Name: Escoton, Kate Angel P.

Case Study #: 2
Course and Section: BSN 2-A3 Date of Submission: March 25, 2021

General Objectives:
Within the context of the case, the student nurse is expected to make quick and critical decisions, advocate for health maintenance
routines, and improve maternal prepartum care.
Specific Objectives:

 To provide the expectant mother with adequate and high-quality care.

 To educate the patient about health care.
 To improve our abilities and knowledge in the area of maternal health care.
 To build a nurse- patient relationship
 To create effective therapies for the comfort of patients.
 To take precise vital sign readings.
Introduction
Patient’s Demographic Data

Patients’ Name: Jennifer T. Lee

Age: 23
Sex: Female
Status: Married
Religion: Roman Catholic
 Citizenship: Filipino
Address: Inayawan, Cebu City
Spouse: Jet Lee
Occupation: HR Personnel
Date of Birth: October 21, 1997
Place of Birth: Cebu City
Name of Mother: Jenny Tan
Name of Father: Lucio Tan

Disease Definition
The abdominal cavity (also known as the peritoneal cavity) is bounded anterolaterally by the xiphoid process and coastal margins,
posteriorly by the vertebral column, superiorly by the diaphragm, and inferiorly by the upper parts of the pelvic bones. It contains
multiple visceral organs and is covered by parietal and visceral layers of the peritoneum.
Abdominal pain occurs when mechanical or chemical stimuli trigger the pain receptors in the abdomen. Stretch is the primary mechanical
stimulus. Other mechanical stimuli, such as expansion, contraction, compression, pulling, and twisting of the viscera, also induce pain.

Assessment of Signs and Symptoms

Chief Complaint(s): Labor pain
S: 10 hours PTL, noted onset of crampy hypogastric pain radiating to Lumbosacral area, associated with mucoid bloody discharge noted
and persistence of symptoms thus decided to seek consult.
Laboratory and Diagnostic Studies

Date Type of Exam Patient’s Results Normal Values Significance/Interpretation

5/14/20 Hematology WBC: 9.70 WBC: 4.4-11.0 A high neutrophil count, low
Specific lymphocyte count, and high monocyte
Examination: Neutrophil: Neutrophil: count indicate the presence of
infection.
CBC %60.9 %37.00-80.00
#5.91 #1.8-7.8
Lymphocyte: Lymphocyte:
%23.8 %10.00-50.00
#2.31 #1.0-4.8
Monocyte: Monocyte:
%14.1 %0.00-12.00
#1.37 #0.0-1.0
Eosinophil: Eosinophil:
%0.8 %0.0-7.0
#0.08 #0.0-0.4
Basophil: Basophil:
% 0.4 %0.0-2.5
#0.04 #0.0-0.2
RBC: 3.95 4.5-5.1
HGB – 12.7 12.3-15.3
HCT 37.7 35.9-44.6
MCV – 95 80-96
MCH – 32.2 27.5-33.2
MCHC -33.8 32.0-36.0
RDW – 11.5 11.6-14.8
PLT – 187 150-450
MPV – 7.4 6.0-11.0
 Date Type of Exam Patient’s Results Normal Values Significance/Interpretation
NONREACTIVE
5/14/20 Immunology Specific Normal outcomes are negative or
Examination: nonreactive, indicating that no
HBsAg Nonreactive: <1.0 hepatitis B surface antigen was
HBsAg (Quantitative) detected. If your test results are
Reactive: >1.0 positive or reactive, you may be
infected with HBV.

HBeAg (Quantitative) Nonreactive: ≤1.0

Reactive: >1.0

Anti-HBs Titer Nonreactive: <10.0

Reactive: >10

Nonreactive: <5
Anti- Hbc (IgM)
Reactive: >10

Anti- Hbc (Total) Nonreactive: <1.0

Reactive: >1.4

Anti- HAV (IgM) Nonreactive: <1.40

 Reactive: ≥1.50

Anti-HCV (Quantitative)
Nonreactive: <0.9
Reactive: >0.9

Date Type of Exam Patient’s Results Normal Values Significance/Interpretation

5/14/20 Clinical Microscopy Color: Dark Yellow Color: pale Normal urine is yellow or amber in
Specific yellow/yellow color. Detection of WBC in urine is
Examination: Volume: 60 mL typically associated with infection.
Transparency: clear
Urine Analysis Transparency: Cloudy
Specific gravity: 1.010 to
Specific gravity: 1.010 1.030
Albumin: 1+ Albumin: less than 20
mg a day
pH: 6.5
pH: 6.0
Ketone: 3+
Ketone: 30 to 40 mg/dL
Blood: 3+
Blood: 0 to 3
WBC: 8-10/HPF
WBC: 0-5/HPF
RBC: 50-60/HPF
RBC: 4/HPF
Glucose: Trace
Glucose: 0 to trace
Nitrite: Negative
 Bilirubin: Negative Nitrite: Negative
Urobilinogen: Normal Bilirubin:
Epithelial cells: Rare Negative
Mucus threads: Rare Urobilinogen: Negative
Bacteria: Moderate Epithelial cells: Negative
Mucus threads: Rare
Bacteria: None

Date Type of Exam Patient’s Results Normal Values Significance/Interpretation

 No. of fetuses-1
5/14/20 Ultrasound Report BPD- 6.31 cm (Normal range at 25 weeks) Fetal growth and weight are estimated
Obstetrics using ultrasound measurements of
HC- 23.9 cm BPD- 6 to 7 cm biparietal diameter (BPD), head
Second and Third AC- 20.7 cm circumference (HC), abdominal
Trimester Fl: 4.91 cm HC- 21.7 to 25.2 circumference (AC), and femur length
Average ultrasonic age- AC-18.4 to 23.3 cm (FL).
25W6D
Estimated fetal weight- FL- 4.2 to 5.0 cm
860 grams
Ultrasonic EDC-5/29/2020
Placenta- Posterior, high
lying
Grade- 2
Presentation- Cephalic
FHB- 129 bpm
Amniotic Fluid Index- 5.12
cm SVP
FHB- 120 to 160 bpm
Amniotic Fluid Index- 5 cm
to 25 cm
Pathophysiology

Gas pain
-Gas can cause excruciating abdominal pain. It may stay in one area or travel throughout your belly, back, and chest. According to
the Mayo Clinic, women experience more gas during pregnancy due to increased progesterone. Progesterone causes intestinal muscles
to relax and extends the time it takes food to get through the intestines. Food remains in the colon longer, which allows more gas to
develop.
Round Ligament Pain
-There are two large round ligaments that run from the uterus through the groin. These ligaments support the uterus. As the uterus
stretches to accommodate your growing baby, so do the ligaments. This may cause sharp or dull pain in the abdomen, hips, or groin.
Constipation
-Constipation is a common complaint among pregnant women. Fluctuating hormones, diet that is short on fluids or fiber, lack of exercise,
iron pills, or general anxiety can all lead to constipation. Constipation may cause severe pain. It is often described as cramping or sharp
and stabbing pain.
Braxton-Hicks contractions
-These “practice” or “false” contractions occur when the uterine muscles contract for up to two minutes. The contractions are not labor
and are irregular and unpredictable. They may cause pain and uncomfortable pressure, but they are a normal part of pregnancy.
Drug Studies

Drug Name Classification Mechanism Indication Contraindication Adverse Reaction Nursing Responsibilities
of Action
Generic Name: antifungal  involves Oropharyngeal Contraindicated CNS: headache, Before: Examine for signs
Fluconazole Pregnancy interruption and in patients dizziness and symptoms of infection.
risk category of the esophageal hypersensitive GI: N/V,
Brand Name: C conversion candidiasis; to drug and abdominal pain, Hepatotoxicity should be
Diflucan/Dyzolor of vaginal other drugs in diarrhea, monitored because severe
lanosterol candidiasis; same class dyspepsia, taste hepatotoxicity can occur in
Dosage, Route, to prevention of perversion patients with underlying
Frequency: ergosterol candidiasis in Hematologic: medical conditions.
150 mg/cap P.O via binding bone marrow leukopenia,
once a month x3 to fungal transplant; thrombocytopenia During:
months cytochrome cryptococcal Skin: rash Infuse IV only; not intended
P-450 and meningitis. Other: for IM or subcutaneous use.
subsequent anaphylaxis
disruption Do not add supplement
of fungal medication to fluconazole.
membranes.
Administer through sterile
equipment at a maximum
rate of 200 mg/hr given as a
continuous infusion.

Monitor renal function tests

weekly, discontinue or
decrease dosage of drug at
any sign of increased renal
toxicity. Monitor liver
function tests monthly
during therapy.

After:
Instruct patient that she may
experience these side
effects: Nausea, vomiting,
diarrhea (frequent small
meals may help); headache
(analgesics may be ordered).

Report rash, changes in stool

or urine color, difficulty
breathing, increased tears or
salivation.
Generic Multivitamins Iron is a critical Multivitamins MV+Iron is Constipation, Before:
Name: component of with iron are contraindicated in Diarrhea, Do not use this 
MV+Iron the body in used to provide patients with liver Nausea,  medicine without 
which its primary vitamins and problems,  Vomiting, doctor's advice or
Brand role is to store iron that are stomach/ intestinal Heart burn, prescription.
Name: and transport not taken in problems.  Stomach
Foralivit iron (as through diet. Iron and certain pain/upset During:
myoglobin or They are also vitamins can cause stomach, Use 
Dosage, hemoglobin) used to treat serious or life- Black or dark multivitamin with 
route, throughout the iron or vitamin threatening side colored stools or iron as directed on
frequency: body. The role of deficiencies effects if taken in large urine, the label. Do 
65 mg, P.O, iron caused by doses. Do not take Temporary not use the 
q.d supplementation illnesses, more of this medicine staining of the medicine in 
is to replace pregnancy, than directed on the teeth, larger amounts 
those iron stores poor nutrition, label or prescribed by Headache, or or for longer 
and to digestive your doctor Unusual or than 
encourage disorders, and unpleasant taste recommended
erythropoiesis many other in your mouth. dosages
and oxygen conditions. 
transportation After:
throughout the Monitor patient for
body.  adverse reactions or
possible side
effects.
Generic Name: Anti- due to selective indicated for contraindicated in headache, fever Before:
Celecoxib inflammatory inhibition of the patients with (pyrexia), upper Assessment for
cyclooxygenase-2 management salicylate abdominal pain, renal impairment,
Brand (COX-2), which is of the signs hypersensitivity or cough, impaired hearing,
Name: responsible for and symptoms NSAID nasopharyngitis, allergies, Hepatic
Celebrex prostaglandin of hypersensitivity abdominal pain, and CV
synthesis, an integral osteoarthritis, who have nausea, conditions,
Dosage, route, part of the pain and rheumatoid experienced arthralgia, lactation,
frequency: inflammation pathway. arthritis, asthma, urticaria, diarrhea and pregnancy.
200 mg 1 cap This pharmacologic juvenile or other allergic vomiting.
BID P.O activity rheumatoid reactions after During:
gives celecoxib its arthritis in taking aspirin or Give drug with
analgesic, anti- patients 2 other NSAIDs. food or meals if GI
inflammatory, and years and upset occurs.
antipyretic effects. older, and  
ankylosing Give only
spondylitis; for prescribed
the dosage; do not
management increase dosage.
of acute pain in  
adults, and for Assess for allergy
the to sulfa, aspirin,
management or NSAIDs
of primary (contraindicated).
dysmenorrhea. -Observe for
bleeding, bruising,
weight gain.
 After:
Report sore
throat, fever rash,
itching, weight
gain, swelling in
ankles or fingers;
changes in vision.
 
Evaluate for
therapeutic
response: pain
relief; decreased
stiffness, swelling;
increased joint
mobility; reduced
joint tenderness;
improved grip
strength.

Generic Name: Imidazole Contains miconazole Treatment of Known Vaginal Before:

Metronidazole derivative nitrate for antifungal vaginal hypersensitivity to Disorders: Have patient void
+ Miconazole anti- effect and candidiasis any active Vaginal irritation prior to
Nitrate infectives metronidazole for caused by ingredients or (burning, procedure.
antibacterial and Candida derivatives of itching)
antitrichomonal albicans, Neo-Penotran Ensure that you
Brand effects, and lidocaine bacterial GI: abdominal have water-
Name: for local anesthetic vaginitis Patients with pain or cramps soluble lubricant
Neo-penotran effect. caused by severe liver (3%), metallic available for
anaerobic function disorders taste (1.7%), medication
Dosage, route, bacteria and (including constipation, dry administration.
frequency: Gardnerella porphyria), mouth, seldom
Vag-supp HS x vaginalis, nervous system diarrhea, lack of During:
1 week trichomonal appetite, Assist patient in
vaginitis vomiting, nausea lying position
caused by before inserting
Trichomonas CNS: Headache, the supp.
vaginalis and ataxia, dizziness,
mixed vaginal mental changes, Encourage the
infections. peripheral patient not to
neuropathy after stand up half an
overdose or long hour after placing
period of usage, the supp.
cramps.
After:
Skin: Rash Report if any
rashes occur.
Hem: Decreased
white blood Advise patient not
cells. to breast feed
without
consulting
physician.
Generic Antibiotic Binds to Treatment of History of CNS: Headache, Before:
Name: Cephalosporin bacterial cell susceptible anaphylactic dizziness, lethargy,
infections due to reaction to paresthesia GI: Assess for history of
(first membranes,
Cefalexin staphylococci, penicillin, Nausea, vomiting, allergies, particularly
generation) inhibits cell
group A hypersensitivity diarrhea, anorexia, cephalosporins,
wall
streptococcus,K. to abdominal pain, penicillin.
synthesis.
Brand pneumoniae, E. cephalosporins. flatulence,
Therapeutic
Name: coli, P. mirabilis, Cautions: pseudomembranous
Effect:
H. influenzae, M. Renal/hepatic colitis, hepatotoxicity During:
Apo- Bactericidal. catarrhalis impairment, GU: Nephrotoxicity
Cephalex including history of GI Hematologic: Bone Assess oral cavity for
(CAN), respiratory tract, disease (esp. marrow depression white patches on
Biocef, genitourinary ulcerative colitis, Hypersensitivity: mucous membranes,
Keflex, tract, skin, soft antibiotic- Ranging from rash to tongue (thrush).
NovoLexin tissue, bone associated fever to anaphylaxis;
(CAN), infections; otitis colitis). serum sickness
NuCephalex media; reaction Monitor daily pattern
(CAN) rheumatic fever Other: of bowel activity, stool
prophylaxis; Superinfections consistency. Mild GI
follow-up to
effects may be
parenteral
Dosage, tolerable (increasing
therapy.
Route, severity may indicate
Frequency: onset of antibiotic-
associated colitis).
500 mg1
cap TID P.O.
x 6 days.
After:
Continue therapy for
full length of
treatment.

May cause GI upset

(may take with food,
milk). Refrigerate oral
suspension.

Report prolonged
diarrhea.
Generic Name: Stimulant Anthraquinone Constipation Should not be Loss of normal Before:
Senna laxatives derivatives such given when any reflexes to move Assess cause of
as senna are stimulant undiagnosed bowels, constipation - is
Brand laxatives. Stimulant acute or melanosis coli, fluid, fiber or
laxatives work by
Name: persistent nephritis. exercise missing
irritating luminal sensory
Senakot abdominal Nausea and from lifestyle,
nerve endings, thereby
stimulating colonic symptoms are rectal burning as fluid balance.
Dosage, route, motility, and reducing present. suppository.
frequency: colonic water absorption. During:
1 amp IVTT q8 Drug should be
hours discontinued if
cramping, rectal
bleeding, nausea,
or vomiting
occur. 

Administer alone
for better
absorption.

Do not administer
within one hour
of other drugs,
antacids, or milk.

After:
Notify physician if
constipation is
unrelieved or
symptoms of
electrolyte
 imbalance occur
(muscle cramps,
pain, weakness,
dizziness). 

If diarrhea occurs,
discontinue use.

Generic Antioxidant Aqueous and Moringa is taken increased the Lower blood Before:
Name: alcoholic by mouth for risk of liver pressure and slow Examine for history of
Moringa extracts "tired blood" and kidney heart rate because allergies.
(methanolic & (anemia), arthritis and damage in of the alkaloidal in
Brand ethanolic) of other joint pain  rats. Do not the plant. Uterine During:
Name: leaves and (rheumatism), asthma,  consume  contractions from Give the prescribed
Feralac roots cancer,  moringa if moringa bark. Cell dosage as directed by the
of Moringa oleif constipation, diabetes,  you are mutations caused physician.
Dosage, era exhibit diarrhea, pregnant, by a chemical
route, strong in-vitro seizures, stomach pain, taking the isolated from After:
frequen antioxidant and stomach and intestinal diabetes drug roasted moringa Monitor patient for
cy: radical ulcers, intestinal Januvia seeds. adverse reactions or
1 cap scavenging spasms, headache, heart  (sitagliptin) or Interference with possible side effects.
OD P.O activity. Its problems, high blood taking drugs fertility.
leaves are rich pressure, kidney stones, that are
source of symptoms substrates of
antioxidant of menopause, thyroid  the
compounds; disorders, and infections. cytochrome
they could P450 family of
protect the enzymes.
animals against
diseases
induced by
oxidative stress.
Nursing Care Plan

Defining Nursing Diagnosis Scientific Analysis Plan of Care Nursing Rationale

Characteristics Interventions
Subjective: Acute pain related Active labor begins Short Term: Independent: These data can be
Pt scores pain 9 out to muscle at 4 cm cervical After 2 hours of Assess pain used to identify the
of 10 contraction due to dilatation and interaction characteristics, extent of the pain
Pt complains active labor as progresses to 7 cm between the nurse (quality), severity, as well as serve as a
hypogastric pain evidenced by cervical dilatation. and the patient, the location, onset, baseline
patient’s During this phase, patient will be able duration, information.
Objective: verbalization of the contraction to: precipitating and
BP: 100/70 mmHg pain intensity increases, relieving factors).
HR: 100 bpm the intervals Pt. will comprehend
RR: 21 bpm shorten, and the the source of his Observe or monitor
T: 36.2° C duration lengthens. discomfort. signs and symptoms Some people deny
Weight: 109 lbs The patient feels associated with the experience of
true discomfort for Pt. will verbalize pain, such as BP, pain when it is
the first time at this decrease in pain. heart rate, present. Attention
point, so she temperature, color to associated signs
becomes and moisture of may help the nurse
dependent and skin, restlessness, evaluating pain.
focuses on herself. Long term: and ability to focus.
Pt. will demonstrate
the use of Assess for probable Different etiological
relaxation cause of pain. factors respond
techniques and better to different
diversionary therapies.
activities.
Assess patient’s Some patients may
Pt. will report knowledge of or be unaware of
pain/discomfort preference for the some strategies and
relieved or array of pain-relief this will give them
controlled. strategies available. better ideas.
 
Provide a quiet Decreases stimuli,
environment and refocus attention,
diversional hence lowering the
activities. Instruct level of discomfort.
client in relaxation
methods such as
meditation, guided
imagery, and deep
breathing.

Collaborative: Promotes rest and

Provide alleviates pain.
pharmacologic pain
management as
ordered with the
permission of a
physician.