slit that resembles lips. Except during

menstruation or ovulation, the cervix is usually a good barrier against bacteria. The cervix has an

alkaline environment, which protects the sperm from the acidic environment in the vagina. The

canal or channel of the cervix is lined with mucus secreting glands. This mucus is thick and
11
impenetrable to sperm until just before the ovaries release an egg (ovulation). The channel in the

cervix is too narrow for the fetus to pass through during pregnancy, but during labor it stretches

to let the newborn through.

The inner lining of the corpus (endometrium) undergoes cyclic changes as a result of

the changing levels of hormones secreted by the ovaries: it is thickest during the part of the

menstrual cycle in which a fertilized egg would be expected to enter the uterus and is thinnest

just after menstruation. If fertilization does not take place during this cycle, most of the

endometrium is shed and bleeding occurs, resulting in the monthly period.

If fertilization does take place, the embryo attaches to the wall of the uterus, where it

becomes embedded in the endometrium (about 1 week after fertilization); this process is called

implantation (Heffner & Schust, 2006). Menstruation then ceases during the 40 weeks (280 days)

of pregnancy. During labor, the muscular walls of the corpus contract to push the baby through

the cervix and into the vagina.

Figure 6: The Corpus

Figure 6. Corpus. Britannica, T. E. of E. (n.d.). Corpus luteum. Retrieved from

https://www.britannica.com/science/corpus-luteum.

Fallopian Tubes

The fallopian tubes are hollow, cylindrical structures that extend 2 to 3 inches from the

upper edges of the uterus toward the ovaries. Each tube is about 7 to 10 cm long (4 inches) and

approximately 0.7 cm in diameter. The end of each tube flares into a funnel shape, providing a

large opening for the egg to fall into when it is released from the ovary. Cilia (beating, hair-like
12
extensions on cells) line the fallopian tube and the muscles in the tube’s wall. The fallopian tubes

convey the ovum from the ovary to the uterus and sperm from the uterus toward the ovary. This

movement is accomplished via ciliary action and peristalsis. If sperm is present in the fallopian

tube as a result of sexual intercourse or artificial insemination, fertilization of the ovum can

occur in the distal portion of the tube. If the egg is fertilized, it will divide over a period of 4 days

while it moves slowly down the fallopian tube and into the uterus.

Ovaries

The ovaries are a set of paired glands resembling unshelled almonds set in the pelvic

cavity below and to either side of the umbilicus. They are usually pearl-colored and oblong.

They are homologous to the testes. Each ovary weighs

from 2 to 5 grams and is about 4 cm long, 2 cm wide, and

1 cm thick (Speroff & Fritz, 2005). The ovaries are not

attached to the fallopian tubes but are suspended nearby

from several ligaments, which help hold them in position.

Figure 7. Ovaries. Mullin, E. (2019, April 23). Will Artificial
Ovaries Mean No More Menopause? Retrieved from
https://www.technologyreview.com/f/609677/will-artificial-ovaries-
mean-no-more-menopause/.
The development and the release of the ovum and the secretion of the hormones estrogen

and progesterone are the two primary functions of the ovary. The ovaries link the reproductive

system to the body’s system of endocrine glands, as they produce the ova (eggs) and secrete, in

cyclic fashion, the female sex hormones estrogen and progesterone. After an ovum matures, it

passes into the fallopian tubes.

Breasts

The two mammary glands, or breasts, are accessory organs of the female reproductive

system that are specialized to secrete milk following pregnancy. They overlie the pectoralis

major muscles and extend from the second to the sixth ribs and from the sternum to the axilla.

Each breast has a nipple located near the tip, which is surrounded by a circular area of pigmented

skin called the areola. Each breast is composed of approximately 9 lobes (the number can range

13
between 4 and 18), which contain glands (alveolar) and a duct (lactiferous) that leads to the

nipple and opens to the outside.

Figure 8: Female Breast

Figure 8. Anatomy of the Female Breast. Breast Anatomy and How Cancer Starts:
About Breast Cancer. (2019, February 28). Retrieved fromhttps://nbcf.org.au/about-
national-breast-cancer-foundation/about-breast-cancer/what-you-need-to-
know/breast-anatomy-cancer-starts/.

The lobes are separated by dense connective and adipose tissues, which also help support

the weight of the breasts (Ramsay, Kent, Hartmann & Hartmann, 2005). During pregnancy,

placental estrogen and progesterone stimulate the development of the mammary glands. Because

of this hormonal activity, the breasts may double in size during pregnancy. At the same time,

glandular tissue replaces the adipose tissue of the breasts. Following childbirth and the expulsion

of the placenta, levels of placental hormones (progesterone and lactogen) fall rapidly, and the

action of prolactin (milk-producing hormone) is no longer inhibited. Prolactin stimulates the

production of milk within a few days after childbirth, but in the interim, a dark yellow fluid

called colostrum is secreted. Colostrum contains more minerals and protein, but less sugar and

fat, than mature breast milk. Colostrum secretion may continue for approximately a week after

childbirth, with gradual conversion to mature milk. Colostrum is rich in maternal antibodies,

especially immunoglobulin. A (IgA), which offers protection for the new-born against enteric

pathogens.

Episiotomy

14
 The incision of the episiotomy was done mediolaterally in the middle of the vaginal

opening and extends down toward the buttocks at a 45-degree angle. During delivery of multiple

babies, an episiotomy allows additional room at the vaginal opening for delivering the second

twin. In cases were both twins are in a headfirst position like this, the doctor did a slow delivery

of the second twin by performing an episiotomy (mediolaterally) which allows room for the baby

to be delivered and prevent any perineal laceration or damage.

Figure 9: Episiotomy

Figure 17. Episiotomy. Management of episiotomy. Retrieved from

https://www.google.com/search?
Twin Pregnancy
q=mediolateral+episiotomy&sxsrf=ACYBGNRekYdTU5eoo4SudAuAQU4i8ksw2w:157164
0033376&source=lnms&tbm=isch&sa=X&ved=0ahUKEwjBwp2v36zlAhXYMt4KHUTHAl
0Q_AUIEigB&biw=1536&bih=722#imgrc=CArYkK7npDjbRM.

Multiple pregnancy is a pregnancy with more than one fetus. If there is more than one

egg released during the menstrual cycle and each egg is fertilized by a sperm, more than one

embryo may implant and will grow in the uterus. This kind of pregnancy results to fraternal

twins or more. When a single fertilized egg splits, it results in multiple identical embryos. This

kind of pregnancy results to identical twins or more. Identical twins are less common than

fraternal twins. A multiple pregnancy occurs when one egg (ovum) splits before implanting or

when separate eggs are each fertilized by a different sperm.

 Identical twins or triplets occur with the fertilization of a single egg that later divides into

two or three identical embryos. Identical twins or triplets have the same genetic identity,

are always the same sex, and look almost exactly the same.

15
  Fraternal multiples develop from separate eggs that are each fertilized by a different

sperm. Fraternal twins might or might not be of the same sex and might not necessarily

resemble each other any more than two siblings from the same parents might.

In a pregnancy with triplets or more, the babies can be all identical, all fraternal, or a

mixture of both. This can happen when multiple eggs are released by the mother and fertilized. If

one or more of these fertilized eggs divides into two or more embryos, a mixture of identical and

fraternal multiples will occur. The chance that a woman will have fraternal multiples is higher if

a woman is older, taller, and heavier. In addition, twins are more likely if a woman is herself a

twin, or if having twins runs in the maternal (mother’s) side of the family.

Figure 10. Genes of Twins

Figure 12. DNA and Identical vs. Fraternal Twins. Retrieved from
https://www.google.com/search?
q=identical+and+fraternal+twins&sxsrf=ACYBGNTe1SGy3biXTWdUnk6H3z6npHgjEQ:15
71640730181&source=lnms&tbm=isch&sa=X&ved=0ahUKEwiMjb_74azlAhWNE4gKHZB
Figure 11. Formation of Twins
7AbYQ_AUIEigB&biw=1536&bih=722#imgrc=OAGB-btHkc-ScM.

16
 Figure 13. Fraternal twins & identical twins. Retrieved from
https://www.google.com/search?
biw=1536&bih=722&tbm=isch&sxsrf=ACYBGNTQvQjBZG2NLCOXMtQm9R5zsDM
NXg
%3A1571640868390&sa=1&ei=JFatXfeAbS_JjQDw&q=formation+of+twins+monozyg
otic+zygote&oq=formation+of+twins+monozygotic+zygote&gs_l=img.3...14180.21079..
21245...0.0..0.100.661.6j1......0....1..gws-
wiz.BvoQ4dUDCAc&uact=5#imgrc=ubg81VZNy8sZ6M:

During pregnancy, the developing babies get oxygen and food from their mother through

the placenta and umbilical cord. Fraternal twins have separate placentas and umbilical cords. The

technical name for this is dichorionic.

Fraternal twins can be the same or opposite sex and their genes are as different as any

other brother and sister. Often, same-sex fraternal twins look different – for example, they might

have different hair or eye color. Occasionally they look quite similar.

There are three types of identical twins.

About one-third of identical twins split soon after fertilization and form completely

separate twins. Like fraternal twins, these twins have separate placentas.

The other two-thirds split after they attach to the wall of the womb. As a result, they share

a placenta. The technical name for this is monochorionic.

In a very small number of identical twins, splitting might happen even later. In this case,

both twins share an inner sac, called the amnion, in addition to sharing a placenta. The technical

name for this is monoamniotic twins. Sharing a placenta means that twins share a blood supply

during pregnancy. Sometimes the blood supply is shared unequally, which can cause health

problems for both twins.

Women who are pregnant with twins sharing a placenta need to be checked more often

than women with twins with separate placentas. Frequent checks can pick up early on any

potential complications. Twins sharing an inner sac (monoamniotic) are also at a higher risk of

complications during pregnancy because of the chance that their umbilical cords might tangle

and cut off their blood supply.

The client, Mrs. Teen had a monozygotic twin where the babies are identical and usually

have the same sex. A monozygotic twin is formed when one zygote, created with one egg and

17
one sperm, splits into two. Instead of having just one embryo, the result is two embryos and

develops as a separate fetus (Gurevich, R., 2019).

There are many factors related to having a multiple pregnancy. Naturally occurring factors

include the following:

 Heredity - A family history of multiple pregnancy increases the chances of having

twins.

 Older age - Women over 30 have a greater chance of multiple conception. Many

women today are delaying childbearing until later in life, and may have twins as a

result.

 High parity - Having one or more previous pregnancies, especially a multiple

pregnancy, increases the chances of having multiples.

II. NURSING PROCESS

a. Biographic Data

Name: Mrs. Teen

Age: 18 years old

Address: Villa Margarita, San Roque, Zamboanga City

Sex: Female

Marital Status: Married

Occupation: None

18
Educational Attainment: Grade 12 Senior high School

Ethnic Group: Yakan/Tausug

Dialect/Languages Spoken: Yakan, Tausug &Tagalog

Religion: Islam

Date of Admission: July 16, 2019, 5:30 P.M.

Chief of Complaint: Abdominal and vaginal pain.

Final Diagnosis: G1P1 (2002) pregnancy uterine delivered vaginally to first of twin, live term

cephalic baby boy 1, Apgar score 8, birth weight 1.75 kg, second of twin live term Cephalic

Surgical Management Episiotomy baby boy, Apgar score 8, birth weight 2.34kg.

Hospital Case Number: 1242032

Expected Date of Confinement: July 17, 2019

Last Menstrual Period: October 25, 2018

OB Score: G1P1 (2002)

B. Comprehensive Nursing History

Present history:

Mrs. Teen is on her 37 weeks and 5 days AOG when she experienced lumbosacral

pain and abdominal pain at the pubis symphysis in secondary of uterine contraction, on

the scale of 1-10 with 10 as the most painful, the patient rates 8. During experiencing

pain, the patient and her family decided to bring her to the Hospital and was admitted and

delivered her twin baby boy cephalic-cephalic via Normal Spontaneous Vaginal Delivery.

Delivered vaginal with episiotomy, where she was confined for 3 days in the ward and

was discharged together with the twin’s ambulatory accompanied by husband. She was

19
 diagnosed with preeclampsia and was treated with mechanical management with a blood

pressure of 140/110 mmHg.

Past health history:

Mrs. Teen have experienced chicken pox at 6 years old and also experience UTI

(Urinary Tract Infection) during her childhood. Patient received immunization so Patient

had instances of cough, fever and colds in related to change of weather and being

remedied with over-the-counter drugs and no hospitalization records.

Family History

According to the patient, her father has history of diabetes and hypertension and

her mother has a history of asthma. Her father also mentioned having a history of mild

stroke at their family’s side. The client’s mother side had history of twin gestation.

OB history

The client had her first menstrual period at the age of 11 and had regular

menstruation ever since. The usual length of her menstrual cycle is 4 days and does not

experiences any dysmenorrhea or pain during menstrual period. Her last menstrual period

was October 25, 2018. The patient does not use of any oral contraceptives but has used

condom once before. Her first pregnancy was successful where she delivered a twin baby

boy cephalic-cephalic, teenage pregnancy and no previous pregnancies and miscarriages.

C. Marjorie Gordon’s 11 Functional Health Problem

a. Health Perception - Health Management Pattern

I. Pre-Hospitalization

The client usually takes home remedies over the counter medicines for common illnesses

such as cough, colds and runny nose. Patient also believes in herbalists where they treat diseases

with herbal plants or for some, determines the cause of an illness through a series of ritual which

they believe. The client was not able to have an ultrasound but has completed a series of prenatal
20
check-ups for the whole 3 semesters of pregnancy in the out-patient department ward and also

religiously have taken prenatal medications such as folic acid and multivitamins with iron as

suggested during checkups. The client usually has lumbosacral pains often especially at night in

her last semester of pregnancy.

b. Nutritional / Metabolic Pattern

Patient said that she doesn’t eat salty food, “yung hindi maasim” translation: “the one

that’s not sour” as verbalized by the patient. Patient mentioned that during 7 months of

pregnancy, her appetite was increased and patient is taking multivitamins, iron, vitamin D and

calcium for her postpartum medications. The client prefers to take small amount of food while

confined but does not crave for a specific food.

c. Elimination Pattern

The patient defecates every other day. She has regular flow of urinations during

confinement but experiences pain while doing so because of the suture from the episiotomy

when she delivered her twins. The appearance of the urine is yellow and transparent which

indicates normal presence of urine.

d. Activity / Exercise Pattern

During the client’s pregnancy, she has enough energy for her desired activities because

most of these activities are watching tv, washing plates and these activities is not enough to drain

her energy. Like when she did not yet give birth, her exercises in the hospital when confined

includes walking 15-30 mins a day, sometimes three times a week to maintain her shape and be

healthy. When the client is alone at the bed she is thinking about her future how she can raise the

baby properly, sometime she perceive about her mistake in becoming the mother at the early age

but then realize that she become mother at the early age for some reason all she need to do was to

find out what it is she just accept everything and ready to take the challenges. Daily activities in

the morning includes taking a walk with her aunt or uncle at least 15-30mins a day sometimes 3

time a week and after that she goes home to fold some laundries.
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e. Sleep Rest Pattern

According to the patient her sleeping pattern is disturb for she mentioned that the

environment in the ward because of high/hot temperature in the room as resulting why she can’t

sleep at night. The client usually sleeps in the afternoon while confined and gets at least 5-6

hours of sleep a day.

f. Cognitive / Perceptual Pattern

The patient is oriented to the people around her, time, place she is and responses to

stimuli (verbally and physically). The client can speak and understand Tausug, Yakan and

Tagalog fluently. The educational attainment of the client is Grade 12 senior high graduate and

able to read and write effectively. The client shows clear vision as evidenced by good visual

acuity test. The assessment resulted a clear, bright, can see numbers and letters about 5 meters

away and was able to identify letters from numbers of a distance of 8 inches for assessing vision

at a near distance and 20 feet for assessing vision at a far distance with an evaluation of 20/20

which indicates normal signs of vision for far and near. When looking straight ahead, the client

can see objects at the periphery which was done by having the client sit directly facing the nurse

at a distance of 2-3 feet. The client demonstrates clear hearing as evidenced by clear, alert and

accurately responsive when her name was called. The client was able to hear ticking on the right

and left ear at a distance of 1 inch. The client said she always have a clear vision and hearing

during her non-pregnant days and the same with the client’s appetite and smell.

g. Self-Perception

The patient states that she believes her admission in a hospital will be best for her and the

delivery of her babies that would be also helpful for her fast recovery from delivery. The client is

able to express her feelings openly to her family especially to her husband about her discomforts.

She does not feel any anxieties after the delivery because she verbalized that she feels contented

seeing her whole family together as she went to labor where she really felt their love, support and

care which she did not have any problem experiencing stress. The client says that she feels

confident due to the environment. The client feels happy that she would be able to deliver her

22
twins in a hospital and looks forward in taking care of them growing up with his partner and

family beside her. According to the client, her weight decreased, got more darker in some areas

of the body and feel happier and according to her, nothing makes her angry.

h. Role Relationship Pattern

The client’s family structure is an extended family and is not married with his partner but

have been together for two years. There are 11 people living in their house including herself. She

belongs to a supportive family at times at problem, everyone talks about it where there are no

conflicts between them as they maintain a good communication with each other. The client is

well supported by the income of her parents and husband that has a business here in the city with

his family which are enough to sustain her family. Her parents and especially his husband share

his ideas when it comes to decision making. She doesn’t go to school anymore but she has circle

of friends who support and cares for her. The client verbalizes that she had difficulties in

handling the twins because it was her first time bearing a child and that she was still young when

she had them.

i. Sexuality-Reproductive Pattern

The client’s OB score is G1P1 (T1P0A0L2). The patient does not use of any oral

contraceptives but has used condom once before pregnancy. The patient had her first menstrual

cycle at the age of 11 years old. Her usual length of cycle is 4 days. She doesn’t experience any

dysmenorrhea. Her last menstrual period was October 25, 2018. She plans to do family planning

and attends seminars with his husband after giving birth because she doesn’t want to have kids as

of the moment after giving birth, not until the twins are able to go to school.

j. Coping Stress Structure

“Hindi ko sinasabi sa iba yung problema ko except sa asawa ko” translation: “I don’t tell

my problems to anyone except my husband” as verbalized by the client. The client used to smoke

cigarette before she was pregnant but stopped eventually for a month.

k. Values/Pattern

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 The patient’s religious affiliation is Islam, but she isn’t really religious but her husband

and her family are. She often goes to the mosque and prays. She believes that her religion is

important in her way of living but she is not very religious as she does not wear hijab. When

encountering health problems in her family, they usually go to what we call in layman’s term

“Panday” which is -a herbalist or someone who does rituals to potentially cure diseases.

d. Physical Assessment
Nursing Assessment in tabular form
PHYSICAL APPEARANCE
Body structure Complete parts of the body: hands feet, and other boy
systems, Eyes, ears, nose complete and symmetrical.
Posture erect, comfortably positioned, appears at stated age
(18 years old), has, well-groomed and nourished. Dresses
neat and appropriate for her age, gender season and
situation.
Mental status
Language Doesn’t have any problem in speaking. Normally speak
fluently, has pleasant tone and can speak properly without
using any accessory or assistance.
The quality and pace of speech are normal with no
exaggeration.
The client speaks Tagalog, Yakan and Tausug only.
Orientation Awake, alert and able to determine full name, location, and
date correctly.
Attention span Able to pay attention in answering questions in the
interview.
Memory intact, patient able to provide adequate history of
the recent and past happenings about her pregnancy.

Level of consciousness Patient is physically and verbally responsive and awake

and also able to have full awareness in answering
questions.
Patient is cooperative and answers the questions.
No personality or attitude disorder showed.
Motor function
Gross motor and balance walking gait Can’t stand alone.
Need s support in ambulation.
Standing on one foot with eyes closed Needs assistance in ambulating, not able to perform.
Heel toe walking Not able to perform.

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Toe or heal walking Not able to perform.
Integumentary
Skin Skin is pale.
Skin turgor is normal goes back within 2 seconds.
Hair Patient’s hair is well Distributed, color black.
Nails Pinkish, symmetrical with both hands and feet with no
breaks and drainages.
Able to return to normal color in less than 3 seconds.
Skull Rounded & cephalic, norm cephalic and consistent in
texture.
No nodules or masses noted.
Face Eyes, and nose symmetrical.

Eyes and vision

Eyebrows Fair hair, symmetrical, skin intact, black in color and well
distributed.
No presence of lice and nits.
Eyelashes Well distributed, no presence of lesions, nodules, lice and
nits in the eyelids.
Eyelids No presence of lesions, nodules, drainage, skin intact.
Bulbar conjunctiva Clear and pinkish
Transparent with capillaries and no visible discharges.
No indications of abnormal bulbar conjunctiva.
Palpebral conjunctiva Clear and pinkish
Transparent with capillaries and no visible discharges.
No indications of abnormal palpebral conjunctiva.
Sclera Appears white in color.
No water discharges.
No indications of abnormalities of the sclera.
Lacrimal gland, lacrimal sac, nasolacrimal No water discharges upon palpations.
duct
No visible edema and tenderness.
Cornea Normal corneal curvature, clear and bright.
Clarity and texture Cornea is clear and bright.
Cornea sensitive Reflexes are symmetrical and slightly displaced nasally to
the center of the pupils.
Both eyes systematically blink when touched trough a
cotton wisp from the back of the client.

25
Pupils Both are equal in size, round, color (black), reacts normally
to light: constricted when looking at near objects, dilates at
far object, actively converge when moving the penlight.
Visual fields Able to respond and see objects clearly at te periphery.
Both eyes were responsive and could see clearly.
Visual acuity Both eyes are able to identify letters, numbers & read
clearly 8 inches clearly at a distance of and 3-5 meters
away.
Ear and hearing
Auricles Peach pink to dark brown in color.
No unusual odor.
Both left and right auricles are symmetrical.
Presence of perforation between the earlobe and the helix.
No redness and tenderness and a symmetric size both left
and right
External ear canal Maintain well, clean.
Minimal presence of cerumen.
Hearing acuity test Able to hear in low voice.
Able to hear at a normal voice and responds accurately
when called.
Watch tick test Able to hear at a whispered voice, finger rub and is clear
and audible when interpreted by questions.
Able to hear a tick 10 inches away from the ear (left and
right ear).
No indication of hearing deficiencies.
Nose and sinuses
External Nose Symmetrical and straight.
No flaring, pink colored mucosa.
Nasal cavity No lesions, swellings and no tenderness.

Mouth and oropharynx Dry lips, and healthy gums.

Teeth No decayed tooth.
Teeth are healthy and well maintained.
Tongue and floor of the mouth Position in center.
Shows pink and whitish coating with prominent veins in
the floor of the mouth.
Tongue movement Able to control and move to different at sides.
Uvula Position from soft palate with no missing or unformed
landmarks.

26
 Gag reflex
Gag reflex Neck Able to swallow without any difficulties.
Head movement Systematic and follows motor functions.
Symmetric movement of head
Muscle strength No unexplained hypertrophy of neck accessory muscles.
Able to push against the hand when examined.
Lymph nodes No tenderness and palpable or visible cervical nodes during
palpation
Thyroid gland Thyroid no palpable.
Thorax and lungs No presence of swollen areas, masses and nodules.
No breaks or drainage in the area.
Posterior thorax Symmetry of left and right chest.
Spinal alignment No evidence of scoliosis, aligned.
Height of shoulders and hips are within the normal range.
Breath sound No presence unusual sound noted.
Client can breathe with no difficulty.
Anterior thorax No sign of abnormalities effortless respiration.
Abdomen
Abdomen Presence of striae and Linea Nigra and Striae Gravidarum.
Client experiences discomfort and minimal pain in the
lower part of the abdomen or at the umbilicus because of
the involution of the uterus.
Auscultation of bowel sound Bowel sounds are heard normally no swishing or hard
noises heard.
Extremities
Upper Extremities No unusual body odor.
Lower extremities No unusual body odor.
Muscle Symmetrical in size, length and width.
Able to move without restrictions.
Bones and joints Symmetrical in size, length and width.
Able to move without restrictions.
Fine motor test for upper extremities
Finger to nose test Able to touch the nose repeatedly and rhythmically.
Alternating supination and pronation of Able to rotate or move the hands and knees without any
hands on knees difficulties even at rapid pace.
Finger to nose and to the nurse finger Able to coordinate and performs rapidity.
Finger to finger Patient able to demonstrate accuracy and rapidity.

27
Finger to thumb Able to perform rapidity.
Pain
Pain sensation Able to identify the quality and location of pain.

Postpartum Physiologic and Psychological Changes Assessment

breast engorgement -is one of the most common difficulties encountered by

breastfeeding women, not all women become engorged. If an infant is feeding
well and the mother is not experiencing painful swelling, she may not recognize
the transition from colostrum to mature milk as engorgement.
Breast
During on the 1st day of our assessment which is her 1 st day of postpartum the
client report that she produces a yellowish fluid which is colostrum for the
lactation and in the 2nd day of assessment which is her 2nd day of her postpartum
the client report that started to secretes whitish milk which are mature milk
Contraction- contractions also help the placenta detach from the uterine wall.
After the placenta is delivered, uterine contractions close off the open blood
vessels where the placenta was attached. You may feel cramps, known as after
pains, as this happens.

Figure 12: The Placenta

Uterus

Figure 12. Physiology of delivery of the placenta Retrieved from https://www.google.com/search?

biw=1536&bih=674&tbm=isch&sxsrf=ACYBGNSxU9CVENBQiB9SWNFbsVO6wcqddw
%3A1571725318157&sa=1&ei=BqCuXeOeCcH6wQOiirSYDA&q=the+placenta+expulsion+adam&oq
=the+placenta+expulsion+adam&gs_l=img.3...7351.8134..8363...0.0..0.258.1084.0j2j3......0....1..gws-
wiz-1820060.0.000.

Bladder Women who have given birth have much higher rates of stress incontinence than
those who never have had a baby. Loss of bladder control may be caused by
pelvic organ prolapse (slipping down) that sometimes occurs after childbirth.
The pelvic muscles can stretch and become weaker during pregnancy or vaginal
delivery. If the pelvic muscles do not provide enough support, your bladder may
sag or droop.

Other causes of bladder control problems include the following:

 Pelvic nerves that control bladder function may be injured
during a long or difficult vaginal delivery.

28
  Delivery with forceps can result in injuries to the pelvic floor
and anal sphincter muscles.
 Prolonged pushing during a vaginal delivery also increases the
likelihood of injury to the pelvic nerves and the bladder control
problems that might follow.

Urinary Retention-Difficulty passing urine or urinary retention, as it is known,

is a common problem in the first day or two following childbirth, but with
careful management this should resolve without long term consequences.

A urinary tract infection (UTI) can cause swelling of the urethra to cause this
problem. During in the first day of our assessment the client mention that she has
an history of UTI(Urinary Tract Infection) also In women, vaginal childbirth can
sometimes damage nerve pathways that control going, The bladder may not
work right because there is a problem getting the messages from the brain to the
bladder and urethra through the nerve pathway.
First bowel movement may be quite painful if there’s an incision (episiotomy) or
a tear in your vagina. You may also have constipation or discomfort with bowel
movements for a few days after delivery.
Bowel+
During the second day of assessment the client reported that she doesn’t defecate
within two days after her delivery because of the pain she experienced. On the
next day the client reported that she already defecated.
Lochia Lochia -Lochia is the vaginal discharge you have after a vaginal delivery. It has
a stale, musty odor like menstrual discharge. Lochia for the first 3 days after
delivery is dark red in color. A few small blood clots, no larger than a plum, are
normal. For the fourth through tenth day after delivery, the lochia will be
waterier and more pinkish to brownish in color. From about the seventh to tenth
day through the fourteenth day after delivery, the lochia is creamy or yellowish
in color.

During our 1st day of our assessment the client report that she experienced a
moderate discharged of blood on her 1st day of postpartum

Types of Lochia
 Lochia Rubra: Lochia rubra occurs in the first 3-4 days after
childbirth. It is reddish in color-hence the term 'rubra'. It is made
up of mainly blood, bits of fetal membranes, decidua, meconium
and cervical discharge.

Figure 13: Lochia

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Figure 13. Lochia serosa. Lochia alba. Lochia rubra. Retrieved from https://www.google.com/search?
biw=1536&bih=674&tbm=isch&sxsrf=ACYBGNRoY0LiH_rDef6_3oZgzwEecAmDsw
%3A1571725023717&sa=1&ei=356uXa26K9WnoATBlbfgBw&q=lochia+color+table&oq=lochia+color+table&gs_l=img.3
...9876.10946..11091...0.0..0.420.1321.0j1j3j0j1......0....1img.......0i67j0j0i30j0i5i30j0i8i30j0i24.NmIqPTCelF8&ved=0ahU
Emotional
KEwjtpeT9m6_lAhXVE4gKHcHKDXwQ4dUDCAc&uact=5#imgrc=rp5xnnBXY4jN3M:
During our assessment from the client,
and is in the taking-hold phase which is
Response or start 2-4 days after delivery, we observe that the client starts to focus on the
Psychological newborn instead of herself and begins to actively participate in newborn care
changes
After pain- the client reports that she experiences intermittent cramping pain
and its similar to that accompany a menstrual period

Postpartum after her labor she also had pain because of the episiotomy and giving birth of
discomfort her twins.

Constipation patients did not defecate for two days after delivery.

B. Diagnostic Tests

Clinical chemistry result-Clinical chemistry refers to the biochemical analysis of body fluids.

Several simple chemical tests are used to detect and quantify different compounds in blood and

urine, the most commonly tested specimens in clinical chemistry.

30
Date: July 17 2019 11:28 PM

I. LDH- The lactate dehydrogenase (LDH) test looks for signs of damage to the body's

tissues. LDH is an enzyme found in almost every cell of your body, including your

blood, muscles, brain, kidneys, and pancreas. The enzyme turns sugar into energy. The

LDH test measures the amount of LDH in your blood or other body fluid.

II. SGOT/AST- The SGOT test is a blood test that’s part of a liver profile. It measures one

of two liver enzymes, called serum glutamic-oxaloacetic transaminase. This enzyme is

now usually called AST, which stands for aspartate aminotransferase. An SGOT test (or

AST test) evaluates how much of the liver enzyme is in the blood.

A.) HEMATOLOGY AND COAGULATION

Date: July 17, 2019, 11:59 PM

I. Hematocrit- A hematocrit test is part of a complete blood count (CBC). Measuring

the proportion of red blood cells in your blood can help your doctor make a

diagnosis or monitor your response to a treatment. A lower than normal

hematocrit can indicate: An insufficient supply of healthy red blood cells (anemia)

II. Red Blood cell- A red blood cell count is a blood test that your doctor uses to find

out how many red blood cells (RBCs) you have. It’s also known as an erythrocyte

count. The test is important because RBCs contain hemoglobin, which carries

oxygen to your body’s tissues. The number of RBCs you have can affect how

much oxygen your tissues receive. Your tissues need oxygen to function.

III. Hemoglobin- measures the amount of hemoglobin in your blood. Hemoglobin is a

protein in your red blood cells that carries oxygen to your body's organs and

tissues and transports carbon dioxide from your organs and tissues back to your

lungs.

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 IV. MCH- If a person is not feeling well and visited the doctor’s office or hospital,

one of the tests ordered is CBC or complete blood count. It checks various

components of the blood so as to give the doctor a general overview of the

patient’s health. The result of the test is used as a basis for diagnosing and treating

the patient’s condition.

V. MCV- this is a corpuscular volume. There are three main types of corpuscles

(blood cells) in your blood–red blood cells, white blood cells, and platelets. An

MCV blood test measures the average size of your red blood cells, also known as

erythrocytes

VI. MCHC- The mean corpuscular hemoglobin concentration (MCHC) test is a

standard part of the complete blood count (CBC) that is done during blood

analysis, and the MCHC value is used to evaluate the severity and cause of

anemia.

VII. RDW- The red cell distribution width (RDW) blood test measures the amount of

red blood cell variation in volume and size. You need red blood cells to carry

oxygen from your lungs to every part of your body.

VIII. White Blood Cell- A white blood cell (WBC) count is a test that measures the

number of white blood cells in your body. This test is often included with a

complete blood count (CBC). ... Sometimes, however, your white blood cell count

can fall or rise out of the healthy range.

IX. H Neutrophils- A normal (absolute) neutrophil count is between 2500 and 7500

neutrophils per microliter of blood.2 The neutrophil count may be high with

infections, due to increased production in the bone marrow as with leukemia, or

due to physical or emotional stress.

X. L Lymphocyte- A blood test that counts how many lymphocytes are in a person's

blood is called a B and T cell screen. In this test, the levels of the main types of

32
 white blood cells in the body are measured. Lymphocyte count is one part of a

larger whole blood test called a complete blood count (CBC).

XI. Monocytes- We are surrounded by germs in our environment that can have a

negative effect on us. They can cause us to be ill and give us harmful infections.

In severe cases, they can cost us our lives. When these germs enter our bodies, our

immune system views them as intruders that must be fought off. Our immune

system has a key component called the white blood cells, of which there are

several different kinds.

XII. Eosinophil- The eosinophil count measures the number of eosinophils in your

blood. The key is for eosinophils to do their job and then go away. But if you have

too many eosinophils in your body for a long time, doctors call this eosinophilia.

XIII. Platelet count- a test is included in a complete blood count (CBC), a panel of tests

often performed as part of a general health examination. Platelets are tiny

fragments of cells that are essential for normal blood clotting

XIV. MPV - The MVP test is blood test measures the average size of the platelets. The

test can help diagnose bleeding disorders and diseases of the bone marrow.

B.) URINALYSIS RESULT

Date: July 18, 2019, 10:11 AM

Urinalysis (UA) simply means analysis of urine. This is a very commonly ordered test

which is performed in many clinical settings such as physicians' offices, hospitals, clinics,

emergency departments, and outpatient laboratories. Urinalysis is a simple test that can

provide important clinical information, has a quick turn-around time, and is also cost

effective. The tests detect and/or measure several substances in the urine, such as byproducts

of normal and abnormal metabolism, cells, cellular fragments, and bacteria. Many disorders

may be detected in their early stages by identifying substances that are not normally present

33
in the urine and/or by measuring abnormal levels of certain substances. Some examples

include glucose, protein, bilirubin, red blood cells, white blood cells, crystals, and bacteria.

Physical, color, transparency and specific gravity= A lab technician examines the urine's

appearance. Urine is typically clear. Cloudiness or an unusual odor may indicate a

problem, such as an infection.

Blood in the urine may make it look red or brown. Urine color can be influenced by what

you've just eaten. For example, beets or rhubarb may add a red tint to your urine.

Ph - indicates the amount of acid in urine. Abnormal pH levels may indicate a kidney or

urinary tract disorder.

Glucose - Normally the amount of sugar (glucose) in urine is too low to be detected. Any

detection of sugar on this test usually calls for follow-up testing for diabetes.

Protein - low levels of protein in urine are normal. Small increases in protein in urine

usually aren't a cause for concern, but larger amounts may indicate a kidney problem.

Urobilinogen - normally present in the urine in low concentrations (0.2-1.0 mg/dL or <17

micromol/L). Bilirubin is converted to urobilinogen by intestinal bacteria in the

duodenum. Most urobilinogen is excreted in the feces or transported back to the liver and

converted into bile

Bilirubin - Bilirubin is a product of red blood cell breakdown. Normally, bilirubin is

carried in the blood and passes into your liver, where it's removed and becomes part of

bile. Bilirubin in your urine may indicate liver damage or disease.

Ketone - As with sugar, any amount of ketones detected in your urine could be a sign of

diabetes and requires follow-up testing.

Blood - Blood in your urine requires additional testing — it may be a sign of kidney

damage, infection, kidney or bladder stones, kidney or bladder cancer, or blood disorders.

Nitrite - The presence of nitrites in urine most commonly means there’s a bacterial

infection in your urinary tract. This is usually called a urinary tract infection (UTI).
34
 Leukocyte - Leukocytes, also known as white blood cells, are a central part of the

immune system. They help to protect the body against foreign substances, microbes, and

infectious diseases

C. Laboratory Results

CLINICAL CHEMISTRY RESULT

DATE LABORATORY RESULT REFERENCE NURSING SIGNIFICANCE AND

NURSING IMPLICATION
July 19, Blood urea The patient’s blood urea nitrogen is
2019 Nitrogen low. It should be necessary to
11:28 PM monitor urine output and report to
L 2.00 2.5-6.1 the doctor for any significant
changes.

Creatinine Patient’s result of low Creatinine

levels indicates preeclampsia. If the
kidneys are damaged
by preeclampsia, the creatinine
clearance value decreases because
the kidneys are filtering less
creatinine out of the blood. The
amount of kidney damage can be
estimated by the amount of
L 45.00 46-92 decrease in the creatinine clearance
value. Pregnancy is often a cause of
low creatinine levels, which should
return to normal after a woman has
given birth. Assess for renal
disorder, high protein diets, GI
bleeding, dehydration, drug
influences and monitor urine
output.

LDH H 306.00 120-246 Patient’s result of elevated LDH

levels is suspected to have
preeclampsia.

35
 SGOT/AST The SGOT test is a blood test. It
helps to determine how well the
liver is functioning by measuring
levels of aspartate aminotransferase
in the blood. Patient SGOT is
26 30-36 normal because it is in the normal
range it also indicates that the
patient liver is normal and no
disease or damage

July 19, Potassium Patient is suspected to have

2019 3:50 Hypokalemia due to Inadequate
PM potassium intake. Assess for the
following red flags: Neuromuscular
alerts: Skeletal muscle weakness,
especially in the legs, is a sign of a
moderate potassium loss. As
weakness progresses, the patient
develops paresthesia and leg
cramps. Deep tendon reflexes may
be decreased or absent and
respiratory muscles can become
paralyzed. Because potassium
affects cell function, hypokalemia
can lead to rhabdomyolysis;
L 3.30 mm/L 3.5-5.1 mmol/L Cardiovascular alerts: The patient's
pulse may be weak and irregular,
and he may have orthostatic
hypotension. Electrocardiograms
may show a flattened T wave, a
depressed ST segment, and a
characteristic U wave. Arrhythmias
associated with hypotension are
premature ventricular contractions
and ventricular tachycardia and
fibrillation. Watch for hypokalemia
in a patient taking digoxin,
especially if he's also taking a
diuretic; hypokalemia can
potentiate the action of the digoxin
and cause a toxic reaction.

HEMATOLOGY AND COAGULATION

DATE LABORATORY RESULT REFERENCE
NURSING SIGNIFICANCE AND
NURSING IMPLICATION

36
Hematocrit The Patient’s result is below normal. It
is necessary to assess fluid balance,
L 0.35 0.36-0.46 respiration status, decreased in RBC:
assess fatigue, monitor vital signs,
dietary deficiencies, (protein, iron in
Red Blood cell food) and locate hemoglobin is due to
loss of blood during delivery. Patient is
4.2 4.0-5.5 suspected to have anemia due to low
levels of Hematocrit.

Hemoglobin Normal hemoglobin values are related

to the person's age and sex. Normal
values may vary slightly between test
systems, and which groups of doctors
4.2 4.0-5.5
have determined "normal values" for
their group of patients, in this test
patient’s Hemoglobin in within normal
range.
MCH 28.0-33.0 MCH levels refer to the average
32.2 amount of hemoglobin found in the
red blood cells in the body, in this test
patient is in the normal range.
MCV An MCV blood test measures the size
of your red blood cells. If blood cells
are too small or too large, it may
indicate a blood disorder, in this test
84.7 78-102 patient is in normal range which is
means patient doesn’t have any blood
disorder

MCHC H 38.0 32.0-35.0 MCHC stands for mean corpuscular

hemoglobin concentration. It’s a
measure of the average concentration
of hemoglobin inside a single red
blood cell. In this test patient exceed in
normal range, it can also occur in
conditions where red blood cells are
fragile or destroyed, leading to
hemoglobin being present outside of
the red blood cells. Patient is suspected
to have Autoimmune hemolytic
anemia or a condition that occurs
when your body develops antibodies
that attack your red blood cells.

37
RDW A test to determine red cell distribution
width shows variation in the size and
volume of a person's red blood cells.
Results are above the normal range,
H 18.4 11-14 this is known as a high RDW count.
The patient is suspected to have
Macrocytic anemia. This is
characterized by red blood cells that
are larger than average. Macrocytic
anemia is linked to a deficiency of
folate or vitamin B-12.
White Blood Cell 9.7 5.0-10.0 Patient is suspected to have
leukocytosis due to an increase in the
number of white cells in the blood.
The increase in white blood cells is
associated with an increased risk of
inflammation, maternal fever
intrapartum and
neonatal infectious morbidity, but not
fever postpartum. Plasma fibrinogen
and ESR remain elevated during the
first week postpartum. It is necessary
to assess

DIFFERENTIAL COUNT

H Neutrophils The increase in the number of the

neutrophils is due to decrease the activity of
their apoptosis mechanism during
pregnancy. During labor, there is further
93 40-70 delayed in the neutrophil apoptosis which
lead to further increase of the white blood
cell count after normal vaginal delivery
Because the white blood cell and neutrophil
counts are physiologically high during early
puerperium, therefore the white blood cell
count is not specific for detection of
postpartum infection.
L Lymphocyte L5 20-45 Patient is suspected to have leukocytosis due
to an increase in the number of white cells in
Monocytes 2 0-10 the blood. The increase in white blood cells
Eosinophil is associated with an increased risk of
0 0-6 inflammation, maternal fever intrapartum
and neonatal infectious morbidity, but not
Basophil fever postpartum. Plasma fibrinogen and
ESR remain elevated during the first week
postpartum. It is necessary to assess
0 0-1 Patient is suspected to have leukocytosis due
to an increase in the number of white cells in
the blood. The increase in white blood cells
may indicate presence of infection.
Platelet count 224 150-350 The patient’s platelet count is elevated

38
MPV The MVP test is blood test measures the
average size of the platelets. The test can
10 8-12 help diagnose bleeding disorders and
diseases of the bone marrow. Based from the
result test of the patient, there is no
significant
BLOOD TYPING
ABO blood group A
Rh type (+)

39
 URINALYSIS RESULT

NURSING SIGNIFICANCE AND

DATE LABORATORY RESULT REFERENCE NURSING IMPLICATION
JULY Physical Physical result is normal because the
19, normal color is pale yellow or yellow
Color = YELLOW YELLOW
2019 and the transparency is normal
Transparency = Clear CLEAR because it’s clear and the gravity is
10:53
also normal because it is in the
PM Specific gravity = 1.004 1.004 therapeutic level (1.004)

Chemical examination
pH =7.00 pH level is normal and within the
6.70 4.6-8
normal range.
Glucose = NEGATIVE NEGATIVE NEGATIVE The results are normal because the
result is negative which means
Protein = NEGATIVE NEGATIVE NEGATIVE
diabetic is negative
Urobilinogen=
NEGATIVE NEGATIVE
NEGATIVE
Bilirubin = NEGATIVE NEGATIVE NEGATIVE
Ketone = NEGATIVE NEGATIVE NEGATIVE
Blood =NEGATIVE NEGATIVE NEGATIVE
Nitrite= NEGATIVE NEGATIVE NEGATIVE
Leukocytes=
NEGATIVE NEGATIVE
NEGATIVE

40
 D. Drug Study
Drug Mechanism of action Indication Contraindication Side effects Nursing Responsibilities

Generic Cefuroxime, like the Treatment of the Contraindicated in: CNS: seizures (high  Assess patient for signs
name: penicillin, is a beta- following infections Hypersensitivity to doses). and symptoms of
lactam antibiotic. By caused by susceptible cephalosporins; GI: Pseudomembranous infection prior to and
Cefuroxime
binding to specific organisms: Serious colitis, diarrhea, throughout therapy.
penicillin-binding Respiratory tract hypersensitivity to cramps, nausea,  Before initiating therapy,
proteins (PBPs) infections, Skin and penicillin. vomiting. obtain a history to
Brand name:
located inside the skin structure Derm: rashes, urticaria. determine previous use of
Zinacef Use Cautiously in:
bacterial cell wall, it infections, Bone and Hemat agranulocytosis,
Renal impairment and reactions to
inhibits the third and joint infections (not bleeding (increase with
(dose adjustments penicillins or
last stage of bacterial cefaclor or cefprozil),
necessary); cefotetan and cefoxitin), cephalosporins. Persons
Classificatio cell wall synthesis. Urinary tract
n: History of GI eosinophilia, hemolytic with a negative history of
Cell lysis is then infections (not
disease, especially anemia, neutropenia, penicillin sensitivity may
Cephalospor mediated by bacterial cefprozil). Meningitis,
colitis. hrombocytopenia.
in cell wall autolytic gynecologic still have an allergic
enzymes such as infections, and Lyme Local: pain at IM site, response.
autolysins. It is diseases. phlebitis at IV site.  Observe patient for signs
Dosage: possible that Misc: allergic reactions and symptoms of
Unlabeled Uses: In
cefuroxime interferes including anaphylaxis anaphylaxis (rash,
50g 1 tab combination with
with an autolysin and serum sickness, pruritus, laryngeal edema,
other agents in the
inhibitor. superinfection. wheezing). Keep
management of
Mycobacterium avium thromepinephrine, an
Frequency:
complex infections. antihistamine, and
BID resuscitation equipment
close by in the event of an
anaphylactic reaction.
Route:  Advise to complete
Oral medication for 1 week as

41
ordered.

42
 Drug Mechanism of action Indication Contraindication Side effects Nursing Responsibilities
Generic name: Short-term treatment of GERD, erosive Contraindicated Dizziness,  Assess vital signs
active duodenal ulcer; acid secretion with headache,  Check for abdominal
Omeprazole
First-line therapy in gastric mucus hypersensitivity asthenia, nausea, pain, emesis diarrhea
treatment of heartburn and bicarbonate to omeprazole or, vomiting, or constipation
or symptoms of gastro production, its components: diarrhea,  Evaluate fluid intake
Brand name: esophageal reflux creating use cautiously constipation,  Instruct patients to
Omepron disease protective during pregnancy abdominal pain, swallow capsuled or
coating on and lactation. back pain, tablet s whole and no
(GERD) \; Short-term
gastric mucosa cough, upper to chew or crash them
treatment of active
Classification: and easing respiratory tract  Health teaching to the
benign gastric ulcer;
discomfort from infection, rashes
GERD, severe erosive patient specific for
Proton pump inhibitor excess gastric
esophagitis, poorly omeprazole.
acid.
responsive symptomatic
Dosage: GERD; Long-term
therapy: Treatment of
40 mg pathologichy
persecretory conditions
(Zollinger-Ellison
Frequency: syndrome, multiple
adenomas, systemic
Now
mastocytosis);
Eradication of H. pylori
with amoxicillin or
Route: metronidazole
IVTT

Drugs Mechanism of action Indication Contraindication Side effects Nursing Responsibilities

43
Generic name: Acts directly on Indicated in Contraindicated in:  Chest pain  Give oral drug with
vascular smooth hypersensitivity  Fast heart rate food to increase
Hydralazine  Hypersensitivity
muscle to cause and eclampsia.  Headache bioavailability (drug
vasodilation,  Some products  Nausea should be given in a
primarily arteriolar, containing  Vomiting
Brand name: consistent
decreasing peripheral tartrazine and  Diarrhea
relationship ti
Apresoline resistance. Maintains should be  Loss of appetite
ingestion of food for
or increase renal and avoided in
cerebral flow. consistent response to
patients with
Classification: therapy)
known
 Discontinue if bloody
Vasodilator intolerance
dyscrasias occur

Dosage:
5 mg

Frequency:
PRN for BP >
160/90 mmHg

Route:
IVTT

Drugs Mechanism of action Indication Contraindication Side effects Nursing Responsibilities

44
Generic name: Stimulates Central Management Hypersensitivity  Dry mouth  Assess blood pressure
alpha-adrenergic of all grades to clonidine, sick  Drowsiness and apical pulse before
Clonidine
receptors to inhibit of sinus syndrome.  Dizziness initial dose. If systolic
(OMIT )
sympathetic cardio hypertension.  Lightheadedness blood pressure is
accelerator and  Irritability <90mmhg or pulse is
vasoconstrictor  Tiredness
Brand name: <60 bpm, withhold drug
centers.  Mood changes
and notify physician.
Catapres  Sleep problems
 Check for edema in feet,
(insomnia or nightmares)
 Headache legs daily
 Monitor input-output
Classification:  Ear pain
 Fever ratio: check for
Centrally- acting decreasing output
 Feeling hot
drugs  Note allergic reactions:
 Constipation
 Diarrhea fever, rash, pruritus,
Dosage:  Stomach pain urticaria, and oedema
 Increased thirst
75 g 1 tab  Impotence
 Cold symptoms such as
runny or stuffy nose
Frequency:  Sneezing
PRN for BP >  Cough or sore throat
150 / 90 mmHg

Route:
Oral

45
Drugs Mechanism of action Indication Contraindication Side effects Nursing Responsibilities

46
Generic name: Calcium supplement is  Dietary Contraindicated with CNS: syncope,  Monitor VS especially
essential for bone supplement allergy to calcium, renal tingling BP and PR
Calcium Carbonate
formation and blood when calcium caculi, hypercalcemia,  Obtain ECG result
CV: cardiac arrest,
coagulation. It is also intake is ventricular fibrillation  Asses for heartburn,
arrythmias,
used as a replacement inadequate during cardiac indigestion, abdominal
Brand name: bradycardia
of calcium in resuscitation. pain
 Treatment of
Tums deficiency states. GI: constipation,  Monitor serum calcium
calcium Use cautiously with
nausea, vomting before treatment
Antacid neutralizes or deficiency renal impairement.
reduces gastric acidity,  Prevention of  Assess for nausea and
Classification: GU: calculi,
increasing the pH, or hypocalcemia hypercalciuruia y vomiting, anorexia,
Antacid, Calcium
reversibly reduce or thirst, severe
supplement Local: phlebitis
block the secretion of constipation
acid by gastric cells to (IV only)

Dosage: reduce acidity in the

stomach.
1capsule

Frequency:
OD

Route:
Oral

Drugs Mechanism of action Indication Contraindication Side effects Nursing responsibilities

47
Generic name: Stimulates CNS alpha Management  Hypersensitivity Dizziness,  Fluid retention and expanded volume
adrenergic receptors, of moderate to  Active liver lightheadedne may cause tolerance to develop within
Methyldopa
producing a decrease severe disease ss, drowsiness, 2-3 months after initiation of therapy.
in sympathetic hypertension.  Oral suspension headache, Diuretics may be added to regimen at
outflow to the heart, contains alcohol stuffy nose, this time to maintain control.
Brand name: kidneys, and blood and weakness.
and bisulfides  Dosage increase should be made with
Aldomet vessels. Result is and should be the evening dose to minimize
decreased BP and avoided in drowsiness.
peripheral resistance,
patients with  Infuse slowly if IVT.
Classification: a slight decrease in
known  Check BP and pulse at least 30 minutes
heart rate, and no
Antihypertensi intolerance until stable
change in cardiac
 Monitor intake and output of fluids
ve output.  Monitor fluid and electrolyte balance
 Report symptoms of mental depression
(anorexia. insomnia and withdrawal)
Dosage:
 Warn patient that drug may impair
250mg mental alertness, particularly at start of
therapy. Once daily dose at bedtime
minimizes daytime drowsiness.
Frequency:
BID

Route:
Oral

Drugs Mechanism of action Indication Contraindication Side effects Nursing responsibilities

Generic Inhibits reuptake of  Moderate to  Hypersensitivit Pruritus,  Monitor respiratory status. Withhold drug
48
name: seretonin and moderately y to drug, its agitation, and contact prescriber if respirations
epinephrine in CNS. severe pain. components, or anxiety, become shallow or slower than 12 bpm
Tramadol
 Adults: In rapid opioids constipation,  Assess patient’s response to drug 30
titration, 50 to  Acute diarrhea, minutes after administration
100 mg PO q 4 intoxication hallucination,  Tell patient drug works best when taken
Brand nausea,
to 6 hours PRN with alcohol, before pain becomes severe
name: tremor,
(not to exceed sedative-  Inform patient (and significant other as
Ultram vomiting, and appropriate) that drug may cause
400 mg/day or hypnotics,
diaphoresis. respiratory depression if used with
300 mg/day in centrally acting
patients older analgesics, alcohol. Recommend abstinence.
Classificati  Instruct patient to immediately report
than 75). In opioid
on: seizure
gradual analgesics, or
 Tell patient drug interacts with many
Opiod titrations, psychotropic
ahonist, common over-the-counter drugs and
initially 25 mg agents
Analhesic  Physical opioid herbal remedies. Instruct him/her to
PO daily;
dependence consult prescriber before taking these
increase by 25
products
mg/day q 3
Dosage:  Inform patient that drug can cause
days to 100
physical and psychological dependence.
50 mg mg/day PRN.
Urge him/her to take it only as prescribed
Alternately, 100
and needed.
mg PO
(extended
release) up to a
maximum of
300 mg daily.

49
 Drug Mechanism of Indications Contraindications Side effects Nursing responsibilities
action
Generic name: Depresses CNS, Treatment and Hypersensitivity to any Although  monitor vital signs
blocks peripheral prevention of component of the incidence is not especially blood
MgSO4 pressure
neuromuscular hypomagnesemia; formulation, heart block, known, the
(Magnesium  monitor input and
transmission, prevention and myocardial damage, IV following side
Sulfate) output
produces treatment of use for effects may
anticonvulsant seizures in severe preeclampsia/eclampsia occur:  instruct client to:
effects; decreases preeclampsia or during the 2 hours prior  drink plenty of fluids
Brand name: amount of eclampsia, to delivery.  diarrhea  slowly get up from
acetylcholine pediatric acute  upset the sitting position
Epsom Salt stomach
released at end-plate nephritis;
 confusion
by motor nerve treatment of
 dizziness
Classification: impulse. cardiac
 lightheaded
arrhythmias
Anticonvulsant Promotes movement ness
(VT/VF) caused
of calcium,  fast, slow,
by
potassium, and or irregular
hypomagnesemia. heartbeat
Dosage: sodium in and out of
cells and stabilizes  low blood
4 grams excitable membranes. pressure
 muscle
weakness
Frequency:  skin
infection
Now after
soaking
 sleepiness
Route:
Slow IVTT

50
 Drug Mechanism of action Indications Contraindications Side effects Nursing responsibilities
Generic name: Multivitamins with They are Hypersensitivity to Common side  Advise patient to take medicine as
iron are used to used to treat any components of effects may prescribed.
Multivitamins include:
provide vitamins and iron or the formulation;  Caution patient to make position
with Iron
iron that are not taken vitamin hemochromatosis;  Constipation changes slowly to minimize
in through the diet. deficiencies hemosiderosis  Diarrhea orthostatic hypotension.
caused by  Nausea  Instruct patient to avoid concurrent
Brand name:
illness,  Vomiting
use of alcohol or OTC medicine
Fero-folic 500 pregnancy,  Heartburn
 Stomach without consulting the physician.
poor  Advise patient to consult physician
nutrition, pain, upset
stomach if irregular heartbeat, dyspnea,
Classification: digestive
 Black or swelling of hands and feet and
Electrolyte disorders,
dark-colored hypotension occurs.
supplement and many
stools or  Inform patient that angina attacks
other
urine may occur 30 min. after
conditions.  Temporary administration due reflex
Dosage: staining of
tachycardia.
the teeth
1 tablet  Encourage patient to comply with
 Headache or
additional intervention for
 Unusual or
unpleasant hypertension like proper diet,
Frequency: taste in your regular exercise, lifestyle changes
OD mouth and stress management.

Route:
Oral

Drug Mechanism of action Indications Contraindications Side effects Nursing responsibilities

51
Generic name: This medication is a Potassium You should not use Common side  Use cautiously in
mineral supplement chloride is used to potassium chloride if you effects may patients with cardiac
KCl
used to treat or prevent or to treat have high levels of potassium include: disease and in those
(Potassium
Chloride) prevent low amounts low blood levels in your blood with renal
of potassium in the of potassium (hyperkalemia), or if you  Nausea,
vomiting, impairment
blood. (hypokalemia). also take a "potassium-  Make sure powders
sparing" diuretic. such as diarrhea
Brand name:  Gas, are completely
amiloride, spironolactone, or
Kalium Durule stomach dissolved before
triamterene.
pain administering
 The  Know that enteric-
Classification: appearance coated tablets are not
if a recommended
Electrolyte
potassium because of increased
supplements
chloride potential for GI
tablet in bleeding and small
Dosage: your stool bowel ulcerations.
 Know that drug is
1 tab often used orally
with potassium-
wasting diuretics to
Frequency:
maintain potassium
TID for 3 days levels.

Route:
Oral

Drug Mechanism of action Indications Contraindications Side effects Nursing responsibilities

52
 Generic name: It blocks the • Spasm in the Myastheniagravies, Common side effects  Hyoscine may make
muscarinic receptors genitourinary megacolon, may include: a patient dizzy or
Hyoscine-N- found on the smooth hypersensitivity to
butylbromide tract  Constipation cause vision
muscle walls which • Spasm in the drug contents, narrow
 Decreased problems; use
means it blocks the angle glaucoma,
gastrointestina sweating caution engaging in
action of acetylcholine prostate hypertrophy
Brand name: on the receptors found l tract with urinary retention,  Mouth, skin, eye activities requiring
within the smooth • Spasm in the mechanical stenosis in dryness alertness such as
Buscopan biliary tract
muscle of the the GI tract,  Blurred feeling driving or using
gastrointestinal and • Colic tachycardia.  Bloating machinery.
urinary tract and thus  Dysuria  Instruct the client to
Classification:
reduces the spasms and  Nausea or avoid or minimize
Antispasmodics contractions. This vomiting drinking alcoholic
relaxes the muscle and
 Lightheadedness beverages.
thus reduced the pain
 Headache  The medication
Dosage: from the cramps and
spasms.  Weakness should be stored at
1 ampule room temperature
away from light and
moisture.
Frequency:  Hyoscine should not
Now then q/o x 2 be placed in the
refrigerator.

Route:
IVTT

E. Nursing Care Plan

Cues/Manifestations Nursing Diagnosis Plan of Care Intervention Implementation Evaluation

53
Subjective: Within a week, the client -Monitor patient’s vital -Monitor vital signs  The goal is
“Masakit lang talaga Altered Comfort: would be able to: signs every 4 hours. every 4 hours. met.
yung tahi ko Acute pain related to Rationale:
paminsan” as surgical incision of  Observe normal To obtain baseline data -Observe the pain  Vital signs
verbalized by the episiotomy range of vital signs from mild to severe were settled
patient. as follows: 36.5- -Assess the quality of and note the within normal
Reference: 37.5 °C, pulse of pain & location. location. range.
Translation: “My Doenges, et al. 60-70 bpm, blood Rationale: to direct
wound is very (2012), Diagnosis, pressure of 110- Intervention. -Explicate to the  The client
painful at times” Prioritized 140/60-90 mmHg & client that an exhibited signs
Interventions and respiratory rate of -Give explanation and episiotomy puts you of decrease in
“Mahapdi lang talaga Rationales: Nurses 15-20 respirations reason of pain and its at risk of fourth- pain and
paminsan” as Pocket Guide, 14th ed. per minute. expected duration. degree vaginal discomfort in
verbalized by the  Exhibit signs of Rationale: to decre- tearing, which the surgical
patient. decrease in pain and ase sense of control extends through the incision area.
discomfort in the & anxiety related anal sphincter and
Translation: “The surgical incision to the surgical inci- into the mucous  The client
wound is very area from the sion of the patient. membrane that lines started to
painful sometimes” patient. the rectum. follow
 -Follow prescribed -Administer prescribed prescribed
Objective: pharmacologic treatments and -Give medications pharmacologic
T- 36.0 °C regimen. medications. on the right time regimens.
P- 122 beats/min Rationale: to be and frequency as
R- 23 breaths/min  -Reduce level of able to reduce pain. prescribed by the  The client has
BP- 100/70 mmHg infection in the doctor. demonstrated
surgical incision -Encourage Sitz bath for the use of
site. the first 24 hours. -Instruct patient to relaxation
Rationale: to reduce maintain clean, dry technique.
 -Demonstrate use of discomfort & edema clothes after the
relaxation skills. Sit’z Bath. Mention
-Give perineal care. to the client that
Rationale: to be moisture harbors
able to reduce ede- microorganisms.

54
 ma, level of infec-
tions, vulvar irrita- -Teach patient to
tions & discomfort. wash and clean
properly the surgical
incision properly.

-Change pad as
needed.
-Perineal care

-Discuss promotion
of perineal care in
relieving comfort
and infections.

Cues/Manifestations Nursing Diagnosis Plan of Care Intervention Implementation Evaluation

55
Subjective: Sleep deprivation After 8 hours patient  Monitor the sleeping  Encourage the After 8 hours of
related to should: pattern of the patient. client to read or nursing
“di ako makatulog ng
uncomfortable drink warm milk intervention, goal
maayos, mainit kasi” Rationale: It’s
sleeping because it can help was met.
as verbalized by the important to monitor  Patient was
environment  Patient must to fall sleep.
patient. the sleeping pattern able to project
(NANDA achieve sufficient of the patient so that
sleep a well-rested
DOENGES pg. you are able to track
 -Encourage the appearance
Translation: I can’t 770)  Must be able to improvements
patient to find her  Verbalized
sleep well because of maintain 7-8 regarding sleep feeling rested
comfortable
the hot room hours of sleep efficiency and  Goal was met
position preferably
temperature as continuity. the following
 Improved sleep the side lying
verbalized by the day patient
and rest pattern  Provide relaxation position
patient. verbalized she
techniques like
 -Encourage the was able to
breathing exercise
client to avoid sleep for 7
Objective: Rationale: drinking coffee of hours
Relaxation alcohol.
-Restless techniques can help
 -Provide comfort
-Irritable the patient quiet her
measure like back
mind and calm her
-Noisy environment rub, sponge bath,
body
cleaning and
 Encourage basic and straightening
regular exercise sheet.
during the day like
 -Simple exercise
walking and Kegels
like sitting and
Rationale: Building lying-in again in
muscles has shown to different position,
improve the quality it can help to aid
of sleep because it in stress control
has an effect in the and release of
56
 circadian rhythm or energy and remind
body clock not to do exercise
at bedtime because
 Monitor the fluid
it may stimulate
intake
rather than relax
Rationale: The client and actually
patient should stay interfere with
hydrated because sleep.
dehydration can lead  Provide proper
to nocturnal leg ventilation
cramps that may keep  Monitor the
you awake patient’s bed time
and wake up time
for a week or so to
be able to know
and understand her
sleeping pattern.

Cues/Manifestations Nursing Diagnosis Plan of Care Intervention Implementation Evaluation

Subjective: Deficient After a few days  Establish an environment  Provide health  The patient
knowledge related of nursing of mutual trust and teaching to the expresses
 “Nahihirapan to neonatal care. patient. For need to
intervention, the respect to enhance
ako alagan sila example: improve her
57
 dalawa kase patient will be learning.  Alternate understanding
sabay sila able to: breastfeeding. of neonatal
umiiyak at Rationale: Achieving  Time care.
hinde ko alam  Express need rapport is especially management in  The patient
sino unahin ko” to improve important in light of the breastfeeding. sets realistic
her maternity patient’s short  Encourage learning
understanding length of stay. family to help goals.
Translation: of neonatal the mother in  The patient
care.  Assess the patient’s level
 “I have a hard taking care of expresses
 Set realistic of knowledge.
time taking care twins, for understanding
learning goals example: of neonatal
of them both for
because they Rationale: To determine  while the mother care.
developing whether the patient is sleeping the  The patients
cry at the same competence
time and I don’t requires basic relatives would demonstrate
in caring for information or look after the ability to care
know which neonate.
one to tend to reinforcement of twins. for neonate,
 Demonstrate  Educate the including
first” previous learning.
ability to care mother the comfortably
for neonate  Select teaching strategies importance of holding and
Objective: independently appropriate for the breastmilk in playing with
 Restless or minimal patient’s individual infant neonate,
 Irritable assistance. learning style, such as development. bottle feeding
 Loud  Express one on one discussion  Influence the or breast
 Big dark circles intention to and demonstration, mother how feeding and
around the eyes adjust to give bath burping
attending unit-based
 Frequent asking lifestyle to to the twin. neonate at
neonatal care class, or
question. accommodate  Educate the appropriate
viewing audiovisual
 Uncomfortable arrival of mother how intervals,
neonate. materials.
position while to put the caring for
breastfeeding.  Family Rationale: Choosing an baby to sleep. umbilical
members will approach that best serves  And maintain cord site,
take active the patient increases the more on providing
role in caring infant care. scalp care and
chance for successful
for neonate.
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 learning. bathing and
diapering the
 Encourage family twin neonates.
members to become  Family
involved in the care of members
the neonate. demonstrate
willingness to
Rationale: To promote take active
family unity and bonding role in
with the neonate. neonatal care.

Cues/Manifestations Nursing Diagnosis Plan of Care Intervention Implementation Evaluation

Subjective: Ineffective At the end of the  provide health  demonstrate the proper After the 8-hour shift,
breastfeeding 8-hour shift, the teachings about positioning of the baby the patient was able to
The patient breastfeeding by using a baby doll gain knowledge about
related to limited patient will be
verbalized “Nanga- (Rationale: for the proper way of
maternal exposure. able to:
ngalay na yung effective breast breastfeeding and was
kamay ko! feeding)  show a picture of able to breastfeed her
- proper proper breastfeeding, babies with the proper
Translation: “My  Breastfeed her support during
positioning techniques.
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hands are sore!” babies the - proper sucking breastfeeding, and
proper way of the babies to cleaning of breast
“May alam ako sa the nipple
breastfeeding pero - breastfeed every
konti lang. 2 to 3 hours  let the patient
 Clean her demonstrate or
breasts  clean breasts using verbalize proper
properly while only water and breastfeeding
Translation: “I only
observing cotton (Rationale:
know a little about
aseptic soap contains
breastfeeding.”  let the patient perform
technique chemicals that are
proper breastfeeding
harmful for the
with her babies
babies)
Objective:
 Hold and
position the  support the baby’s the patient re-demonstrates
 uncomfortable
babies head, neck, and the proper way of handling
position
properly back during the baby
 kept on changing breastfeeding
positions (Rationale: to
ensure the comfort
 restless and safety of the
babies)

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F. Discharge Plan

Before Mrs. Teen was discharged, we were able to provide her some important health

teachings that she can use in her everyday life as a new teenage mother having twins. These are

the following health teachings:

Exercise –Mrs. Teen should limit the number of stairs she climbs to one flight per day for the

first week at home. She should continue doing muscle-strengthening exercises such as abdominal

crunches, aerobics activity and Kegel exercises to strengthen the muscles of the pelvic floor.

These muscles are weakened by the birth process and should be exercised right after birth.

However, it may be hard to do these exercises soon after her delivery. She should do as many as

she can, and the tone will slowly return.

Rest –Mrs. Teen should have at least one rest period each day while her baby is asleep and as

much a possible try to get a good night’s sleep. If she has other family members dependent on

her, explore the possibility of another family member or a person from a community health

agency to relieve her so she can rest.

Hygiene –Mrs. Teen may either take a hot Sitz bath to relieve perineal pain or hot showers. She

should continue to apply any perineal cream or ointment. She should be reminded to cleanse her

perineum from front to back after voiding to prevent fecal contamination. Any perineal stitches

will be absorbed within 10 days.

Work – Mrs. Teen should avoid heavy work such as lifting or straining for at least the first three

weeks after birth. It is important to know what she considers as heavy work. If she plans to do

much, help her to modify her plans. It is advised that a woman should not return to an outside job

for at least three to six weeks not only for her own health but also to create close bonding with

her new born.

Coitus – Coitus or sex is safe as soon as a Mrs. Teen lochia has turned to alba and if her

episiotomy is already healed (usually the first week after birth). Vaginal walls may not be as

thick as before because pregnancy hormones have not yet completely returned to supply

lubrication. Use a lubricating jelly to aid comfort during intercourse. The couple should avoid

61
sexual intercourse in the 4–6 weeks following vaginal delivery. Having intercourse too early,

especially within the first 2 weeks, increases the risk of postpartum hemorrhage or uterine

infection.

Diet – Mrs. Teen needs between 1,800 and 2,200 calories each day. If she is breastfeeding, she

will need up to 500 more. If she’s underweight, she needs to work out more than 45 minutes each

day, since Mrs. Teen is breastfeeding more than one infant, that number should be higher. Eat a

variety of healthy foods and include choices high in fiber and iron. These include fruits, dark

leafy vegetables, whole grains, protein, and low-fat dairy products. When breastfeeding, the

woman doesn’t need to avoid foods she normally eat because they are spicy. Amniotic fluid (the

fluid around your baby in the womb) takes on the flavors of the food the mother eats, such as

garlic and spices. After the baby is born, he or she will continue to enjoy a variety of flavors in

your breast milk. The exception to eating normally is that you should avoid fish that contains

mercury, such as tuna steaks, canned albacore tuna, swordfish, tile fish, and king mackerel. Drink

enough liquids so that you don't feel thirsty and your urine is light yellow in color.

Medication – If Mrs. Teen is breastfeeding and plan to take any kind of drug, whether

prescription or over-the-counter, be sure to discuss with the doctor or child's pediatrician. While

many medications are safe during breastfeeding, a few can have serious side effects for you

and/or your baby and they are not necessarily the same ones that were most concerning during

pregnancy. The following medicines are prescribed to Mrs. Teen:

 Multivitamins with iron: If your provider prescribes this for you, begin taking it after

the first normal bowel movement. Given PO, BID

 Hydralazine – 5mg PRN for BP > 160/90 mmHg
 Calcium + Vitamin D – PO BID
 Cefuroxime – 500g PO BID
 Lozartan – 500 mg PO OD
 Clonidine – 75 mg 1 tab BP > 150/90 mmHg
 Omeprazole – 40g 1 tab

Contraception – If desired, Mrs. Teen should begin a contraception measure with the initiation

of coitus. if she wants an intrauterine device, this may be fitted immediately after birth or at her

first post partal check-up. Mrs. Teen can also use Pills as a contraception one example is the

62
twenty-one-day pill packs which contains 21 active pills. If the mother is planning on using these

pills, take one pill every day for 21 days. Then, for seven days, don’t take any. This is when

you’ll get your period.

Follow-up check-ups – Mrs. Teen should notify her primary care provider if she notices an

increase not a decrease in lochial discharge. Should go back for a follow up check-up after 2

weeks or on August 7,2019

III. EVALUATION

The researchers were able to conduct a case study about a primigravida teenage mother

who delivered via normal spontaneous vaginal delivery to an alive twin full-term baby. The

researchers performed physical examination and interviewed the client of her past history and

present illness and family history. The researchers also performed the Gordon’s 11 functional

health pattern. The patient states that she still feels pain in her genital area from her wound due to

episiotomy. The researchers gave the client a health teaching about proper hygiene and time

management that will help her to balance her time to take care of her twins. The patient was able

to verbalize understanding the importance of taking the medicine on time.

We the case study group was able to gain more knowledge about this condition through

case study where in the group gathered and researched more information regarding the patient’s

situation, such as clinical manifestation of the disease, diagnostic procedures done and the

nursing management and intervention that was taken. The case study group were all able to get

the information and assessed the patient well without any problems applying the therapeutic

techniques of communication to obtain the patients trust and for her to feel comfortable sharing

experience.

We can proudly say that we have achieved our objectives we have set for ourselves and

this study to the best of our ability and knowledge. The study is important to us because we

have gained more knowledge about the teenage pregnancy, episiotomy and eclampsia. We will

able to apply what we have learned during this care to future patients with similar condition.

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IV. RECOMMENDATIONS

The researchers recommend the patient a series of things that are needed to be followed

to improve her health and prevent complication and disease. Episiotomy appears to be a

protective factor for women’s wellness. Women who had episiotomy and who experienced

perineal symptoms have a better psycho-physical health status in 12.79 months (±3.3) follow up.

First, the patient should be able to develop positive attitude towards her family and

promote family engagement that lead positive outcomes for everyone. Second, modify their

lifestyles practices that include proper diet and to promote healthy lifestyles and the nutrition of

food intake that are rich in iron, fiber and increase fluid intake to help regulate the patient bowel

movement and prevent constipation.

Lastly, the family of the patient was advised to take proper care to the client and continue

monitoring the client. The researchers recommended the therapeutic approach and establish good

relationship with patient and family that engage and give health teaching and give awareness to

the community.

To the parents of all the group’s members, the group would like to thank them for the

understanding and patience they have shown us all throughout the course this case study, and for

their emotional and financial support. Thank you for believing in the group’s facilities, and for

boosting our self-confidence whenever we needed it.

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