INTRODUCTION

Obstetric Nursing is a specialized nursing practice which deals with the

application of concepts, principles and techniques of caring normal pregnant woman’s

during antepartum, intrapartum and postpartum period. Level 2 Student Nurses,

focuses on the care that they will be giving to antepartum, intrapartum, and postpartum

mothers. As level 2 students nurses it is our responsibility to take care of our pregnant

clients and their newborns. Part of our responsibility is to monitor the patient, take the

patient's vital signs, attend to their concerns, and give them necessary medications

according to the doctor's order. We also educate patients on how to take care of

themselves and how to handle their newborn/s.

With that being said this case study is to showcase the learnings, skills, and

attitude that they were able to obtain in their exposure in the hospital. In this study the

student nurses were able to come up with a nursing diagnosis that is prior to the signs

and symptoms that the patient gave.

After 48 hours of being fielded in the hospital, the OB-ward group of Block NC

of the First semester of School Year 2019-2020 chose the case of a postpartum

mother that is being able to give birth to her third child, through normal delivery. This

case tackled on how the assigned nurse used the appropriate skills that helped her

identify the key concerns of the patient by checking her vital signs, intake and output,

and applying her own nursing interventions, based on the nursing care plan that she

made, that will be discussed in the later portions of the paper.

1
GENERAL OBJECTIVES

At the end of 48 hours, the student nurses of the OB-ward group of Block NC of the

First Semester of School Year 2019-2020 will be able to:

 Expand our learnings through first-hand experiences on caring for a normal

pregnant woman during antepartal, intrapartal, and postpartal period.

 Perform safe and quality nursing care appropriate for a specific patient in the

OB ward.

 Demonstrate our knowledge on the application of concepts and principles on:

vital signs taking, weight and height, antepartum and postpartum exercises,

Leopold’s Maneuver, fundal height taking, and fetal heart beat monitoring.

 Embody the attitude of an OB ward nurse in caring for pregnant and postpartum

mothers and newborns by being patient, and showing dedication and sincerity

in providing both physical and emotional care to patients and their families, and

being concerned about the well-being of others.

2
SPECIFIC OBJECTIVES

At the end of 4 hours of case presentation, the student nurses of the OB-ward group

of Block NC of the First Semester of School Year 2019-2020 will be able to:

Knowledge:

 Able to explain the lab results of the patient and connect them to the patient's

present condition

 Emphasize understanding of the mechanism of the drugs and how they are

used to cure the patient.

 Being able to explain the reason behind the nursing care plans formulated.

 Processing the different components of the case and answer the different set

of questions that may be given prior to the case.

Skills:

 Creatively and skillfully create the case presentation in a way that it is easy to

understand without leaving any important details

 Develop and improve communication skills, self-confidence, and

professionalism

 Be able to explain clearly and effectively the contents of the case study

Attitude:

 Develop a sense of teamwork with the existing colleagues to come up with and

deliver an informative case study.

 Being able to answer questions sufficiently without hesitation or pressure.

3
SCOPE AND LIMITATIONS

The study covers the obstetric cases that Station 2A of Maria Reyna - Xavier

University Hospital was handling. This includes the progressive assessment of

newborns and postpartum mothers during their admission in the Saint Mary ward,

analyzing their data and conditions, understand the medications prescribed to the

patients, and formulating appropriate and effective nursing care plans.

The study is limited in Maria Reyna - Xavier University Hospital Station 2A. The

nursing students were able to assess and deliver care to the client for 2 days (July 22-

23, 2019). The patient’s personal and health information were collected from the

assessments of the student nurses, interview of the patient’s watcher, and the data

from the patient’s chart. The patient was discharged after July 23, 2019 so all

information from the patients admission to discharge was taken into account but the

days where the student nurses were able to assess the patient would be highlighted.

The patient’s right to permission, privacy and confidentiality were ensured and

maintained. To give respect to the client’s rights, she would be referred to as Patient

or Client JDL. All information and details regarding the Patient will be kept private and

secure.

4
SIGNIFICANCE OF THE STUDY

This case presentation will be of significance to the following:

To Xavier University – Ateneo de Cagayan, its College of Nursing, the

College Dean, and the Faculty of the College of Nursing., this case study

presented contains facts and experiences of a patient – student nurse interaction

during its OB WARD exposure at Maria Reyna - Xavier University Hospital. Which

provided student nurses an opportunity for growth and development in terms of skills

and knowledge which basically is the main goal of the university towards forming

holistic formation among its students. Therefore, if other nursing students are to

undertake a case study presentation, they may be granted access to this document

as a guide and promote improvement in the quality of their case study such as this.

To the staff of Maria Reyna – Xavier University Hospital Station 2A, the

presented interventions and care management can serve as a basis for better nursing

care interventions and to improve the quality of care towards their patient in order to

promote better healthcare experience to its clients.

To Patient JDL and her significant others/watchers, the understanding of

postpartum care and the importance of breastfeeding will promote personal care and

effective breastfeeding for the baby.

To the student nurses, they should anticipate numerous data collection for

patients with complications. Also, a data collection that is performed systematically

without violating patients’ rights and keeping utmost confidentiality of the information

obtained.

5
NARRATIVE ASSESSMENT

Patient JDL is a female, 33 years of age, married, a Roman Catholic and a

traffic aid. Her chief complaint upon admission is labor pain with a diagnosis/

impression of “pregnancy, full term, cephalic in labor, female neonate”. The history of

present illness is that patient received ambulatory, non-dyspnea with complaints of

brownish vaginal discharge, internal examination done by midwife, 10 minutes later

her bag of water ruptured.

Her medications involves Cephalexin 500mg cap q8h for skin and genitourinary

and skin infection due to episiotomy , Tramadol + Paracetamol per orem q8h for

moderate to severe acute pain and Senokot Forte 1 tab at hours of sleep per orem as

a laxative. Upon assessment of her vital signs, heart rate is at. 68 beats per minute,

respiratory rate of 22 breaths per minute, blood pressure at 120/80, the temperature

is at 36 Celsius. She is 5 feet and 2 inches tall with a weight of 61.5 kg. Body mass

index is 24.8 and is within the normal weight range.

Patient JDL’s history of family illness involves hypertension and diabetes

mellitus. For her obstetric history, she had a total number of 2 births and 2

pregnancies, Parity is 2 and Gravidity is 2 (P2G2). For the TPAL, T as full term, P as

preterm birth, A as abortion and L as living (TPAL) is 2-0-0-2. Two full term, no preterm

and abortion and 2 living. Prenatal care coverage involves prescription of vitamins and

it was held at MRXUH with a total number of 8 visits.

No abnormal findings found during pregnancy while her pre-pregnancy weight

is 47kg with a weight gain of 4.5 kg during pregnancy. Her last menstrual period was

October 11, 2018 and the expected date of confinement is on July 18, 2019. The age

of gestation was at 38 weeks and the actual date and time of delivery was July 21,

6
2019 at 11:19 PM. It was a normal spontaneous vaginal delivery for 3 hours, the fetus

was in a cephalic presentation. There was episiotomy in median at the perineum and

lochia rubra is observed approximately 250 ml. She also plan to exclusively breastfeed

her baby. Her first menstruation started at 12 years old with a cycle of 28 days that

would last up to 5 days with moderate flow. During menstruation she would experience

menstrual discomfort such as dysmenorrhea. Based on patient JDL, she often

experience vaginal discharge that is milky white in color.

Patient JDL has an enlarged breast with enlarged and darkened areola.

Furthermore, colostrum is observable but breastfeeding is challenged due to inverted

nipples. It was verbalized that she performs a monthly BSE, has a fundal height of

38cm, Leopold’s maneuver shows that the fetus is in a right occiput anterior, fetal

position of cephalic, 12cm gynecoid pelvis measurement. For circulation. she has

increase urinary urges and has a negative homans sign. Upon assessment , Patient

JDL has Blood Pressure of 120/80, Heart rate of 68 and has a capillary refill of less

than 2 sec. Nails are convex smooth and shiny with moist mucous region. Has a

respiratory rate of 22 bpm and has a normal and symmetrical breathing patterns and

is not in use of cigarettes. In addition, has a regular diet and eat 3 times a day.

Normally, has a bowel pattern of once a day of approximately 1 cup and a dark colored

stool. Also, has a regular pattern for voiding of 3 times a day

Patient JDL is fond of cleaning and watching television at home. She has an

average of 8 hours of sleep everyday with 30 minutes nap in the afternoon. She also

reported on stress factors such as work and handles it by "pahangin, mugawas sa

office".

7
 Patient JDL has no allergies or any adverse reaction to drugs. No history of

Sexually Transmitted Diseases, Blood Transfusions, history of accidental injuries,

fractures, dislocations, arthritis and unstable joints. She did have a concern on her

back because she stated that she has “pamaol”. Patient JDL did not have any changes

in the size and quantity of her moles and nodes. No unusual bleedings and prosthesis.

Patient JDL is married for 8 years. She is currently living with her husband and

daughter. She did not have any stress or concerns at present. She did not have any

other support person because she and her husband are working. She did not have

any report of related to illness conditions. Patient’s dominant language is Bisaya. She

is literate, and her educational attainment is on college level. Health belief/s is only

“Palina”. Patient JDL’s body map shows her affected areas; left hand for Intravenous

fluids, abdomen for her Linea Negra, Perineum for her Episiotomy and her Breasts for

her inverted nipples.

Patient JDL’s laboratory results; Total WBC: 8.0 out of the normal range of 5.0-

10.0. RBC: 3.74 out of the normal range of 3.69-5.90. Hemoglobin: 11.0 out of the

normal range of 11.7-14.0. Hematocrit: 34.1-44.0. MCV: 87.2 out of the normal range

of 70.0-97.0. MCH: 29.4 out of the normal range of 26.1-33.3. MCHC: 33.7 out of the

normal range of 32.0-35.0. RDW-CV: 12.8 out of the normal range of 11.0-16.0.

Platelet Count: 292 out of the normal range of 150-390. Differential count of patient

JDL’s Neutrophils: 72.8 out of the normal range of 55.0-62.0. Lymphocytes: 23.2 out

of the normal range of 20.0-40.0. Monocytes: 2.4 out of the normal range of 4.0-10.0.

Eosinophil: 1.5 out of the normal range of 1.0-6.0. Basophils: 0.1 out of the normal

range of 0.0-1.0. Patient JDL’s blood type is O Rh positive. Patient JDL’s urinalysis

results shows that the color of her urine is yellow, the transparency is hazy, ph level is

7.7, and specific gravity is 1.010. Her urine is Protein and Sugar negative. Her Pus

8
Cells is 13-15, RBC is 0-3 and epithelial cells is abundant. Bacteria found in her urine

is plenty while mucus threads are rare.

Patient JDL’s Developmental milestone whose age is 33; for Psychosexual:

Genital, -Sexual Relationship. On her Psycho-social: Intimacy vs Isolation –

Establishing Bonds and Relationships. Lastly for her Cognitive: Formal Operational –

able to think abstractly and critically.

9
NARRATIVE PATHOPHYSIOLOGY

Childbirth, or parturition, typically occurs within a week of a woman’s due date.

As a pregnancy progresses into its final weeks, several physiological changes occur

in response to hormones that trigger labor. Progesterone inhibits uterine contractions

throughout the first several months of pregnancy. As the pregnancy enters its seventh

month, progesterone levels plateau and then drop. Estrogen levels, however, continue

to rise in the maternal circulation. The increasing ratio of estrogen to progesterone

makes the myometrium more sensitive to stimuli that promote contractions.

A common sign that labor will be short is the so-called “bloody show.” During

pregnancy, a plug of mucus accumulates in the cervical canal, blocking the entrance

to the uterus. Approximately 1–2 days prior to the onset of true labor, this plug loosens

and is expelled, along with a small amount of blood. Meanwhile, the posterior pituitary

has been boosting its secretion of oxytocin, a hormone that stimulates the contractions

of labor. At the same time, the myometrium increases its sensitivity to oxytocin by

expressing more receptors for this hormone. As labor nears, oxytocin begins to

stimulate stronger, more painful uterine contractions, which stimulate the secretion of

prostaglandins from fetal membranes. Like oxytocin, prostaglandins also enhance

uterine contractile strength. The fetal pituitary also secretes oxytocin, which increases

prostaglandins even further. Finally, stretching of the myometrium and cervix by a full-

term fetus in the vertex position is regarded as a stimulant to uterine contractions. The

sum of these changes initiates the regular contractions known as true labor, which

become more powerful and more frequent with time. The pain of labor is attributed to

myometrial hypoxia during uterine contractions.

10
 The process of childbirth can be divided into three stages: cervical dilation,

expulsion of the newborn, and afterbirth

Cervical Dilation: For vaginal birth to occur, the cervix must dilate fully to 10 cm in

diameter—wide enough to deliver the newborn’s head. The dilation stage is the

longest stage of labor and typically takes 6–12 hours. True labor progresses in a

positive feedback loop in which uterine contractions stretch the cervix, causing it to

dilate and efface, or become thinner. Cervical stretching induces reflexive uterine

contractions that dilate and efface the cervix further. In addition, cervical dilation

boosts oxytocin secretion from the pituitary, which in turn triggers more powerful

uterine contractions. When labor begins, uterine contractions may occur only every 3–

30 minutes and last only 20–40 seconds; however, by the end of this stage,

contractions may occur as frequently as every 1.5–2 minutes and last for a full minute.

Each contraction sharply reduces oxygenated blood flow to the fetus. For this reason,

it is critical that a period of relaxation occur after each contraction. Fetal distress,

measured as a sustained decrease or increase in the fetal heart rate, can result from

severe contractions that are too powerful or lengthy for oxygenated blood to be

restored to the fetus.

Expulsion Stage: The expulsion stage begins when the fetal head enters the birth

canal and ends with birth of the newborn. The fetus faces the maternal spinal cord and

the smallest part of the head exits the birth canal first. Upon birth of the newborn’s

head, an obstetrician will aspirate mucus from the mouth and nose before the

newborn’s first breath. Once the head is birthed, the rest of the body usually follows

quickly. The umbilical cord is then double-clamped, and a cut is made between the

clamps. This completes the second stage of childbirth.

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Afterbirth: The delivery of the placenta and associated membranes, commonly

referred to as the afterbirth, marks the final stage of childbirth. After expulsion of the

newborn, the myometrium continues to contract. This movement shears the placenta

from the back of the uterine wall. It is then easily delivered through the vagina.

Continued uterine contractions then reduce blood loss from the site of the placenta. If

the placenta does not birth spontaneously within approximately 30 minutes, it is

considered retained, and the obstetrician may attempt manual removal. If this is not

successful, surgery may be required.

12
LABORATORY RESULTS

Hemolysis

April 16, 2019 7:53 am

High Low Norma

Result Unit
Complete Blood Count
Total WBC 8.0 x10^9/L
Total RBC 3.74 x10^12/L
Hemoglobin 11.0 g/L
Hematocrit 32.6 %
MCV 87.2 fL
MCH 29.4 pg
MCHC 33.7 g/dL
RDW-CV 12.8 %
Platelet Count 292 x10^9/L
Differential Count
Neutrophil 72.8 %
Lymphocytes 23.2 %
Monocytes 2.4 %
Eosinophils 1.5 %
Basophils 0.1 %
Blood Type
Blood Type “O” Rh Positive

Urinalysis
May 7, 2019 7:20 am

Result
Macroscopic
Color Yellow
Transparency Hazy
pH 7.5
Specific Gravity 1.010
Chemical
Protein Negative
Sugar Negative
Microscopic- CELL

13
 PUS Cells 13-15
Red Blood Cells 0-3
Epithelial Cell Abundant
Microscopic- EPITHELIUM
Bacteria Plenty
Mucus Thread Rare

April 16, 2019 7:20 am

Result
Macroscopic
Color Yellow
Transparency Slightly Hazy
pH 6.5
Specific Gravity 1.010
Chemical
Protein Negative
Sugar Negative
Microscopic- CELL
PUS Cells 20-25
Red Blood Cells 0-2
Microscopic- EPITHELIUM
Bacteria Few
Squamos Few

Clinical Chemistry, Immunology, Hepatitis B Screening

Conventional Unit SI Unit

Result Normal Range Result Normal
Range
Clinical Chemistry
RBS 134.5 mg/dL [80.0-140.0] 7.46 mmol/L [4.44-7.77]

Result Unit
Immunolgy Method/Principle Used: Immunochromatographic Assay
VDRL NON-REACTIVE

Result Unit
Hepatitis B
HbsAg (Screening) NON-REACTIVE
November 28,2018

6 weeks and 6 days by LMP Impression:

14
Gestational sac: 2.39 cms= 7 weeks and 3 Pregnancy Uterine 7 weeks & 0 day by
days CRL
Crown rump length: 0.76 cms = 6 weeks and Live, Singleton
5 days Cervix long and closed
Yolk Sac: 0.35 cm Normal Both Ovaries
FHB: 113 bpm
EDC: July 17, 2019
Right Ovary: 2.33 x 1.12 x 2.04 cms (vol=2.78
cm3)
Left ovary: 2.98 x 1.56 x 2.86 cms (vol= 6.96
cm3)
Cervix: 2.70 cms , long closed

July 15,2019

Biometry Impression
BPD =36 weeks and 4 days Pregnancy uterine 37 weeks and 0
HC = 36 weeks and 3 days day by fetal biometry
AC = 36 weeks and 6 days Live, Singleton, in cephalic
FL = 38 weeks and 0 days presentation
Average Ultrasonic Age: 37 and 0 days Adequate amniotic fluid volume
Ultrasound EDD: August 5, 2019 Placenta Posterior, grade 3, no previa
Estimated Fetal Weight: 3075 grams (6 lbs Biophysical Score 10/10
and 12 oz)

Biophysical profile
Fetal tone = 2
Fetal Movement = 2
Fetal Breathing = 2
Amniotic Fluid = 2
NST = 2
16.1 th Percentile 10/10

Biometry Impression
BPD =36 weeks and 0 days Pregnancy uterine 35 weeks and 4
HC = 35 weeks and 6 days day by fetal biometry
AC = 34 weeks and 3 days Live, Singleton, in cephalic
FL = 35 weeks and 6 days presentation
Average Ultrasonic Age: 35 and 4 days Adequate amniotic fluid volume
Ultrasound EDD: July 18, 2019 Placenta Posterior, grade 2, no previa
Estimated Fetal Weight: 2601 grams (5 lbs Biophysical Score 10/10
and 12 oz)

15
Biophysical profile
Fetal tone = 2
Fetal Movement = 2
Fetal Breathing = 2
Amniotic Fluid = 2
NST = 2
37.1 th Percentile 10/10

16
LABORATORY INTERPRETATION

Patient JDL’s Complete Blood Count

WBC: A laboratory test that counts the actual number of WBC’s in the blood.

Result: 8.0 out of the normal range of 5.0-10.0, which indicates a normal finding.

RBC: A laboratory test that counts the actual or estimated number of RBC’s per cubic

mm of whole blood.

Result: 3.74 out of the normal range of 3.69-5.90, which indicates a normal finding.

Hemoglobin: A test used to determine the amount of hemoglobin in the blood. HGB is

the pigment part of the erythrocyte, and the oxygen-carrying part of the blood.

Result: 11.0 out of the normal range of 11.7-14.0, which indicates a normal finding.

Hematocrit: The hematocrit measures percentage by volume of packed red blood cells

in a whole blood sample.

Result: 32.6 out of the normal range of 34.1-44.0, which indicates an abnormal finding.

If the Hct is abnormal, then the RBC count is possibly abnormal. If the RBC count turns

out to be normal, then the average size of the RBC is probably too small. Shock,

hemorrhage, dehydration, or excessive IV fluid administration can reduce the Hct.

MCV: Mean Corpuscular Volume. (The volume of the average RBC)

Result: 87.2 out of the normal range of 70.0-97.0, which indicates a normal finding.

MCH: Mean Corpuscular Hemoglobin: (Weight of hemoglobin in each cell)

Result: 29.4 out of the normal range of 26.1-33.3, which indicates a normal finding.

17
MCHC: Mean Corpuscular Hemoglobin Concentration. (Concentration of hemoglobin

in the average RBC)

Result: 33.7 out of the normal range of 32.0-35.0, which indicates a normal finding.

RDW-CV: a measure of the range of variation of red blood cell (RBC) volume that is

reported as part of a standard complete blood count.

Result: 12.8 out of the normal range of 11.0-16.0, which indicates a normal finding.

Platelet Count: A test which is a direct count of platelets (thrombocytes) in whole blood.

Result: 292 out of the normal range of 150-390, which indicates a normal finding.

Patient JDL’s Differential count

Neutrophils: 72.8 out of the normal range of 55.0-62.0, which indicates an abnormal

finding.

Increased by:

 Infection; gonorrhea, osteomyelitis, otitis media, chickenpox, herpes, others

 Ischemic necrosis due to MI, burns, carcinoma

 Metabolic Disorders; diabetic acidosis, eclampsia, uremia, thyrotoxicosis

 Stress Response; due to acute hemorrhage, surgery, emotional distress, others

 Inflammatory disease; rheumatic fever, acute gout, vasculitis, myositis

Lymphocytes: 23.2 out of the normal range of 20.0-40.0, which indicates a normal

finding.

Monocytes: 2.4 out of the normal range of 4.0-10.0, which indicates and abnormal

finding.

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Decreased by: Unknown

Eosinophils: 1.5 out of the normal range of 1.0-6.0, which indicates a normal finding.

Basophils: 0.1 out of the normal range of 0.0-1.0, which indicates a normal finding.

Patient JDL’s Blood Type

Blood type “O” Rh POSITIVE

Patient JDL’s Clinical Chemistry

RBS: Random blood sugar (RBS) measures blood glucose regardless of when you

last ate.

Result: 134.5 mg/dL over the normal range of 80.0- 140.0 (Conventional Units), which

indicates a normal finding.

Patient JDL’s Immunology

VDRL: Venereal disease research laboratory (VDRL) test is a nontreponemal test,

used for screening of syphilis due to its simplicity, sensitivity and low cost.

Result: Non-Reactive

Hepatitis: involves measurement of several hepatitis B virus (HBV)-specific antigens

and antibodies.

Result: Non-Reactive

Patient JDL’s Urinalysis

Color: Yellow. Urine can be a variety of colors, most often shades of yellow, which

indicates a normal finding.

19
Transparency: Substances that cause cloudiness but are not considered unhealthy

include mucus, sperm and prostatic fluid, cells from the skin, normal urine crystals,

and contaminants such as body lotions and powders, which indicates a normal finding.

Result: Slightly hazy

Protein: provides a rough estimate of the amount of albumin in the urine. Albumin

makes up about 60% of the total protein in the blood. Normally, there will be no protein

or a small amount of protein in the urine. When urine protein is elevated, a person has

a condition called proteinuria.

Result: NEGATIVE, which indicates a normal finding.

Sugar: Glucose is normally not present in urine. When glucose is present, the

condition is called glucosuria. It results from either:

1. An excessively high glucose level in the blood, such as may be seen with

people who have uncontrolled diabetes

2. A reduction in the "renal threshold;" when blood glucose level reach a certain

concentration, the kidneys begin to eliminate glucose into the urine to decrease

blood concentrations. Sometimes the threshold concentration is reduced and

glucose enters the urine sooner, at a lower blood glucose concentration.

Some other conditions that can cause glucosuria include hormonal disorders, liver

disease, medications, and pregnancy. When glucosuria occurs, other tests such as a

fasting blood glucose are usually performed to further identify the specific cause.

Result: NEGATIVE

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Pus Cells: The normal range of pus cells in the urine is 0-5. Since the report

suggests pus cells of 8-10 and bacteria is present, it is suggestive of urinary tract

infection (UTI).

Result: 13-15

Red Blood Cells: Normally, a few RBCs are present in urine sediment (0-5 RBCs per

high power field, HPF).

Result: 0-3, which indicates a normal finding.

Epithelial cells: Normally, in men and women, a few epithelial cells can be found in the

urine sediment. In urinary tract conditions such as infections, inflammation, and

malignancies, an increased number of epithelial cells are present.

Result: ABUNDANT

Bacteria: If microbes are seen, they are usually reported as "few," "moderate," or

"many" present per high power field (HPF). In women (and rarely in men), yeast can

also be present in urine. They are most often present in women who have a vaginal

yeast infection because the urine has been contaminated with vaginal secretions

during collection. If yeast are observed in urine, then the person may be treated for a

yeast infection.

Result: PLENTY

Mucus Threads: Mucus in urine may be caused by urinary tract infection, kidney

stones, and ulcerative colitis. As the mucus moves through the urinary tract, it flushes

out germs that may otherwise cause infection.

Result: RARE

21
DRUG STUDY

Generic Name Dosage, Classification Indications Mechanism of Side Effects Nursing

(Brand Name) & Timing & General Class Action Considerations
Date Ordered Route and Family

5% Dextrose in 1 Liter @ Hypertonic Replacement Hypertonic Increase serum 1. Do not administer

Lactated 30 gtts/min Solution; therapy solutions pulls the osmolality, unless solution is
Ringer’s (D5LR) Nonpyrogenic, particularly in fluid into the Hypernatremia, clear and container
parenteral fluid, extracellular vascular by Hypokalemia, is undamaged.
07/21/19 electrolyte, and fluid deficit for osmosis resulting Altered 2. Caution must be
Time Started: nutrient expected in an increase thermoregulation exercise in the
11:00 PM replenisher electrolytes vascular volume. It administration of
needs during raises parenteral fluids.
delivery intravascular 3. Solution containing
osmotic pressure acetate should be
and provides fluid, used with caution
electrolytes and as excess
calories for energy. administration may
result in metabolic
alkalosis.

22
 Generic Name Dosage, Classification Indications Mechanism of Side Effects Nursing
(Brand Name) & Timing & General Class Action Considerations
Date Ordered Route and Family

Oxytocin 10 iu’ Uterine-active To induce or By direct action of Increase heart 1. Continuously

IM agent stimulate myofibrils, rate, monitor fetal and
07/21/19 labor and produces phasic Systemic maternal heart
11:15 PM initiate or contractions venous return, rate, and maternal
improve characteristic of Cardiac output, blood pressure and
uterine normal delivery. Nausea, contractions.
contractions Uterine sensitivity Vomiting 2. Monitor patient
to oxytocin extremely close
increases during during first and
gestation period second stage of
and peaks sharply labor.
before parturition. 3. Assess fluid intake
and output. Watch
for signs and
symptoms of water
intoxication.

23
 Generic Name Dosage, Classification Indications Mechanism of Side Effects Nursing
(Brand Name) & Timing & General Class Action Considerations
Date Ordered Route and Family

Cephalexin 500mg Antibiotic Prophylaxis for Bactericidal, Headache, 1. Assess patient

(Zelexin) 1 capsule Cephalosporin genitourinary Inhibits cell way Dizziness, before and after
Q8° (First infection due to synthesis, Nausea, giving the drug.
07/22/19 PO Generation) the presence causing cell Vomiting, 2. Monitor vital signs.
(4AM- of episiotomy death Diarrhea, 3. Check for side
12NN-8PM) wound @ Bone Marrow effects.
perineum Depression, 4. Ensure that patient
Superinfections takes full course of
Cephalexin as
prescribed.

24
 Generic Name Dosage, Classification Indications Mechanism of Side Effects Nursing
(Brand Name) & Timing & General Class Action Considerations
Date Ordered Route and Family

Tramadol + 37.5mg/325 Analgesics Treatment for Binds to mu- Postural 1. Assess type,
Paracetamol mg (Centrally moderate to opioid receptors. Hypotension, location, and
(Centra) 1 tablet acting) severe pain Inhibits reuptake Bradycardia, intensity of pain
Q8° of serotonin and Collapse, before and 2-3 hr
07/22/19 (4AM- norepinephrine in Hypersensitivity, (peak) after
12NN-8PM) the CNS. Thrombocy administration.
PO topenia, 2. Assess BP & RR
Agranulocytosis before and
periodically during
administration.
3. Assess bowel
function routinely.
4. Assess previous
analgesic history.

25
 Generic Name Dosage, Classification Indications Mechanism of Side Effects Nursing
(Brand Name) & Timing & General Class Action Considerations
Date Ordered Route and Family

Senokot Forte 1 tablet Stimulant Treatment for Senna contains Persistent 1. Assess pattern of
(Calcium QHS laxative constipation sennosides nausea/vomiting bowel movement
Sennosides) PO which acts as a /diarrhea, and signs of
stimulant Muscle cramps/ constipation.
07/22/19 laxative. It works weakness, 2. Take senokot with
by irritating and Irregular full glass of water.
stimulating heartbeat, 3. Tell patient that
intestinal cells, Dizziness, discoloration of
producing Decreased urine may occur
contractions in urination, (pink to red, yellow
intestines, water Mental/mood to brown).
influx to the changes (such
intestines and as confusion),
bowel Reddish brown
movement. urine

26
 Generic Name Dosage, Classification Indications Mechanism of Side Effects Nursing
(Brand Name) & Timing & General Class Action Considerations
Date Ordered Route and Family

Ferrous Sulfate 2-3 mg/kg Iron Prevention of Essential Peptic ulcer, 1. Give between
OD for 30 supplement iron deficiency component in the Vomiting, meals with water
07/22/19 days (Anti-anemic) anemia due to formation of Diarrhea, but may give with
(8 AM) inadequate hemoglobin. Pallor or meals if GI
PO diet, Myoglobin and cyanosis, discomfort occurs.
malabsorption enzymes. It is Darkened color 2. Avoid
pregnancy, necessary for of stool simultaneous
and blood loss effective administration of
during delivery erythropoiesis tetracycline.
and transport or 3. Instruct patient that
utilization of eggs and milk
oxygen. inhibits absorption.
4. Monitor daily
pattern of bowel
activity, darkening
of stool.

27
NURSING CARE PLAN

Priority #1

CUES NURSING OBJECTIVES INETRVENTION RATIONALE EVALUATION

DIAGNOSIS
S: “Sakit Acute Pain Short term goal  Performed an  Indicates need After 30
akong tahi sa related to assessment of pain for/ effectiveness of minutes of
pagpangana episiotomy At the end of 30 to include location, interventions and nursing
k kung incision minutes of nursing characteristics, onse may signal intervention,
mulihok ko secondary to intervention, the t/ duration, development/resoluti goal met.
nagsugod ni normal patient will be able to: frequency, quality, on of complications The patient
adtong spontaneous severity, grimacing verbalized
kadlawon vaginal  verbalize the (0 – 10 scale)  To promote non- “sge di kayo ko
pagkahuman delivery risk factor  Provided comfort pharmacological pai mulihok dayun
nakog associated measures, quiet n management di nako istrain
panganak” with the environment and akoang
as verbalized incision calm activities  To distract attention kaugalingon
by the  determine  Encouraged and reduce tension para di
patient. possible diversional activities musamot ang
method so to and relaxation sakit skong
minimize pain techniques such as tahi” as a risk
O: Guarding  follow focused breathing factor
behavior on prescribed and imaging  To facilitate associated
the pharmacologic  Conducted health understanding about with incision;
buttocarea; al regimen teachings on pain, its risk and was able
Grimace management follow correct

28
expression Long term goal physiology of pain  To prevent fatigue timing of taking
when and its risk factor that can impair ability of drug
moving; At the end of 1 hour of  Encouraged to manage or cope regimen.
Laying on nursing intervention, adequate rest with pain.
one side of the patient will be able periods
bed to ease to:  To maintain After 1 hour of
the pain;  Administered “acceptable” level of nursing
Pain scale of  Report pain is analgesic per pain intervention,
5 out of 10. relieved/ doctor’s order goal met. The
controlled, with patient
the pain scale verbalized
of 2/10 from relief of pain
5/10 from pain
 Demonstrate scale of 5/10 to
use of 1/10; Patient
relaxation skills performed
and diversional deep breathing
activities exercises and
diversional
activities such
as taking care
of her infant
and watching
videos.

29
 Priority #2

CUES NURSIING OBJECTIVES INTERVENTION RATIONALE EVALUATION

DIAGNOSIS
S: “Wala gyuy Ineffective Short term goal:  Health  To help the client After 2 hours of
gagawas na breastfeeding Teaching understand nursing
gatas sa akong related to At the end of 2 hours regarding the proper facilitation intervention,
totoy kay insufficient of nursing proper of care of the infant goal met. The
inverted man parental intervention, the breastfeeding, and to provide patient
gyud akoang knowledge patient will be able breast care satisfying feeding verbalized “grabi
nipple. Kato regarding to: and care for time for both mother man diay ang
akong una na importance of infant and baby sustansiya aning
anak ing-ani breastfeeding  verbalize  Encouraged  To ensure that gatas para sa
gyapon and importance mother to mother gets enough mga bata ba”; “
giformula nalang breastfeeding and benefits drink at least water to hydrate isa sa mga tima-
nako” as techniques of 2000 mL of oneself and make ilhan kung
verbalized by breastfeeding fluid per day breastmilk for infant gutom na ang
the patient.  identify or 6 to 8 oz  Early recognition of bata kay
feeding cues every hour. infant hunger musopsop sa
of infant  Discussed promotes kamot kung dili,
O: Infant is  find the most early infant timely/more muhilak” ;
unable to latch comfortable feeding cues rewarding feeding patient held
on maternal position for experience for infant baby in cradle
breast correctly; her and her and mother hold since it is
Unsustained infant during  To aid in the comfort most
suckling at breastfeeding of the mother and the comfortable for
breast; baby

30
Insufficient  Discussed the her and the
infant weight use of  To find the most infant.
gain; infant is At the end of 8 hours breastfeeding comfortable position
crying during of nursing aids for mother and infant
breastfeeding. intervention, the After 8 hours of
patient will be able  Suggested nNURursing
to: Variety of intervention,
nursing  To limit fatigue and goal met.
 Demonstrate position facilitate relaxation at The patient was
comfortable feeding times able to use hand
position and  Encouraged massage to
correct frequent rest  To maintain or stimulate milk
latching period increase milk supply production; was
 Demonstrate able to hold
breastfeeding  Demonstrated infant in cradle
technique the use of position with
hand infants mouth on
expression breasts areola in
and hand correct latching
pump position

31
 Priority #3

CUES NURSING OBJECTIVES INTERVENTION RATIONALE EVALUATION

DIAGNOSIS

S: “medyo Risk for Short term goal:  Monitored vital  Alteration from Goals met. At the
gangutngot ang infection At the end of 2 signs and normal values end of 2 hours, the
akng tahi dre sa related to hours of nursing assess indicate signs of patient was able to:
ubos ug tukar inadequate interventions, the symptoms of infection
tukar pod ang primary patient will be able infection especially  “ang
kasakit,” as defenses to: especially temperature gapamatuod na
verbalized by secondary to temperature naay inpeksyon
the patient post surgical  state some  Aseptic and akong tahi
incision at the symptoms of technique kay ang
O: Patient perineum infection  Conducted a decreases the pagpanghupong,
reported pain  identify ways health teaching changes of naay gagawas
scale of 5 out of to reduce risks regarding the transmitting or na tubig-tubig,
10; surgical for infection symptoms and spreading gapanginit ang
incision at the  demonstrate ways to reduce pathogens to panit palibot sa
perineum due appropriate risks of infection. the patient. akong samad,”
to natural perineal care Maintained or Interrupting the as verbalized by
spontaneous teach asepsis for transmission of the patient
vaginal Long term goal: dressing infection along  identified ways
delivery; weak At the end of 1 changes and the chain of to reduce risk for
in appearance week of nursing wound care. infection is an infection such as
interventions, the effective way to using aseptic
technique when

32
patient will be able prevent changing wound
to: infection. dressings; intake
of protein-rich
 remain free of  Emphasized the  To promote and calorie-rich
infection importance of cleanliness to foods; increasing
 exhibit proper perineal the perineal intake of fluid,
evidence of care (wash area and etc.
progressive hands before  demonstrated
healing as starting perineal properly how to
demonstrated care, use warm do the perineal
by clean, dry, water and clean care
absent edema, washcloth
and intact moving from At the end of 1 week,
episiotomy site front to back) the patient was able
to:
 Encouraged
intake of protein-  Helps support  remained free of
rich (such as the immune infection
lean meat, eggs, system throughout shift,
chicken breast) responsiveness. without any
and calorie-rich signs and
(such as symptoms of
avocado, dark infections
chocolate, eggs)  exhibited
foods. evidence of
progressive
 Encouraged fluid healing as
intake of 2,000 demonstrated by

33
 to 3,000 mL of  Fluids promote clean, dry,
water per day. diluted urine absent edema,
and frequent and intact
emptying of episiotomy site
bladder –
reducing the
stasis of urine,
in turn, reduces
risk for bladder
 Emphasized infection or
necessity of urinary tract
taking antibiotics infection.
as ordered.
 To prevent drug
resistance

34
DISCHARGE PLAN

Medications  Cephalexin (every eight hours) orally

 Tramadol + Paracetamol (every eight hours) orally

 Senokot Forte (every night at bedtime) orally

 Ferrous Sulfate (once a day for one month) orally

Exercise  Postpartum exercises :

 abdominal breathing (breathe in through the nose

and exhale through the mouth)

 curl up ( Lie on your back with your arms along your

sides. Keeping your lower back flush to the floor,

bend your knees with your feet flat on the floor. Relax

your belly as you inhale. As you exhale, slowly lift

your head and neck off the floor)

 Encourage rest in between periods of activities.

Treatment  Give medications on time and as ordered to promote

recovery

 Monitored vital signs every 4 hours for documentation of

changes.

 Demonstrated proper breastfeeding techniques.

35
 Health  Instruct to continue medication compliance as prescribed

Teachings  Encourage to maintain an environment conducive for

recovery/rest

 Reinforce to continue healthy lifestyle such as smoking and

alcohol cessation and promotion of healthy meals

 Emphasize breastfeeding

Out-Patient  Instruct client to continue follow-up check up to Dr. RB

 Instruct client to comply with the medications.

Diet  Eat healthy foods such as fruits (apples, oranges, bananas,

grapes, and watermelons), vegetables( leafy greens:

broccoli, spinach, kangkong, kale) , and meat(low fat meat:

chicken, fish, and lean pork)

 Drink a lot of water, at least 8-10 glasses of water a day

Spirituality  Consider spiritual guidance through praying/worshipping

her God.

 Maintain positive outlook in life.

36
PROGNOSIS

Legend:

 Excellent (5) — the patient performs excellently, cooperative and responds

actively to nursing interventions; is independent

 Good (4) — the patient performs well; responds actively to nursing

interventions; is somehow independent

 Fair (3) — the patient performs weakly; responds minimally to nursing

interventions; is dependent in some ways

 Poor (2) — the patient performs poorly; does not respond to some of the nursing

interventions; is very dependent to other persons

 Very Poor (1) — the patient does not perform; does not respond to any nursing

interventions; is fully dependent on other person; is fully dependent to other

persons

CRITERIA 5 4 3 2 1 JUSTIFICATION

a.) x As of July 21, 2019 the client has been

in the OB ward and has been actively

Physiologic
responding well to the nursing
response of the
interventions and is somehow
body to the disease
independent. This is evidenced by her
process
vital signs that have constantly been

normal, it is within the normal range.

37
b.) x The patient felt pain during stretching.

This incision can cause great pain and

Relief of symptoms
discomfort to mothers.
associated with the

disease condition

c.) x The client can perform some of the

activities of daily living but due to her

Performance of
episiotomy incision on her perineal area
activities of daily
the client needs to be assisted.
living

d.) x The patient receives all her medications

during the time needed and does not

Compliance to the
have any complains. The client was
medication and
very obedient in observing and
therapy
maintaining her daily scheduled intake

of medications.

e.) x The client has an adequate amount of

sleep, specifically 7-8 hours at night.

Adequacy of rest
Furthermore, she takes naps at least
and sleep
once a day most commonly during the

afternoons. The client does not have

difficulty in sleeping and does not use

any sleeping aids.

38
f.) x The patient has no complaints about

her diet or the food taken prior or after

Appetite of the
the medication
patient considering

the medication

g.) x Patient’s watcher’s behavior on the

health teachings given by the health

Patient’s watcher’s
care providers
behavior on the

health teachings

given by the health

care providers

h.) x The patient is well aware and attentive

with the instructions given by the

Patient’s
healthcare providers and stated that
perception to
she is feeling better as the medication
illness
continues. The patient perceives that

she is getting better after following the

nursing interventions and medication

regime.

39
 i.) x While assessing the patient, it was

evident that the client was able to talk

Patient’s social
and interact with the different health
interaction
providers. She talked and answered the

student nurses well with a gentle tone.

Scoring

Weight Frequency Score

(Frequency x Weight)

Excellent 5 5 25

Good 4 3 12

Fair 3 1 3

Poor 2 0 0

Very Poor 1 0 0

Total Score 37

Percentage (Total Score / 45 = N x 100 = %) 82.2 %

40
Rating Scale

90 % - 100 % - Excellent

77 % - 89.99 % - Good

68 % - 76.99 %- Fair

50 % - 67.99 %- Poor

50 % below- Very Poor

Prognosis: Good

41
CONCLUSION

Patient JDL, as of the submission of this case presentation, was already

discharged last July 23, 2019 from the OB Ward unit of Maria Reyna - Xavier University

Hospital. The patient was in good condition and is feeling better however her case still

needs to be supervised because not only has it affected her but her neonate as well.

As a response, particular nursing interventions were given to the patient.

The patient's vital signs remained stable postpartum. She was having a hard

time breastfeeding her neonate due to her inverted nipple. Her infant was unable to

latch on the maternal breast correctly, thus, there was an unsustained suckling at

breast. She had also undergone a 3-inch median episiotomy during delivery, and has

been experiencing pain in her perineum when she pursues movement. Furthermore,

there was also a risk for infection related to her post-surgical incision. The healing

process of her episiotomy may take some time. However, this will be aided by her

home medications and with keen obedience to the health teachings that were taught.

Some nursing interventions include stating some symptoms of infection, identifying

ways to reduce the risk of infection, demonstrating the appropriate perineal care,

demonstrating the use of relaxation skills and diversional activities, identifying feeding

cues of infant, finding and demonstrating the most comfortable position, correct

latching, and breastfeeding techniques for the mother.

The case presentation has endeavored to analyze, examine, and give

legitimate nursing insights on the condition of patient JDL. The study incorporates all

the various parts of consideration that was given to the patient, with emphasis to the

nursing management that was administered. The student nurses mean to give quality

and all-encompassing nursing care for the patient.

42
BIBLIOGRAPHY

Deglin, J. H., & Vallerand, A. H. (2009). Davis's Drug Guide for Nurses(11th ed.).

Philadelphia: F.A Davis Company.

Doenges, M. E., Moorhouse, M., & Murr, A. C. (2016). Nurse's Pocket Guide:

Diagnosis, Prioritized Interventions, and Rationales(14th ed.). Philadelphia: F.A

Davis Company.

Skidmore-Roth, L. (2015). Mosby’s Drug Guide for Nursing Students (11th ed.). St.

Louis, Missouri: Elsevier Mosby.

43
APPENDIX

VITAL SIGNS

Date and Time BP (mmHg) T (°C) P (bpm) R (cpm)

07/21/19 11:30P 120/80 36.6 76 20

07/21/19 11:45P 120/80 36.8 70 19

07/22/19 12:00A 120/80 36.8 74 20

07/22/19 12:15A 110/80 36.8 68 19

07/22/19 12:30A 120/80 36.8 68 19

07/22/19 01:00A 110/70 36 80 20

07/22/19 04:00A 120/70 36 100 21

INTAKE

Time Oral Parenteral Total

6-2

2-10

10-6 750 150 + 450 1350

Total 750 600 1350

44
 OUTPUT

Time Urine NGT Drainage Total

6-2

2-10

10-6 400 - - 400

Total 400 400

PHYSICIAN’S ORDERS

PHYSICIANS ORDERS

NOTES

7/21/19 > Admit under service package

10:10 PM > Soft Diet

> General liquids when in active labor

> Monitor progress labor

> Monitor FHT every hour

> Start D5LR 1L @ 30gtts/min when in active labor

> Attach lab results to the chart

> Let patient stay at labor room

45
 > Refer accordingly

12:00 AM > Transport back to ward

> DAT

> Regulate IVF to 30 gtts

> Oxytocin 10 u IM

> Cephalexin 500g; q5

> Tramadol + Paracetamol q8

> Senocot forte H.S

> Perineal care

> Hypogastric massage as needed

> Vital Signs q 15 minutes x 4 takings then every 4 hours until

stable

> Watch out for profuse bleeding

> Refer accordingly

46
 NURSES NOTES

DATE FOCUS DATA/ACTION/RESPONSE

AND TIME

07/21/19 Admission - Received patient from ER, c labor pains

10:30 pm - Ushered to labor room

- (+) complains of strong contractions

- Transferred to DR

- i.e done – fully dilated

- informed ap and pedia

- started ivf of d5lr 1L @30 gtts/min

- placed on lithotomy position

- shaving done

- skin pup done

- drapings put on

- pushing techniques instructed

- Lidocaine given

- episiotomy done

- received a live baby girl

47
 - placenta out

- Cord clamped and cut

- Placenta out

- BP taken – 120/80 mmhg

- Episiorraphy done

- Vital signs taken and recorded

- Lactation support done

- May go back to ward

- Transported per wheelchair

7/22/19 Post trans for - Transported per stretcher

assessment
1:00 am - Endorsed to station nurse on duty

- Received from DR per stretcher

- NSVD

- IVF well regulated, maintained for profuse vaginal

bleeding, encouraged to verbalize concerns, kept

watched.

- Patient endorsed

48
 XAVIER UNIVERSITY IV. HISTORY OF FAMILY
ATENEO DE CAGAYAN  HYPERTENSION
OBSTETRIC ASSESSMENT TOOL  CORONARY ARTERY DISEASE
 CEREBRO-VASCULAR DISEASE
 DIABETES MELLITUS
I. GENERAL INFORMATION  KIDNEY DISEASE
NAME: JDL AGE: 33 BIRTHDAY: 3/25/86
 TUBERCULOSIS
CIVIL STATUS: MARRIED SEX: F RELIGION: ROMAN CATHOLIC
OCCUPATION: TRAFFIC AID ADDRESS: #0930 PIAPLNG MACABALAN,  CANCER
CAGAYAN DE ORO CITY, MISAMIS ORIENTAL
V. OBTETRIC HISTORY
INFORMANT: MR. L RELATION: HUSBAND
ADMISSION DATE: 7/21/19 TIME: 10PM PARA: 2 GRAVIDA: 2 TPAL: 2-0-0-2
CHIEF COMPLAINT: LABOR PAINS PRENATAL CARE COVERAGE: PRENATAL VITAMINS
ATTENDING PHYSICIAN: DR. RB PLACE OF PRENATAL CARE: MRXUH
DIAGNOSIS/IMPRESSION: PREGNANCY FULL TERM CEPHALIC INLABOR TOTAL NUMBER OF VISITS: 8 AND MORE
FEMALE NEONATE ABNORMAL FINDINGS: -
PRE-PREGNANCY WEIGHT: 47KG
WEIGHT GAIN: 4.5KG
II. HISTORY OF PRESENT ILLNESS: LAST MENTRUAL PERIOD: OCT. 11, 2018
PATIENT RECEIVED AMBULATORY, NON-DYSPNEA WITH COMPLAINTS OF EDC: JULY 18, 2019
BROWNISH VAGINAL DISCHARGE. INTERNAL EXAMINATION DONE BY AGE OF GESTATION: 38 WEEKS
MIDWIFE, 10 MINUTES LATER BOW RUPTURED ACTUAL DATE OF DELIVERY: 7/21/19 TIME: 11:19PM
TYPE OF DELIVERY: NORMAL SPONTANEOUS VAGINAL DELIVERY
CURRENT MEDICATIONS: POSITION OF FETUS: CEPHALIC PRESENTATION
NAME, DOSE TIMING, ROUTE INDICATION COMPLICATIONS OF LABOR: -
CEPHALEXIN 500MG CAP q8h SKIN AND GENITOURINARY INFECTION ONSET AND DURATION OF LABOR: 3HRS
EPISIOTOMY: MEDIAN LOCHIA: RUBRA AMOUNT: 250ML
TDL+ PCM P.O q8h MODERATE TO SEVERE ACUTE PAIN COMPLICATIONS OF PREGNANCY: -
EXCESSIVE BLEEDING: -
INFECTIONS: -
SENOKOT FORTE 1 TAB HS P.O LAXATIVE INFANT’S APGAR SCORE:
PLANS FOR FEEDING: EXCLUSIVE BREASTFEEDING FOR 6 MONTHS

UPON ASSESSMENT: VI. GYNECOLOGIC HISTORY

VITAL SIGNS: HR: 68BPM RR: 22BPM BP: 120/80MMHG TEMP: 36 C AGE OF MENARCHE: 12
Ht: 5’2 Wt: 61.5KG BMI: 24.8 MENSTRUAL CYCLE:
INTERPRETATION OF BMI: NORMAL WEIGHT INTERVAL/LENGTH: 28
DURATION OF FLOW: 5
III. PAST OBSTETRIC/MEDICAL/SURGICAL HISTORY AMOUNT OF FLOW: MODERATE
UN 2 TRIMESTER OF PREGNANCY
ND MENSTRUAL DISCOMFORT: DYSMENORRHEA
VAGINAL DISCHARGE: NO SMELL, MILKY WHITE COLOR
BLEEDING BETWEEN PERIODS: -
SEXUALLY ACTIVE: YES SEXUAL DIFFICULTIES: -

49
RECENT CHANGE IN INTEREST/FREQUENCY: - EDEMA IN EYELIDS NONE
REPRODUCTIVE TRACT SURGERY: - SCLERA AND CONJUCTIVA: PINK AND MOIST
FAMILY PLANNING METHODS USED: NATURAL- CALENDAR METHOD SPOTS BEFORE THE EYES: NONE
FOR HOW LONG: 8 YEARS DOUBLE VISION: NONE
SIDE EFFECTS IF ANY: - SUBJECTIVE
PREVIOUS MISCARRIAGES/ABORTION: NONE
NOSE
VII. ASSESSMENT OF SYSTEMS NASAL CONGESTION: NONE
OBJECTIVE SENSE OF SMELL: ABLE TO SMELL WELL
GENERAL APPEARANCE AND MENTAL STATUS: ALERT, WELL GROOMED, EPISTAXIS: NONE
INTERESTED
PERSONAL HYGIENE: WELL KEPT MOUTH, TEETH AND THROAT
HAIR: STRAIGHT, EVENLY DISTRIBUTED OBJECTIVE
CLOTHING/ MANNER OF DRESS: CONDITION OF MOUTH: HEALTHY NO LESIONS
BODY ODOR: NONE CONDITION OF TEETH AND GUMS: NO CAVITIES, PINK GUMS, NO LESIONS
SKIN INTEGRITY: INTACT, NORMAL TURGOR APPEARANCE OF TONGUE: PINK, MOIST, NO LESIONS
SPEECH: LESIONS: -
 CLEAR DENTAL HYGIENE: GOOD HYGIENE
 UNINTELIGABLE DENTAL CARRIES: -
 SLURRED
 APHASIC NECK/ LYMPH NODES
OBJECTIVE
SUBJECTIVE THYROID HYPERTROPHY: -
PAIN: PALPABLE LYMPH NODE: CERVICAL LYMPH NODE PALPABLE
PRECIPITATING: “SAKIT SA TAHI”
QUALITY: “KANA MURAG STRETCHING” BREAST
LOCATION: PERINIAL AREA SEVERITY: 5 OUT OF 10 OBJECTIVE/SUBJECTIVE
TIME: “WHEN MOVING” BREAST CHANGES:
AREOLA: LARGER, DARKER
HEAD AND SCALP BREAST SIZE: ENLARGED
SYMMETRY: SYMETRIC PRESENCE OF COLOSTRUM: YES
CONTOUR: SMOOTH DISTRIBUTION: EVENj ADEQUACY OF BREAST FOR BREASTFEEDING: NOT ENOUGH MILK
THICKNESS: MODERATE DRYNESS/OILINESS: OILY PRODUCED
USE OF HAIR DYE: - ABNORMAL SIGNS: INVERTED NIPPLE
LESIONS: - PERFORM BSE (FREQUENCY AND SCHEDULE): 1X A MONTH
SUBJECTIVE
HEADACHE SEVERITY: - LOCATION: - FREQUENCY: - ABDOMEN
DIZZINESS: - OBJECTIVE (ANTEPARTUM)
WEAKNESS: - FUNDAL HEIGHT: 38CM
EYES/EARS LEOPOLD'S MANEUVER: RIGHT OCCIPUT ANTERIOR
FETAL POSITION: CEPHALIC
OBJECTIVE:

50
PELVIC MEASUREMENT: 12CM GYNECOID
ACTIVITY AND REST
CIRCULATION HOBBIES: “LIMPYO SA BALAY”
ANKLE/LEG EDEMA: - LEISURE TIME ACTIVITIES: “TAN.AW TV”
HISTORY OF HYPERTENSION: - SLEEP
EXTERMITIES: NUMBNES: - TINGLING: - # OF HOURS: 8HRS NAPS:30 MIN
CHANGE IN FREQUENCY/AMOUNT OF URINE: INCREASE IN FREQUENCY FEELING ON AWAKENING: “OKAY RA”
HOMAN'S SIGN: NEGATIVE DIFFICULTY IN SLEEPING: -

OBJECTIVE EGO INTEGRITY

BP: 120/80MMHG SUBJECTIVE
HEART RATE: 68BPM REPORT OF STRESS FACTORS: WORK
CAPILLARY REFILL: <2SECONDS WAYS OF HANDLING STRESS: “PAHANGIN, MUGAWAS SA OFFICE”
COLOR: PINK FINANCIAL CONCERNS: NONE
CYANOSIS/PALLOR: - RELATIONSHIP STATUS: MARRIED
VARICOSITES: - LIFESTYLE: ACTIVE
NAIL BEDS: CONVEX, SMOOTH, SHINNY HELPLESSNESS, HOPELESSNESS, POWERLESSNESS: NONE
MUCOS MEMBRANES: MOIST, PINK, NO LESIONS
EMOTIONAL STATUS: CALM
RESPIRATION:
OBJECTIVE
RR: 22BPM SAFETY
DEPTH: NORMAL SUBJECTIVE
SYMMETRY: SYMETRIC ALLERGIES: -
SMOKER: NO HISTORY OF STD: -

FOOD/ FLUID INTAKE SOCIAL INTERACTIONS

USUAL DIET: REGULAR DIET SUBJECTIVE:
NO. OF MEALS: 3X A DAY MARITAL STATUS: MARRIED
LAST MEAL INTAKE: BREAKFAST YEARS IN A RELATIONSHIP: 8YEARS
NAUSEA: - LIVING WITH: HUSBAND
EXTENDED FAMILY: NONE
ELIMINATION ROLE WITHIN THE FAMILY: WORKING MOTHER AND WIFE
USUAL BOWEL PATTERN: EVERYDAY
CHARACTER OF STOOL TEACHING/LEARNING
AMOUNT: ONE CUP SUBJECTIVE
COLOR: BLACK DOMINANT LANGUAGE: “ OO, BISAYA”
FREQUENCY: ONCE A DAY LITERATE: YES
ODOR: FOUL EDUCATIONAL LEVEL: TERTIARY
USUAL VOIDING PATTERN: 3X A DAY
PAIN WHEN VOIDING: -
HISTORY OF KIDNEY DISEASE: -

51
DEVELOPMENTAL MILESTONE
AGE PSYCHOSEXUAL PSYCHO-SOCIAL COGNITIVE

32 GENITAL INTIMACY VS FORMAL

Y/O -SEXUAL ISOLATION OPERATIONAL
RELATIONSHIPS -ESTABLISHING -ABLE TO THINK
BONDS AND ABSTRACTLY AND
RELATIONSHIPS CRITICALLY

LEGEND:
Episiotomy
IVF (D5LR) on left hand
Linea Negra
Inverted Nipple
BODY MAP

52