I.

INTRODUCTION

Pregnancy is the state of carrying a developing embryo or fetus within the female
body. This condition can be indicated by positive results on an over-the-counter urine
test, and confirmed through a blood test, ultrasound, detection of fetal heartbeat, or an
X- ray. Pregnancy lasts for about nine months, measured from the date of the woman’s
last menstrual period (LMP). It is conventionally divided into three trimesters, each
roughly three months long. When gestation has completed, it goes through a process
called delivery, where the developed fetus is expelled from the mother’s womb. There
are two options of delivery: Cesarean section and NSVD or normal spontaneous
vaginal delivery.

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.
This occurs after a pregnant woman goes through labor, which opens, or dilates, her
cervix to at least 10 centimeters 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.

With the group’s patient, Patient E, 18 years old, prim gravida was admitted at
Laguna Medical Center in Sta. Cruz, Laguna last November 9, 2019. Her chief
complaint was the pain during labor. She was directly sent to the delivery room when
she got to the OB ER. According to her the pregnancy is unexpected since she was a
student. She had undergone a normal spontaneous vaginal delivery.
B. STATISTICAL REPORT
UNICEF estimates that at least 130 million babies are born each year, with some
reports in the past 10 years putting that figure at 136 million. But it's difficult to know
exactly how many babies are born globally, the World Health Organization notes,
because some children are not registered.
LOCAL
During the World Population Day Forum held in Quezon City last July 2019,
the Commission on Population (Popcom) raised concerns about early and unplanned
pregnancies by citing that around 500 teenage girls have given birth in the country
every
day as more adolescents engage in premarital sex. Popcom said some 196,000 Filipinos
between the ages of 15 and 19 years old get pregnant each year.

According to the data given by the Laguna Medical Center on 2019 the number
women who gave birth through a normal spontaneous delivery (NSD) last January
were 380 on February 350 women. March was 305; April was 371, 425 on May, 372
on June, 405 on July while on August it was 444 and 446 last September. The total
number of women who gave birth through NSD starting from January 2019 up to
September 2019 is 3,498 women. There still no final tally on the remaining months.

C. OBJECTIVES OF THE CASE STUDY

GENERAL OBJECTIVES:
This case study is intended to widen the student’s knowledge for Normal
Spontaneous Delivery by acquiring adequate data, which could fill in as a guide for the
students to improve their skills and attitudes in the application of nursing process and
management.
SPECIFIC OBJECTIVES:

 To know the client’s personal data, family profile, past health history,
current health history, and physical assessment
 To review the anatomy and physiology of the female reproductive system and
the changes after the delivery.
 To relate the results of diagnostic procedures to its normal values.

 To formulate a drug study for normal spontaneous delivery.

 To develop an effective nursing care plan in which the client may benefit.

 To formulate a discharge plan for the continuity of care to the client.

D. SCOPE AND LIMITATIONS

The patient was admitted last November 09, 2019 at 8:38 am. The student nurses
were the one who performed an actual delivery, assisted during the procedure and
performed essential intrapartum newborn care. They were assigned at the Laguna
Medical Center from 6am to 2pm shift under the supervision of their clinical instructor
Mrs. Mimie H. Monedo R.M, R.N. Patient E was received in stretcher with said to be a
fully dilated cervix. The coverage of the duty was Nurse- Patient- Interaction and
interview, head to toe physical assessment, taking vital signs, observation and health
teachings.
II. PATIENT’S PROFILE

Name: Patient E

Sex: Female

Age: 18 years’ old

Address: Purok 6 Sibulan Nagcarlan, Laguna

Birthdate: June 11, 2001

Nationality: Filipino

Religion: Catholic

Civil Status: Single

Date of admission: November 9, 2019

Time of admission: 8:38am

Admitting Physician: Ma. Shella O. Magpantay, M.D

Admission Diagnosis: G1P0 PU 39 4/7 weeks

III. PHYSICAL ASSESSMENT

Patient E, an 18 years old female patient, admitted on November 09, 2019 at

08:38 AM stands 154 cm and weight of 57 kilos with a blood pressure of 130/80,
pulse rate of 65 beats per minute, respiratory rate of 24 breathe per minute, and a
temperature of 36.5 ⁰C. The patient was conscious and was able to answer the
questions being asked comfortably.

INTEGUMENTARY
Body Parts Method Findings Implications
Skin Inspection There were no lesions,
bruising, and rashes present
on the skin but some old
small scars of wounds in the
lower extremities are
present.

Palpation Skin was warm, soft and Normal Findings

smooth to touch.
Hair Inspection Black hair was in bun pony Normal Findings
style, and thick. Scalp was
clean and dry. There are no
lesions appear. Lice and nits
(eggs) were not present.

Palpation Hair was smooth and soft.

Nails Inspection Extended and unclean nails Due to poor hand
were seen. hygiene and/or
Pink tones were observed. habituated bad
160-degree angle between sanitation.
the nail base and the skin.

Palpation Nails were hard, immobile, Color return immediately

smooth and firm. to normal in less than 3
seconds after pressure
Capillary refill test >3 was released.

4
HEAD AND NECK

Body Parts Method Findings Implications

Head Inspection Head was well rounded and Normal Findings
symmetrical.
Neck Inspection Neck was slightly enlarged. Normal Findings
Palpation
There were no enlarged
nodules.

EYES AND VISION

Body Parts Method Findings Implications
Eyebrows Inspection Eyebrows were symmetric. Normal Findings
Hair distribution in
eyebrows was in its entire
length.
Eyelashes Inspection Eyelashes span outwards and Normal Findings
evenly distributed.
Eyelids Inspection Eyelids have no edema and Normal Findings
there were no presence of
discharges or discoloration.
Sclera Inspection Sclera was white in color. Normal Findings

Palpebral Inspection Palpebral conjunctiva appears Normal Findings

Conjunctiva pink.
Pupils Inspection Pupils were black in color Normal Findings
and equal in size.

EARS

Body Parts Method Findings Implications

Tympanic Inspection Tympanic membranes were Normal Findings
Membranes clear and landmarks were
visible.
Auricles Inspection Auricle was clean and same Normal Findings
of color as facial skin.

NOSE
Body Parts Method Findings Implications
External nose Inspection Nose was symmetric, align Normal Findings

5
 and the color was same as the
facial skin.

BREAST
Body Parts Method Findings Implications
Abdomen Inspection Linea nigra and striae Normal Findings
were present. Striae
appear in white color.

Body Parts Method Findings Implications

Breast Inspection Hyper-pigmentation in Normal Findings
areola were present. Nipples
were inverted.

ABDOMEN

VAGINA
Body Parts Method Findings Implications
Vagina Inspection Vagina appears to be As evidence by redness
swollen. There are and episiorraphy done.
no discharges
present.

According to Erik Erikson, who was a psychoanalyst and was known for his
theory of psychosocial theory. Correspond to his Developmental Level of
adolescence prior to age 12 – 20 years old, the patient belonged to the fifth stage,
IDENTITY versus ROLE CONFUSION, which in this level, Erikson suggested that
adolescents explore their independence and develop a sense of self. He also added that
in this stage, adolescents seek to be the same as others yet unique. Erikson concluded
that people progress through a series of stages as they grow and change throughout
life. During each stage, people face a developmental conflict that must be resolved to
successfully develop the primary virtue of stage. The negative resolution in this stage
are confused and non- focused which came up in major question “WHO AM I?” In
this stage, he was interested in how social interaction and relationships affect
development and growth.

On the other hand, the patient belonged to FORMAL OPERATIONAL on Dr.

Jean Piaget’s Cognitive Development at approximately age of 11 and lasts into
adulthood. In this stage, he stated significantly characteristics such as the person
6
develops ability to problem solve both real-world and theoretical situations. They can
logically think about the past, present and future. They gain the ability in an abstract
manner by manipulating ideas in their head without any dependence on concrete
manipulation. The patient belongs to this stage because at her age based on the theory
she starts come up with conclusions.

Nevertheless, the patient possesses the level of conventional in the fourth

stage, Orientation to Maintenance of Social Order which have the average age of
adolescence through adulthood, on Lawrence Kohlberg’s Six Stages of Moral
Development. The patient belongs to this stage because it said that they attempt to
make decision and behave by strictly conforming to fix and the written law – whether
these are of a certain group, family, community, or the nation. “Right” consist of
“doing one’s duty”.

IV. REVIEW OF ANATOMY AND PHYSIOLOGY

7
 The female reproductive system includes the following: ovaries that produce and
develop eggs; fallopian tubes or oviducts that transport egg to the uterus and acts as a
site of fertilization; uterus that supports a developing embryo; cervix which allows
passage between the uterus and the vagina; vagina that receives penis during
intercourse and acts as a birth canal and a passageway during menstrual flow; and
breasts that produce and deliver milk during child birth.

During puberty, the hypothalamus signals the pituitary gland to produce two
hormones, the follicle-stimulating hormone (FSH) and luteinizing hormone (LH). In
females, FSH and LH stimulate the ovaries to produce the female sex hormones,
estrogen and progesterone. This results in the development of secondary sex
characteristics such as breasts, and causes the ovaries to begin producing mature eggs.

Ovulation occurs approximately every twenty-eight days, and is part of a larger

process called the menstrual cycle. If an egg is fertilized after ovulation, it attaches to the
wall of the uterus and embryonic development begins.

If an egg is fertilized (or a fertilized egg does not attach to the wall of the uterus), the
egg and the lining of the uterus are discharged from the body hence starting a menstrual
cycle.

V. PATIENT’S HISTORY

8
A. Present History
The patient went first to OB ER then immediately transferred to the delivery room.
The student nurses received the patient with fully dilated cervix, with 39 and 4 days’
age of gestation, experienced high intensity of labor pain, and the baby was almost
crowning. She was transferred to the DR table immediately and the student nurses
prepare all the equipment that will be used. She suffered in pushing the baby since it is
her first child and it was resulted to caput succedaneum or what we called moulding.
She delivered her baby boy via normal spontaneous delivery at 8:44am while the
placenta was out at 8:47am and the type of placenta was Schultz’s. Since it is her first
child, she had a laceration due to pushing of the baby and then episiotomy and
episiorrhapy was done.

After episiorrhapy, caring of the mother was done through cleaning her perineum
and changing a new diaper. Blood pressure was taken with 110/80mmHg. Skin to skin
contact between mother and baby was done.

Based on the chart written at OB ward it said that she has a scheduled of IUD after
a day of childbirth but according to the consent letter she wrote, she refused to use IUD
because she was scared and her parents doesn’t want also. She also has a discharge
order from the Doctor on November 12, 2019 but since she was not NBB, she stayed
until November 15, 2019 to complete her billing.

B. Family History
Based on the interview by the student nurse at the patient, there is no known
disease or history of disease of their parents. She has four siblings with ages 20, 18, 16
and 4 years old. She was second the second child of the family. As stated by the patient,
none of the siblings has a history or record of any kind of disease.

9
 A/W
A/W A/W A/
5 W
43 47 5
3 0

A/ A/W
A/ A/ A/ A/ A/
W
2 W W W W W
1 1 4 2 2
0 1 2
6 4 7
8

Female

Male

Client

Married

Lover

A/WAlive and Well

C. Obstetric History
The patient was primigravida, since it was her first baby; she doesn’t have any
past delivery complications. She goes to check-ups at Laguna Medical Center or
Provincial Hospital with her Gyne, Doctora Masa The baby’s gender was male which
was delivered on the 9th day of November 2019 with the anthropometric measurement
of 2700 grams (weight), 32cm (head circumference), 29.5cm (chest circumference),
28cm (abdomen circumference) and 51cm (height).

D. Socio-economic
The patient was a student while the patient E’s partner was a construction
worker with a salary range of 300 to 400 pesos per day.

E. Psychological
An hour after the fetal delivery, the patient was endorsed to the student nurse.
The patient was conscious and was able to answer questions asked by the student
nurse, cooperative but has a feeling of exhaustion due to delivery

10
VI. PHYSIOLOGY

Name: Patient E

Age: 18 years’ old

LATENT PHASE

STAGE 1: LABOR
DILATION

ACTIVE PHASE

TRANSITION PHASE

STAGE 2: EXPULSION
OF FETUS

STAGE 3: EXPULSION OF
PLACENTA

STAGE 4: IMMIDIATE
RECOVERY PERIOD

Figure 1: Physiology of Labor

PHYSIOLOGY OF LABOR
Labor usually begins with the passing of a woman’s mucous plug. This is a clot of
mucous that protects the uterus from bacteria during pregnancy. The length of the labor
process varies from woman to woman. Women giving birth for the first time tend to go
through labor for 12 to 24 hours, while women who have previously delivered a child
may only go through labor from six to eight hours.

Laboring cannot that be easy; thereby implicating that there are processes and
stages to be undertaken to achieve spontaneous delivery. Through which, Obstetrics
have divided labor into four (4) stages thereby explaining this continuous process.

STAGE 1:

11
 It is usually the longest part of labor. It begins with regular uterine contractions
and ends with complete cervical dilatation at10 centimeters. This stage is broken down
into three:

a. Latent Phase
- Where the contractions are usually very light and maybe approximately 20
minutes or more apart from the beginning, gradually becoming closer, possibly up
to five minutes apart;
b. Active phase

- Where contractions are generally four or five times apart, and may last up to 60
seconds long. Cervix dilates with 4-7 cm and initiates a more rapid dilatation. It is
known that to get through active labor, mobility and relaxations are done to
increase contractions; and

c. Transition phase
-Where it is definitely known as the shortest phase but the hardest, contractions
maybe two or three times apart, lasting up to a minute and a half, about
approximately 8-10 cm of cervical dilatation. Some women will shake and may
vomit during this stage, and this is regarded as normal. Most of the time, women
would find a comfortable position to acquire complete dilatation.
STAGE II

This stage lasts for three or more hours. However, the length of this stage depends
upon the mother’s position (e.g.; upright position yields faster delivery). Once the
cervix has completely dilated, the second stage had begun. This stage ends with the
expulsion of the fetus.
STAGE III

This stage focuses on the expulsion of the placenta from the mother. Placenta
exclusion is much easier than the delivery of the baby because it includes no bones,
and this is during this stage that the baby is placed on top of the mother’s womb.
STAGE IV

No more expulsions of conception products for this stage as this is generally

accepted as POST PARTUM juncture. This phase is from the placental delivery to full
recovery of the mother.

12
VII. MEDICAL/SURGICAL MANAGEMENT

DATE DOCTOR’S
INTERPRETATION
ORDER
November 9,  Please admit to LR  For proper managing and
2019  Secure consent monitoring of progress of
labor
 NPO  To make sure the patient
understands and agrees to the
procedure legally.
 To prevent aspiration
 IVF: D5LR 16 x 8 https://www.webmd.com/baby/new
s/20100120/eating-drinking-may-
be-ok-during-labor#1
 Lactated Ringer's and
5% Dextrose Injection, USP is
indicated as a source of water,
electrolytes and calories or as an
alkalinizing agent.
 Dx: CBC w PC https://www.rxlist.com/lactated-
ringers-in-5-dextrose-
drug.htm#indications
 A complete blood count (CBC) is a
 Monitor progress
test that measures the cells that
of labor
make up your blood: red blood
cells, white blood cells, and
 Vs q1; FHT
platelets. https://www.webmd.com/a-
q30mins
to-z- guides/complete-blood-count#1
 Recognizing incipient problems in
 Refer order to avoid their development to
serious problems.
 Meds  Monitoring the fetal heart rate tests
 Cefuroxime 500mg the baby's heart rate and rhythm
cap #14 (fetus). It helps your doctor to see
how the baby is doing.
 For delivery

13
  Cefuroxime is a
cephalosporin antibiotic. It works
by fighting bacteria in your body.
 Mefenamic Acid
Cefuroxime is used to treat many
500mg cap #21
kinds of bacterial infections,
including severe or life-threatening
forms.
https://www.drugs.com/mtm/cefuro
xime.html
 Mefenamic acid is used for the
short-term treatment of mild to
moderate pain from various
 Ferrous Sulfate
conditions. It is also used to
cap #30
decrease pain and blood loss from
menstrual periods. Mefenamic acid
is known as a nonsteroidal anti-
inflammatory drug (NSAID).
https://www.webmd.com/drugs/2/d
 Multivitamin rug-11586/mefenamic-acid-
(Nature C) cap #30 oral/details
 This medication is an iron
supplement used to treat or
prevent low blood levels of iron
(such as those caused
by anemia or pregnancy.
https://www.webmd.com/drugs/2/d
rug-4127/ferrous-sulfate- oral/details
 This medication is a multivitamin
product used to treat or prevent
vitamin deficiency due to poor diet,
certain illnesses, or
during pregnancy.
https://www.webmd.com/drugs/2/d rug-
18820-9038/multivitamin-
oral/multivitamins-includes- prenatal-
vitamins-oral/details

14
Medical Date General Indication/ Client’s
management/ performed/ Description Purpose reaction to
Treatment Date treatment
discontinued
Intravenous Performed: Hypertonic, Treatment for With no
Fluid of 5% 11/09/18 nonpyrogenic, persons signs of
Dextrose in Discontinued: parenteral fluid, needing extra distress or
Lactated 11/10/19 electrolyte and calories who adverse
Ringer’s nutrient cannot effects, the
Solution 1L x replenisher tolerate fluid patient was
30 gtts/min Administered overload. able to
intravenously, has It helps to tolerate the
a value as a source prevent treatment
of water, dehydration well.
electrolytes and to the patient
calories or as an
alkalinizing agent.

15
SURGICAL MANAGEMENT
Name of Date Brief Indica- Client’s
Nursing
procedu- perfor- descript- tion/Pur- response to
Responsibilities
R med tion poses operation
e
Episio- 11/09/16 An episio- One Client stated that 1. Instructed to
tomy and tomy is a benefit, she flinched tighten
repair perineal, particular- upon cutting the buttocks upon
the region ly in area, but didn’t sitting to
between fragile feel too much prevent from
the vagina premature pain towards the stretching and
and the infants, is cutting due to pulling at the
anus, the the severe pain stitches.
surgical reduction the labor has 2. Instructed to
incision. of damage caused. keep the area
During the to the fetal She felt the pain clean and dry
second head. right after the to encourage
stage of baby was the stitches to
pregnancy One expelled and heal
episioto- benefit mostly when the
mies are suggested health provider 3. Instructed to
done to is to was stitching pour water
widen the shorten the tear. over the
vagina’s the second wound during
opening stage of urination to
and avoid labor, reduce
tearing of thereby discomfort
the tissue providing and to keep it
of baby at respite clean.
birth. from the
intensive 4. Instructed to
delivery perform
process Kegels
for mother exercise to
and baby. improved
circulation
Its and speed up

16
purpose is the healing
to enlarge time.
the 5. Drink plenty
vaginal of water to
introitus reduce
so that the constipation
fetus can upon bowel
be movement.
delivered
easily and
safely.
This
minimizes
The
perineal
muscles
and fascia's
over-
stretching
and
breakup.
Reducing
stress and
strain on
the head of
the fetus.
The second
stage of
labor, too,
should be
shortened

17
VIII. DIAGNOSTIC PROCEDURE
Date: November 9, 2019; 8:35pm

Complete Blood Count/ Haematology Section

Normal Value Results Interpretation Implication

Red Blood 3.50-5.00 4.12 Within the
Cells normal range
Hgb 110-150 124g/L Within the
normal range
Hct 37.0-47.0 36.6L Within the
normal range
Mch 27.0-34.0 30.1pg Within the
normal range
Mchc 320-360 339g/L Within the
normal range
Mcu 80.0-100.0 88.8 FL Within the
normal range
White blood 4.00- 10.00 17.95 High White blood cell
cells count is elevated
during
pregnancy, with
the lower limit of
the reference
range being
around 6,000
cells per μl and
the upper limit
around 17,000
cells per μl.5 The
stress imposed
on the body
through
pregnancy
causes this rise
in white blood
cells.

18
Lymphocytes 20.0- 40.0 15.4 Within the
normal range
Monocytes 6.3 3.0-12.0
Eosinophil 1.0 0.5-5.0 Within the
normal range
Basophil 0.2 0.0-1.0 Within the
normal range
Platelet Count 42.7 10^9/L 100-300
MPV 8.1 FL 6.5-12.0 Within the
normal range
PDW 16.1 9.0-17.0 Within the
normal range
Others:
Blood type: O
Rh factor: Positive
HBsAg Non-reactive

Pelvic
 Ultrasound

Date: October 2, 2019

Findings:

Within the gravid uterus is single, live fetus in cephalic presentation with good cardiac
and somatic activities with the following biometry measurements:

Fetal heart rate: 130 beats per minute

Biparietal diameter: 8.2 cm= 33 weeks and 1 day

Head circumference: 30.4 cm =33 weeks and 6 days

OFD: 10.8 cm

Cephalic index: 76%

Abdominal circumference: 29.3 cm= 33 weeks and 2

days’ Femoral length: 6.1 cm = 31 weeks and 6 days
Amniotic fluid index: 13.2 cm (4
quadrants) Placenta: anterior, grade II,
high kying
Sonographic estimated fetal weight: 2079 grams by Hadlock (+/-311.81 grams)

Impression:

Single live intrauterine pregnancy in cephalic presentation, 32 weeks and 3 days

(+/-21 days) by composite aging with good cardiac and somatic activities

Normal amniotic fluid volume, placenta, anterior, grade II, high

lying Sonographic estimated fetal weight is appropriate for
gestational age
IX. DRUG STUDY

Generic Name: Cefuroxime Brand Name:

Dosage & Route of
Indication Mechanism of Action
Administration
Oral.500mg 1 cap,BID A cephalosporin (SEF Cefuroxime axetil is a
a low spor in) bactericidal agent that acts
antibiotic. It works by by inhibition of bacterial
fighting bacteria in cell wall synthesis.
your Cefuroxime axetil has
body. Cefuroxime is activity in the presence of
used to treat many some β-lactamases, both
kinds of bacterial penicillinases and
infections, including cephalosporinases, of
severe or life- gram-negative and gram-
threatening positive bacteria.
forms. Cefuroxime ma
y also be used for
purposes not listed in
this medication guide.

22
 Contraindication Side Effects Adverse Reaction
Cefuroxime is contraindicated in  severe stomach  Decreased
patients with cephalosporin pain, diarrhea hemoglobin or
hypersensitivity or cephamycin that is watery haematocrit
hypersensitivity. Cefuroxime shou or bloody;  Vaginitis
ld be used cautiously in patients  jaundice  Transient rise in
with hypersensitivity to penicillin. (yellowing of hepatic
the skin or transaminases
eyes);  Diaper rash

 skin rash,  Increase in alkaline

bruising, phosphatase
severe  Thrombophlebitis
tingling, or  Increase in lactate
numbness; dehydrogenase

 seizure
(black- out or
convulsions);

Generic Name: Mefenamic Acid Brand Name:

 Dosage & Route of
Administration
Oral, 500mg 1 cap., TID
Indication Mechanism of Action
For relief of mild to Mefenamic acid has
moderate pain in patients analgesic, anti-
≥ 14 years of age, when inflammatory, and
therapy will not exceed antipyretic properties.
one week (7 days). For The mechanism of
treatment of primary action of mefenamic
dysmenorrhea acid, like that of other
NSAIDs, is not
completely understood
but involves inhibition
of cyclooxygenase
(COX-1 and COX-
2). Mefenamic acid is a
potent inhibitor of
prostaglandin synthesis
in vitro.

Contraindication Side Effects Adverse Reaction

Known hypersensitivity (e.g.,  Stomach pain. Long-term treatment
anaphylactic reactions and can lead to enteritis or
serious skin reactions)  Nausea. colitis (sometimes with
to mefenamic acid or any  Vomiting. steatorrhea).
components of the drug product
(see WARNINGS; Anaphylactic  Heartburn.
Reactions, Serious Skin  Constipation.
Reactions).  Diarrhea.
History of asthma, urticaria, or
 Rash.
other allergic-type reactions after
 Dizziness.
taking aspirin or other NSAIDs.
Generic Name: Ferrous Sulfate Brand Name:
Dosage & Route of Indication
Administration
Oral, 1 cap, TID Myoglobin helps your
muscle cells store
oxygen. Ferrous Sulfate is
an essential body
mineral. Ferrous sulfate is
used to treat iron
deficiency anemia (a lack
of red blood cells caused
by having too little iron in
the body). Ferrous
sulfate may also be used
for other purposes not
listed in this medication
guide
Contraindication Side Effects
Contraindicated in patients  Constipation.
receiving repeated blood  Contact irritation.
transfusions and in those with
 Diarrhea.
hemosiderosis, primary
 Dark stools.
hemochromatosis, hemolytic
anemia unless iron deficiency  Gastrointestinal
anemia is also present, peptic (GI)
ulceration, ulcerative colitis, or hemorrhage
regional enteritis. (rare)
Mechanism of Action
Iron combines with
porphyrin and globin
chains to form
hemoglobin, which is
critical for oxygen
delivery from the lungs
to other tissues. Iron
deficiency causes a
microcytic anemia due
to the formation of
small erythrocytes with
insufficient
hemoglobin
Adverse Reaction
 Aggravate
existing GI
tract disease
 Severe
abdominal
pain

 Gastrointestinal
(GI) irritation.

 Gastrointestinal
(GI) obstruction
(wax matrix
products; rare)

 Gastrointestinal
(GI) perforation
(rare)

24
Generic Name: Multivitamin Brand Name:
Dosage & Route of
Indication Mechanism of Action
Administration
Oral, 1 cap, OD Multivitamins are used to Multivitamins are used
provide vitamins that are to provide vitamins that
not taken in through the are not taken in through
diet. Multivitamins are the
also used to treat vitamin diet. Multivitamins are
deficiencies (lack also used to
of vitamins) caused by treat vitamin deficiencies
illness, pregnancy, poor (lack of vitamins) caused
nutrition, digestive by illness, pregnancy,
disorders, and many other poor nutrition, digestive
conditions. disorders, and many
other conditions.
Contraindication Side Effects Adverse Reaction
 upset stomach; Not expected to cause a
 headache; or serious effect.

 unusual or
unpleasant taste in
your mouth

27
X. NURSING CARE PLAN
 XI. NURSING THEORIES

Dynamic Nurse-Patient Relationship

The Dynamic Nurse-Patient Relationship , published in 1961 and written by Ida

Jean Orlando, described Orlando’s Nursing Process Discipline Theory. The major
dimensions of the model explain that the role of the nurse is to find out and meet the
patient’s immediate needs for help. The patient’s presenting behavior might be a cry
for help. However, the help the patient needs may not be what it appears to be. Because
of this, nurses have to use their own perception, thoughts about perception, or the
feeling engendered from their thoughts to explore the meaning of the patient’s
behavior. This process helps nurses find out the nature of the patient’s distress and
provide the help he or she needs.
The concepts of the theory are: function of professional nursing, presenting
behavior, immediate reaction, nursing process discipline, and improvement.
The theory Ida Jean Orlando proposed relates to the nurse-patient relationship
of the students and the client. The students built rapport in order to perceive their own
perception of the client’s state. Communication is the key to establish an understanding
between the patient and the student nurse. Initiating a conversation to gather
information, then analyze about the gathered data. Caring about the client via proper
handling of work—taking vital signs at the prescribed hour, perineal care, and health
teachings about the newborn baby.
XII. DISCHARGE PLAN/ SUMMARY

Name: Patient E Age: 18 years old

Gender: Female Ward/Room/Bed: OB Ward

Date Admitted: 11/08/19 Date Discharge:

11/15/19 Admission Diagnosis: G1P0 Pregnancy Uterine 39 4/7
weeks
Discharge Diagnosis: G1P1( 1001) 39 4/7 weeks cephalic in labor delivered via NSD

a. MEDICATIONS

1. Cefuroxime 500mg 1 cap take orally twice a day.

2. Mefenamic Acid 500mg 1 cap take orally twice a day.

3. Ferous Sulfate 500 mg 1 cap take orally three times a day

4. Multivitamin 1cap take orally once a day.

b. HEALTH TEACHINGS

1. Breastfeeding

 Instruct the mother to wipe her nipple with cotton and water only before
she feed the baby.
 Teach the mother about breastfeeding position technique for proper
breastfeeding position and to promote comfortable and bonding between
the mother and the baby.
 Teach also the proper burping position technique to prevent the discomfort
feeling of the baby before, during and after breastfeeding.
2. Diet

 If the mother’s milk is insufficient, advice the mother to eat malunggay

leaves that can help her to provide enough milk for the baby.

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 Instruct the mother to eat food that is rich in protein for faster recovery
from childbirth and keep the body strong.
 It is important to eat well-balanced diet and drink plenty of fluids. Drink
two quarts of fluid per day if you are breastfeeding.
 Continue taking prenatal iron and vitamin pills until the post-partum visit.

3. Care of Episiotomy

 Continue washing the perineum with betadine wash using tap water or
lukewarm water with guava leaves
 Keep the area clean and dry to speed up the healing process.

 Stitches will dissolve in 1-3 weeks.

4. Post-partum Visit

 Follow the allotted date of post-partum visit thus the post-natal check-up

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 XIII. REFERENCES

 Patient’s Chart
 Patient
 Lectures

 Observation
 Interview

Internet Reference

https://www.verywellmind.com/identity-versus-confusion-2795735
https://edition.cnn.com/2013/07/22/health/worldwide-baby-
facts/index.html https://www.medicinenet.com/script/main/art.asp?
articlekey=11893 https://en.wikipedia.org/wiki/Vaginal_delivery
https://www.slideshare.net/pinoynurze/case-studynsvd
https://pia.gov.ph/features/articles/1026925
http://nursing-theory.org/theories-and-models/orlando-nursing-process-discipline-
theory.php#:~:targetText=The%20Dynamic%20Nurse%2DPatient
%20Relationship,Orla ndo's%20Nursing%20Process%20Discipline
%20Theory.&targetText=This%20means%2 0finding%20out%20and%20meeting
%20the%20patient's%20immediate%20needs%20fo r%20help

emedecine.medscape.com

Book Reference
 Mosby's Nursing Drug Handbook (Linda Skidmore -
Roth, 2006) Health Assessment Nursing Sixth Edition
 Nurse’s Pocket Guide , Doenges,Moorhouse, Murr (Edition 1)1To know the client’s
personal data, family profile, past health history, current health history and
physical assessment.

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