Group Case Study OB GR5

Saint Mary’s University
School of Health and Natural Sciences

Nursing Department
In partial fulfillment of
the Care of mother, Child at Risk or with
Problems (Acute and Chronic) NCM 109 RLE
PRE ECLAMPSIA, G1P0 (0000) 37 weeks AOG s/p “e” CS
Submitted to:
Mrs. Joan Taroma
Mrs. Marie Curie De Pona
Mrs. Jezerel Credo
Mrs. Jenifer Joy Camacho
Mr. Mayer Tominez
Submitted by:
Pumaras, Jhanna Mae A.
Rabanal, Krystelle Cassandrah
Ragual, Mica T.
Ramos, Angela C.
Respicio, Meryl Priss M.
Sajor, Ryan Paul M.
Silisilon Lady Alexzandrea C.
Tayaban, Summer Janie A.
Tolentino, Jamie Ann Nicole P.
Tumanut, Josephine Mae D.
BSN2B
CODE 5053
Nursing Department
TABLE OF CONTENTS
I. 3P’s 3
II. BRIEF DSCRIPTION 7
III. ANATOMY AND PHYSIOLOGY 10
IV. PATHOPHYSIOLOGY 15
V. LABORATORY RESULT AND DIAGNOSTIC STUDIES
2nd Urinalysis 17
rd
3 Urinalysis 18
Hematology 18
VI. PHYSICAL ASSESSMENT AND its PHYSIOLOGICAL BASIS
Psychosocial 21
Elimination 29
Rest and Activity 32
Safe Environment 39
Oxygenation 41
Nutrition 54
VII. DRUG STUDY 55
VIII. COURSE VISIT 69
IX. NURSING CARE PLAN 75
X. REFERENCES 81
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Nursing Department
CHAPTER I
3P’s
Personal Profile
Name: Mrs. CT
Age: 32 years old
Birthdate: March 10, 1989
Birthplace: Bayombong, Nueva Vizcaya
Sex: Female
Blood Type: A+
Address: Zamora St., Brgy. Don Domingo Maddela (District I), Bayombong, Nueva Vizcaya
Religion: Roman Catholic
Height: 5’3”
Marital Status: Married
Occupation: High School Teacher
Educational Attainment: College Graduate
Nationality: Filipino
Ethnicity: Ilokano
Dialect: Ilokano and Tagalog
Weight before Pregnancy: 68 kg

 First Trimester: 70 kg
 Second Trimester: 73 kg
 Third Trimester: 78 kg
BMI: 30.5
Significant Others:
Name of Spouse: Mr. S
Age: 34 years old
Occupation: OFW in Riyadh, Saudi Arabia
Educational Attainment: College Graduate
Name of Parents: Mr. B and Mrs. D
Age:both 60 years old
Objective
 Temperature: 37.2°C
 BP 150/100 mmHg
 PR: 90 bpm
 RR: 25 bpm
 Fundal height 37 cm
 FHT 147 Left Lower Quadrant
 IE upon admission 4cm active labor
 Edema on upper extremities
 Labor pain, number 8 in pain scale
Subjective
“Hindi ako makahinga” as verbalized by the client
Admitting Diagnosis: Pre-eclampsia, G1P0 (0000) 37 weeks AOG s/p “e” CS

Admitting Physician: Dr. TC
Date of Admission: January 12, 2020
Date of Discharge: January 16, 2020
Mrs. CT is a 32-year-old Catholic married woman from Bayombong, Nueva Vizcaya, who was
born on March 10, 1989. She states that she lives with her parents at Brgy. Don Domingo Maddela,
Bayombong, Nueva Vizcaya while her husband is away. Her height is 5'3’’. Client declares that she is a
college graduate and works as a teacher in Saint Mary’s Junior and Science High School. She states
that she is a Filipino national and belongs to the Ilocano ethnic group. She claims that she can speak and
understand Ilokano, Tagalog and English. Mr. S, Mrs. CT's husband, is a college graduate who is now
working as an OFW in Riyadh, Saudi Arabia. For more significant others, her parents are Mr. B and Mrs.
D which are both 60 years old.
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Nursing Department
Health History
I. Present OB History
Mrs. CT visited R2TMC on June 9, 2019 after experiencing nausea and vomiting for several days.
Her menstrual period has already been six weeks late, she said. Her cycle is 28 to 30 days long, according
to her. She recalled that her last menstrual period (LMP) occurred on April 28, 2019. A pregnancy test
was performed by the Ob-gyn doctor, and it was discovered that the pregnancy result was positive. Mrs.
CT claims that this is an unintended pregnancy because they recently got married last May 2, 2019 and
both have jobs. She went on to say that her spouse left to Riyadh, Saudi Arabia for work on June 3, 2019,
and that they need to start earning as soon as possible after their marriage. Her vital signs were also
obtained at her first pregnancy check-up, and the results were BP 120/80 mmHg, PR 80 bpm, RR 18
breaths per minute, and Temperature 35.6°C. On the same day, the doctor ordered various tests,
including HBsaG testing, which came back negative or nonreactive from hepatitis B surface antigen, and
her total blood count was normal. Mrs. CT was also taking folic acid 600 mcg supplements daily at her
first prenatal check-up as prescribed by the physician.
Mrs. CT returned for her second prenatal appointment on July 14, 2019, at 11 weeks AOG. The
vital signs were obtained, and the results were: blood pressure of 130/80 mmHg, pulse rate of 81 bpm,
respiratory rate of 17, and temperature of 37°C. During the appointment, laboratories such as
Hematology, STD, HIV, CBC, blood typing and RH incompatibility were done. The result of the
Hematology, STD, HIV tests were negative. The CBC was normal and blood type of the mother was A+,
it means that the blood contains type-A antigens with the presence of a protein called the rhesus (Rh)
factor. She was ordered by the physician to take ferrous sulfate 30 mg/day.
Mrs. CT came in for her third prenatal appointment at R2TMC on August 4, 2019 when she was
14 weeks AOG. The nurse used a Doppler fetal monitor to record the fetus's heart rate, which was 130
beats per minute. Then for the fourth visit at 18 weeks AOG, the client had UTZ, and the baby is a female.
She underwent her first urinalysis, which revealed that her level of protein was normal. She also
mentioned during the visit that when she was resting on her back and working on her lesson plan, she
felt dizzy and tired. Her doctor recommended that she sleep on her left side. A vital sign was obtained at
23 weeks AOG at her fifth prenatal appointment, and the results were BP-130/90 mmHg, PR-84 bpm,
and RR-19 breaths per minute, and Temperature-36.8 ° C. Mrs. CT claims that she had already begun
to feel baby movements and that a Doppler fetal heart monitor revealed a fetal heart tone of 145 beats
per minute.
Mrs. CT came to R2TMC for her sixth prenatal appointment on October 27, 2019, at 26 weeks
AOG. Mrs. CT's abdomen was measured at 26 cm by the OB ward nurse who did a fundic height
measurement. There was also a non-stress test, fetal biophysical profile and the fetal heart rate was 146
beats per minute. The overall score of the fetal biophysical is 10 which indicate that the baby is normal.
Mrs. CT came to the clinic for her 7th prenatal appointment on November 10, 2019, when she was 28
weeks AOG. She underwent ultrasound which the baby is growing at a normal rate. The presentation of
baby is Cephalic. A vital sign was also obtained, and the results were BP-140/100 mmHg, PR-86 bpm,
and RR-18 breaths per minute, and Temperature-36.9 ° C. Mrs. CT also mentioned that she was on her
leave since she was on her third trimester already. The doctor diagnosed that she has pre-eclampsia at
her 28 weeks AOG. She has an edema in her upper extremities. It was noticed that when her skin was
pinch, it does not go back to normal immediately. The doctor grade it 1 on the scale of 1-4. On November
24, 2019 at 30 weeks AOG, another complete blood count and urinalysis, were performed at this
appointment. The urine results reveal that the level of protein has a trace amount of 15 mg/dL hours. Mrs.
CT also stated that she is eating a lot during her third trimester including fast food. Mrs. CT had to go to
the hospital once a week since she was in her eighth month already.
Mrs. CT was taken to R2TMC by her parents on January 12, 2020, in the ninth month of her
pregnancy at 37 weeks AOG around 8:00 am. Mrs. CT complaints of labor pain and she stated that “hindi
ako makahinga”. She has an edema on her upper extremities that when the doctor push on her skin, it
goes back immediately. The Ob-gyn doctor grades it 2 on the scale of 1-4. The following vital signs were
recorded: BP 150/100 mmHg, PR 90 bpm, RR 23 breaths per minute, and temperature 37.2°C. Then
Laboratory test and Diagnostic studies were performed. Tests such as Urinalysis, CBC, and PTT were
done. The urine results reveal that the level of protein has increased to 30 mg/dL. The CBC test result
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was normal and the PTT test result shows a normal blood coagulation. The admitting doctor inserted
D5LRS 1L at 30gtts/min to run for 8 hours to the mother and placed her on the labor room. Internal
examination was done and it was found out that the mother’s cervix was 4 cm dilated. She underwent
Leopold's maneuver and was found to have a fundal height of 37 cm. Her baby is lying in a longitudinal
lie and has a cephalic presentation. Due to her BP 150/100mmHG and diagnosed with pre-eclampsia,
the doctor call for emergency CS.
II. History of Past Illness
Mrs. CT had no serious health concerns when she was young and had never undergone surgery.
She was 11 years old when she had her chicken pox. She said that they did not visit the hospital because
her mother said to let it heal on its own. She also takes 500 mg of paracetamol twice a day for 2 days for
her fever. She then added that she experienced common colds and cough thrice a year without phlegm.
Mrs. CT stated that she is completely immunized.
Vaccine Date
Hepa B1 and BGC March 10, 1989
Hepa B2,DPT1,OPV1 April 21, 1989
DPT2, OPV2 May 25, 1989
Hepa B3,DPT3,OPV3 June 22,1989
Measles AMV December 15,1989
III. Gynecologic History
She had her menarche at the age of 12, regular about 3-4 days and used 12 pads her whole
period. She mentioned that she had a regular menstrual period every 28 to 30 days. She was also 12
years old when she has her thelarche. She had her first coitus at the age of 20. There is no bleeding or
spotting occur after coitus. According to her, she got married at the age of 31 and this was her first baby.
IV. Family Health History
She is the eldest child, according to Mrs. CT, and she has two siblings. Her family has a history
of high blood pressure. Both of her parents have been diagnosed with hypertension.
V. Social Health History
Mrs. CT is a 32-year-old married woman who was born and raised in Brgy. Don Domingo
Maddela, Bayombong, Nueva Vizcaya. Her husband is gone on work and she is living with her parents.
Her spouse is an OFW in Riyadh, Saudi Arabia. Mrs. CT is a college graduate and she works as a
secondary high school teacher in Saint Mary’s University Junior and Science High School. Mrs. CT and
her family go to church every Sunday at 6:00 pm and generally dine at a fast food restaurant afterward.
During the weekends, the family spends time chatting to one another. She is also a member of PhilHealth
and GSIS. Her husband’s estimated income for one month is Php 36, 000 while Mrs. D is Php 25,000
per month with a total of Php 61,000 monthly.
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VI. Environmental History
Mrs. CT stated that because their home is close to town, they can readily get their daily
necessities. She also said that they did not have any smokers in their home and that they did not have
any breeding of mosquitos’ sites around their house. There was no stagnant water or canal within walking
distance of their home. When it came to garbage collection, their barangay's timetable was Wednesday
and Saturday, and it needed to be segregated.
VII. Lifestyle and Health Practices
Mrs. CT says that she likes fatty, greasy dishes as well as fast food. She makes their breakfast
before leaving to work, and she generally eats lunch at the school cafeteria. Mrs. CT claims she does not
have any allergies. While she is pregnant, she spends the majority of her leisure time working on her
schoolwork on her laptop. She stated that she does not consume alcoholic beverages and that no one in
her family smokes. Since she lives with her parents, Mrs. CT tries to get to bed as early as 9:30 pm so
that she may wake up at 6:00 am and cook meals for her family.
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CHAPTER II
BRIEF DESCRIPTION
When she was on her First trimester of pregnancy, she experience the following discomforts like
breast tenderness, so when she has experience it, we advise the mother to wear a bra with a wide
shoulder, dress warmly and avoid cold and get examined. Next is when she experienced nausea and
vomiting which is the earliest symptoms of pregnancy so we advise the mother to take small, frequent
meals and avoid greasy foods and encourage her to keep in an upright position after meals to avoid
reflux. Then she also experienced frequent Urination which we advise the client not to restrict her fluids,
offer assurance and do Kegel’s exercise, it helps to reduce the incidents of stress incontinence.
During her second trimester of pregnancy, as she gaining weight, she experienced physical
changes, which includes growing belly and breasts. As the uterus expands to make room for the baby,
the belly grows. The breasts will also gradually continue to increase in size.
The third trimester marks the home stretch, as she get ready for the birth of the baby. Childbirth
education should be designed to assist expectant mothers and their families through pregnancy based
on the physical and emotional changes occurring during each trimester. Accurate information concerning
conception, nutrition, physiologic changes of pregnancy, labor and birth, and newborn care should be
included. The fetus continues to grow in weight and size, and the body systems finish maturing. She
also felt being more uncomfortable and her weight also continues to gain
On her third trimester, she had her every week check-up and the nurse is already counseling the
mother in preparation for her birth. On her third trimester, she had her every week check-up and the
nurse is already counseling the mother in preparation for her birth. The type of delivery that the mother
undergo was caesarean section. A surgical procedure by which one or more babies are delivered through
an incision in the mother's abdomen, often performed because vaginal delivery would put the baby or
mother at risk.
There are various high risk of pregnancy that includes High blood pressure, obesity, diabetes,
heart or blood disorders and infections can increase pregnancy risks. Various complications that develop
during pregnancy can pose risks. To prevent having a high-risk pregnancy the nurse should teach the
mother to maintain and achieve a healthy weight before pregnancy, take prenatal supplement, avoid
alcohol, tobacco and drugs lastly visit the doctor regularly during pregnancy.
The client is already on her 37 weeks AOG and in her case she is already experiencing signs of
pre-eclampsia.
Pre-eclampsia, formerly called toxemia, is when pregnant women have high blood pressure,
protein in their urine, and swelling in their legs, feet, and hands. It can range from mild to severe. It
usually happens late in pregnancy, though it can come earlier or just after delivery. In addition to
swelling (also called edema)
Pre-eclampsia symptoms include:
 Weight gain over 1 or 2 days because of a large increase in bodily fluid

 Shoulder pain
 Belly pain, especially in the upper right side
 Severe headaches
 Change in reflexes or mental state
 Peeing less or not at all
 Dizziness
 Trouble breathing
 Severe vomiting and nausea
 Vision changes like flashing lights, floaters, or blurry vision
Caesarean Section
Cesarean section is delivery of the fetus usually through transabdominal , low segment
incision of the uterus.
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A cesarean delivery is typically performed when complications from pregnancy make traditional
vaginal birth difficult, or put the mother or child at risk. Sometimes cesarean deliveries are planned early
in the pregnancy, but they’re most often performed when complications arise during labor.
The NPO of the mother started when they bring her to the emergency room and inserted a
dextrose as ordered by the physician.
Type of C-section:
 Classical Cut - The incision is made vertically from just below the belly button to the top of the
bikini line.
 Bikini Cut - An incision from one side of the abdomen to the other, just above the pubic hair
line.
A cesarean delivery is typically performed when complications from pregnancy make traditional
vaginal birth difficult, or put the mother or child at risk. Sometimes cesarean deliveries are planned early
in the pregnancy, but they’re most often performed when complications arise during labor.
Reasons for a cesarean delivery include:
 baby has developmental conditions

 baby’s head is too big for the birth canal
 the baby is coming out feet first (breech birth)
 early pregnancy complications
 mother’s health problems, such as high blood pressure or unstable heart disease
 mother has active genital herpes that could be transmitted to the baby
 previous cesarean delivery
 problems with the placenta, such as placental abruption or placenta previa
 problems with the umbilical cord
 reduced oxygen supply to the baby
 stalled labor
 the baby is coming out shoulder first (transverse labor)
A cesarean delivery is becoming a more common delivery type worldwide Trusted Source, but
it’s still a major surgery that carries risks for both mother and child. Vaginal birth remains the preferred
method for the lowest risk of complications. The risks of a cesarean delivery include:
 bleeding
 blood clots
 breathing problems for the child, especially if done before 39 weeks of pregnancy
 increased risks for future pregnancies
 infection
 injury to the child during surgery
 longer recovery time compared with vaginal birth
 surgical injury to other organs
 adhesions, hernia, and other complications of abdominal surgery
Nursing Management:
Preoperative
1. If planned, prepare the mother and partner.
2. If an emergency, quickly explain the need and procedure to the mother and partner
3. Obtain informed consent.
4. Make sure that the preoperative diagnostic tests are done, including the Rh factor
determination
5. Prepare to insert IV line and Foley Catheter
6. Prepare the Abdomen as prescribed
7. Monitor the mother and fetus continuously for sign of labor
8. Provide emotional support
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9. Administer preoperative medications as prescribed
Post-Operative
1. Monitor Vital Sign
2. Provide Pain Relief
3. Encourage Tuning , coughing and deep breathing
4. Encourage ambulation
5. Monitor for signs of infection and bleeding
6. Burning Pain on urination may indicate bladder infection
7. A tender uterus and foul smelling lochia may indicate endometritis
8. A productive cough or child may indicate pneumonia
9. A positive Homan’s sign pain, or edema of an extremity may indicate thrombophlebitis
Discharge teaching to our client:

1. Rest - we have to encourage the mother to rest when infant is sleeping.
2. The mother should also avoid heavy lifting or heavy house work and limit her exercise and
activities.
3. Coitus - should be avoided for 6 weeks, and practice safe sex using a contraceptive but your
doctor or midwife will want to ensure that your incision is healing well and that your postpartum
bleeding has stopped.
4. Diet - mothers are encouraged to eat variety of healthy foods such as fruits, vegetables, and
prenatal vitamins.
5. Make Follow up - appointment for about six weeks after delivery or refer to the discharge
instructions from the physician or call the doctor’s office.
Postpartum
The Postpartal period, or puerperium (from the latin; puer, for “child”, and parere, ‘to bring
forth”). It refers to the 6-week period after childbirth and is also termed as the fourth trimester of
pregnancy. It is a stage of maternal changes that are both retrogressive and progressive and the return
of the uterus and other organs to a pre-pregnant state.
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CHAPTER III
ANATOMY AND PHYSIOLOGY
PHYSIOLOGICAL CHANGES DURING PREGNANCY
INTERPRETATION
RESPIRATORY SYSTEM The chest increases in size. The diaphragm, the
large flat muscle used in breathing, moves
upward toward the chest. Increase in the amount
of air breathed in and out. Decrease in amount of
air the lungs can handle.
CARDIOVASCULAR SYSTEM Cardiac output is assumed to be mediated early

in pregnancy by an increase in stroke volume,
whereas it is thought to be mediated later in
pregnancy by a rise in heart rate. The volume of
the stroke increases gradually during pregnancy
until the end of the second trimester, after which
it remains steady or declines late in the
pregnancy.
During pregnancy there is actually a drop in blood

pressure, so an increase in blood pressure might
indicate abnormality due to many things, but one
thing to consider is Pre-eclampsia.
In the case of Mrs. CT, she was in pain due to the

contraction and based on her elevated blood
pressure which is at 150/100 mmHg, that’s why
her doctor decided to do an emergency cesarean
section on her.
MUSKULOSKELETAL SYSTEM Weight gain, increased blood volume, and the
ventral growth of the fetus cause the center of
gravity to no longer fall over the feet, resulting in
an increase in anteroposterior and medial-lateral
sway, and women may need to lean backwards
to regain equilibrium, resulting in spinal curve
disorganization.
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ENDOCRINOLOGICAL CHANGES The endocrinology of human pregnancy is

dominated by multiple placental hormones that
induce physiologic changes in the mother in favor
of pregnancy. Hormones synthesized by the
placenta include chorionic gonadotropin which
prevents regression of the ovarian corpus luteum
during the first several weeks of pregnancy and
progesterone which promotes uterine
quiescence. Placental somatotropins such as
placental lactogen and placental growth hormone
generate maternal metabolic changes in the
mother that are favorable to the fetus, though in
some cases can contribute to gestational
diabetes.
DERMATOLOGICAL CHANGES Physiological dermatologic signs include
hyperpigmentation, hair and nail alterations,
vascular abnormalities, and variations in
apocrine and eccrine gland activity due to a
transitory shift in immunologic, metabolic, and
hormonal variables during pregnancy.
FEMALE REPRODUCTIVE SYSTEM The main pregnancy hormones are oestrogen

(Gynecological Changes) and progesterone. The uterus, which grows from
the size of a tiny pear in its non-pregnant
condition to five times its normal size at full term,
is one of the internal structures affected by high
amounts of progesterone.
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Breast The mammary glands undergo changes during

pregnancy. They become bigger and firmer
because of the hormonal (progesterone)
changes and production of milk. This happens as
a preparation for the coming baby.
The mammary glands are the first source of food

of an infant. Infants are purely breastfed until they
reach six months which is the start of their
supplementary feeding. The ex ternal parts of the
breast are the nipple and the areola. The nipple
contains the ducts where the milk will pass
through during breastfeeding. The areola on the
other hand is the dark-pigmented skin
surrounding the nipple where Montgomery
glands are located. These glands function as
lubricator to allow smooth breastfeeding. These
glands also function to keep bacteria away from
the breast.
Mrs. CT begin producing milk weeks before her

due date. Colostrum were the first milk produced
by her breasts in preparation for feeding her
baby.
Fetal and Maternal Circulation
At 36 weeks AOG, the baby depends on getting oxygen and nutrients that he needed in growing
on the placenta through the umbilical cord. Here is an illustration and explanation on how it works for the
mother and the fetus inside her.
 The placenta is a unique vascular organ that receives blood supplies from both the maternal and
the fetal systems and thus has two separate circulatory systems for blood: (1) the maternal-
placental (uteroplacental) blood circulation, and (2) the fetal-placental (fetoplacental) blood
circulation.
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 The uteroplacental circulation starts with the maternal blood flow into the intervillous space
through decidual spiral arteries. Exchange of oxygen and nutrients take place as the maternal
blood flows around terminal villi in the intervillous space.
 The in-flowing maternal arterial blood pushes deoxygenated blood into the endometrial and then
uterine veins back to the maternal circulation. The fetal-placental circulation allows the umbilical
arteries to carry deoxygenated and nutrient-depleted fetal blood from the fetus to the villous core
fetal vessels.
 After the exchange of oxygen and nutrients, the umbilical vein carries fresh oxygenated and
nutrient-rich blood circulating back to the fetal systemic circulation. At term, maternal blood flow
to the placenta is approximately 600–700 ml/minute.
 The functional unit of maternal-fetal exchange of oxygen and nutrients occur in the terminal villi.
No intermingling of maternal and fetal blood occurs in the placenta.
CESAREAN SECTION
Cesarean section, C-section, or Cesarean birth is the surgical delivery of a baby through a cut
(incision) made in the mother's abdomen and uterus. Healthcare providers use it when they believe it's
safer for the mother, the baby, or both.
The skin is first incised, then the subcutaneous tissues. The fascia that covers the rectus
abdominis muscles is the next layer. There are normally two layers to the anterior abdominal fascia. The
aponeurosis of the external oblique rectus muscle makes up one layer, while the aponeuroses of the
transverse abdominis and internal oblique muscles make up the other. The surgeon enters the abdominal
cavity through the parietal peritoneum after separating the rectus muscles, which run from cephalad to
caudal.
Upon identifying the uterus, the surgeon can then identify the vesicouterine peritoneum, or
vesicouterine serosa, that connects the bladder and the uterus. The uterus consists of the serosal outer
layer (perimetrium), the muscle layer (myometrium), and the inside mucosal layer (endometrium). All
three of these layers are incised to make the uterine incision or hysterectomy. It's important to keep in
mind that the uterine vessels run along the lateral aspects of the uterus on both sides, and that when the
uterine incision is made or extended, care must be taken to avoid damaging these blood vessels — the
uterine arteries branch from the anterior division of the internal iliac artery.
 Up-and-down (vertical). This incision extends from the belly button to the pubic hairline.
 Across from side-to-side (horizontal). This incision extends across the pubic hairline. It's used
most often, because it heals well and there is less bleeding.
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Several conditions make a Cesarean delivery more likely. These include:

 Abnormal fetal heart rate. The fetal heart rate during labor is a good sign of how well the fetus
is doing. Your provider will monitor the fetal heart rate during labor. The normal rate varies
between 120 to 160 beats per minute. If the fetal heart rate shows there may be a problem, your
provider will take immediate action. This may be giving the mother oxygen, increasing fluids, and
changing the mother's position. If the heart rate doesn’t improve, he or she may do a Cesarean
delivery.
 Abnormal position of the fetus during birth. The normal position for the fetus during birth is
head-down, facing the mother's back. Sometimes a fetus is not in the right position. This makes
delivery more difficult through the birth canal.
 Problems with labor. Labor that fails to progress or doesn't progress the way it should.
 Size of the fetus. The baby is too large for your provider to deliver vaginally.
 Placenta problems. This includes placenta previa, in which the placenta blocks the cervix.
(Premature detachment from the fetus is known as abruption.)
 Certain conditions in the mother, such as diabetes, high blood pressure, or HIV infection
 Active herpes sores in the mother’s vagina or cervix
 Twins or other multiples
 Previous C-section
Physiological Processes of Placental Separation and Expulsion
After the birth of a baby, the placenta is pushed out or delivered through the vagina - the third
stage of labor. There are two options for placenta delivery - active management and physiological
management.
Active management is a fairly quick process. During active management, a drug, oxytocin, is
injected into the thigh of a woman who is going to give birth to a baby. The umbilical cord is clamped and
cut in about 1 to 5 min after the baby is born. When the placenta is separated from the uterus wall, the
midwife pulls it out.
In physiological management, injection is not used. When the cord stops pulsating, it is clamped
and cut. Women giving birth to baby’s push and move the placenta out of the uterus; it may take about 1
hour to deliver the placenta through vagina.
Placenta delivery after a cesarean
There are two most common methods that doctor use in delivering a placenta during a cesarean section.
Controlled Cord traction

This reduces the risk of postpartum hemorrhage greater than 500 mL but less than 1,000 mL and
slightly reduces the incidence of manual placenta removal. A doctor may also give drugs, like as Pitocin,
to make the uterus contract and grow firmer if it is unable to do so. The uterus can also contract if the
mother breastfed her baby just after birth or put the infant on her skin (known as skin-to-skin contact).
Manual removal.
There is a study suggests that manual removal of the placenta may do more harm, by increasing
maternal blood loss and increase the risk of infection.
In the case of Mrs. CT which is a cesarean delivery, the doctor physically removed the placenta
from her uterus before closing the uterus and stomach incisions. Her doctor massages the top of her
uterus (known as the fundus) after delivery to urge it to contract and shrink.
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CHAPTER IV
PATHOPHYSIOLOGY
PRE - ECLAMPSIA
RISK FACTOR
Modifiable Non Modifiable

 Hypertension  Gender
 Physical Inactivity  Age
 Physiological Stress  Family History
 High Calorie Intake  Race
 Obesity
DISEASE PROCESS
Spiral Arteries in Placenta will become

the uterus does ishemic and reacts to Releases
not increase the stress inflammatory cells
Affect the endothelia

cells lining in the
blood vessel
Permeability Leakage of protein and H2O

issue goes to interstitial tissue
Tone and permeability

function of the
PROTEINURIA AND EDEMA
endothelial cells
Tone issue Vasospasm
Less blood is able to

perfuse organs
especially the liver, HYPERTENSION
kidneys, brain and
heart
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Nursing Department
SIGN AND SYMPTOMS NURSING MANAGEMENT
 Increase blood pressure  Promote bed rest

 Proteinuria  Frequent check of v/s
 Edema  Monitor fluids
 Sudden weight gain  Ambulate
 Visual disturbances  Promote good nutrition
 RUQ Pain
 Monitor fetal well being
 Nausea and Vomiting
 Administer medication
 Decrease urine output
Page 16 of 84
Nursing Department
CHAPTER V
LABORATORY RESULTS AND DIAGNOSTIC STUDIES
A. 2nd Urinalysis: November 24, 2019, 9:00 am, 30 weeks AOG
Examination Result Normal Nursing Implication

Range
Color Pale yellow Clear, Pale, Normal
Transparent yellow,
amber yellow
Appearance/Tran Clear and Clear and Normal

sparency Transparent Transparent
Specific Gravity 1.020 1.010-1.025 Normal
pH 5 4.5-8 Normal
Protein 15mg/dL Negative Abnormal
There must be no protein or a small

amount of protein in the urine. Protein
is usually found in the blood, so if there
is a problem, protein can leak or have
a trace in the urine that the mother is at
risk for pre-eclampsia.
For the nursing action, the patient is

advised to eat foods rich in proteins
such as lean meats, chicken, eggs, fish
and dairy products. Because there is a
leak of protein in her urine, that means
that her body is not receiving enough
protein which plays a significant role in
the body.
Glucose Negative Negative Normal
Epithelial Cells Few Few Normal
Bacteria Rare No Bacteria Normal
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Nursing Department
B. 3rd URINALYSIS: January 12, 2020, 8:00 am, 37 weeks AOG

Range
Color Pale yellow Clear, Pale, Normal
Transparent yellow,
amber yellow
Appearance/Tran Clear and Clear and Normal
sparency Transparent Transparent
Specific Gravity 1.020 1.010-1.025 Normal
pH 4.6 4.5-8 Normal
Protein 30mg/dL Negative Abnormal
There must be no protein or a small

amount of protein in the urine. A
negative result indicates normal
findings. Protein is usually found in the
blood, so if there is a problem; protein
can leak or have a trace in the urine
that the mother is at risk for pre-
eclampsia.
Glucose Negative Negative Normal
Epithelial Cells Few Few Normal
Bacteria Rare No Bacteria Normal
C. HEMATOLOGY FOR COMPLETE BLOOD COUNT, January 12, 2020, 8:00 am, 37 weeks
AOG

Range
Hemoglobin 14 12-16 Normal

g/L
(Hgb) Hemoglobin value below 12 and hematocrit below 34% is
considered iron-deficiency anemia and below 10.5 as an
Hematocrit 42.0 36-47 % anemia
(Hct)
In the case of Mrs. CT, her hemoglobin is adequate in red

blood cells and blood volume which means that there is
enough oxygen to carry to her body organs and supply the
need of fetus and support the growth and development
inside the womb. It is indicated that there are no sign of
anemia and dehydration in the case of Mrs. CT.
WBC 9.0 5.0-10.0 Increased

×109/𝐿
Mrs. CT has an increased white blood cells because it also
affects the other component of white blood count. Elevated
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Nursing Department
(White Blood white blood cell is very likely due to physiologic stress from
Cells) pregnancy. Additionally, it increases when the immune
system is fighting off an infection
Neutrophils 50 40-60
. For white blood cell count is to verify infections in the body.

Usually increased or low WBC indicates infection or
Monocytes 30 20-40 something that the body is fighting off. Neutrophils are
elevated during pregnancy through it only indicates the bone
marrow response to the increase production of RBC. Also
Eosinophils 5 2-8 increased monocytes happen due to the mother immune
system goes through alteration to avoid attacking of fetus.
Increase or decrease eosinophils indicates weak immunity.
There were no significant changes in the number of
Basophils 1 1-4 basophils. Lastly, For the lymphocytes it usually decreases
for the first and second trimester and increases in last
trimester. It is due to the suppression of immunological
Lymphocytes 1 0.5-1 activity during pregnancy.
Platelet 289 150-450 Normal

×109/𝐿
Mrs. CT. platelet count is normal. Therefore, it has an
adequate amount to stop a bleeding and clot the blood.
There are no problems found in terms of clotting or excess
bleeding.
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Nursing Department
CHAPTER VI
PHYSICAL ASSESSMENT AND ITS PHYSIOLOGICAL BASIS
V. PERSON ASSESSMENT
Date of JANUARY 12, 2020 JANUARY 13, 2020 JANUARY 16, 2020
assessment
Patient initials Mrs. CT
Age 32
Sex Female
Admitting G1 P0 T0 A0 L0 36 weeks AOG, G1 P0 T1 A0 L1 36 weeks AOG, G1 P0 T1 A0 L1 36 weeks AOG, preeclampsia rule
diagnoses preeclampsia status post preeclampsia status post emergency CS out eclampsia status post emergency CS
emergency CS
Health history:
Current health Labor pain and increase blood Pain related to surgical incision due to CS Pain related to surgical incision due to CS, increase
problems pressure as evidenced by 150/100 and increase of blood pressure as evidenced blood pressure as evidenced by 130/80 mmHg and
mmHg by 140/100mmHg bleeding
Past health Mrs. CT experienced common colds
problems and cough which was manageable
Surgical History None
Obstetrical history
Menarche 12 years old
Thelarche 12 years old
LMP April 28, 2019
EDC January 12, 2020
Accidents None
Family risk Both her parents are hypertensive
factors
Medications: Name of drug: Name of drug: Name of drug:
Bupivacaine Cefuroxime Cefuroxime
Ranitidine Methyldopa Methyldopa
Methyldopa
Nursing Department
1st 2nd
3rd
PSYCHOSOCI ASSESSMENT ASSESSMENT
ASSESSMENT PHYSIOLOGICAL BASIS RATIONALE
AL January 12, January 13, 2020
January 16, 2020
2020
Mr. S – husband Mr. S – husband Her parents were the one Having a support person after delivery helps the
who supported her in the client to cope up easily and prevent postpartum
Mr. S – husband Mr. B Mr. B hospital because her blues, depression or severe psychosis.
Significant Mr. B Mrs. D Mrs. D husband was working in the
Others Riyadh
Mrs. D
Coping Deep breathing Bed rest Bed rest The role changes: Coping strategies is used to overcome stressful
Mechanism events that people face in every day because it
Taking care of the Taking care of the Taking in phase helps to relieve stress and regain control over
new baby new baby that stressful events. (Source: HelpGuide. org)
Bonding with their child
Start of Start of
breastfeeding breastfeeding
Health Teaching
Encourage the patient to express her feelings
about the labor and give positive reinforcement to
her efforts during labor. Also, establish a goal in
the changes of roles in becoming a mother and
handling the baby.
Encourage breast feeding to stimulate oxytocin
Religion Roman Catholic Roman Catholic Roman Catholic
Primary Tagalog and Tagalog and Tagalog and

Language Ilocano Ilocano Ilocano
Page 21 of 84
Nursing Department
Financial PhilHealth &

Resources
Related to PhilHealth & SSS
Health Care SSS
PhilHealth & SSS
Occupation Teacher in Teacher in Private Teacher in Private

Private secondary school secondary school
secondary
school
Education College College Graduate College Graduate
Graduate BSED BSED major in BSED major in
major in science science high science high
high school school school
General  Her hair  Her hair is bit  Her hair tied During her labor phase the Health Teaching:
Appearance color is dry and has a up with pony patient assess her hair to be
black and a shed and thicker and hair Incision care due to emergency cesarean section
clump of hair
little bit  Brown skin becomes shinier it implies that delivery using in sterile draping’s and keeping it
loss
messy changes in texture because of dry to prevent infection.
 She is wearing
 Pale skin  Brown skin higher levels of estrogen It is normal that there is a clump of care during
 She is casual dress
prolong the growth phase. postpartum due to the decrease estrogen which
wearing  She is wearing
 The client
gown gown After labor phase the patient peaks around 4 month
appears to her assess her hair becomes dry
 The client Positioned into dorsal recumbent and transferred
 The client in stated age and and has a clump of hair to her Room
appears to
appears to be
be her in
her in stated  She answers loss due to decrease of
stated age estrogen which is normal
age my questions
 Sitting during postpartum
 In semi with eye
position
fowler’s contact
(lordotic)
 She position
answered
my
Page 22 of 84
Nursing Department
question  She answered

correctly my question
and she correctly and
cannot she can
maintain maintain eye
eye contact contact
 The client
has poor
posture and
gait
Affect Restricted: As I As I observed she As I observed This is normal because the This is normal because the mother is in taking in
observed when is still displaying when asking her, mother is in labor and phase
asking her, she facial expression of she is responsive experiencing the after pains
was lowering of pain there was a and when sitting of cesarean delivery.
the eyebrows, minimal lowering of down she is
squeezing of the the eyebrows and display facial
eyes and squeezing of the expression of pain
wrinkling of the
eyes due to the but compared to
nose which
after pain of the previous
indicate a
painful facial cesarean delivery assessment she is
expression due and show little a lot better
to the labor response when because her pain
contractions asking her. scale was 3/10.
Orientation Questions Time: Questions The client is well oriented to The client is well oriented to time, place and
time, place, and person. person.
Time: Question: anong Time:
oras po kayo
Question: nanganak? Question: anong
anong petsa po oras po yung
ngayon? discharged niyo?
Answer: Answer: mga

January 5, 2020 nasa bandang
10am ng tanghali Answer: mga alas
kwatro
Page 23 of 84
Nursing Department
(delayed Person: Person:

response)
Question: sino Question: sino
Person: pong nagbabantay pong kasama
sa inyo ngayon? niyong magaalaga
Question: sino sa bata kapag
pong kasama Answer: yung nasa bahay na
nyong pumunta mother ko po kayo?
dito? Place: Answer: yung mga
Answer: Question: saang magulang ko po
yung mga pong kwarto po
magulang ko po ang gusto niyo?
Place:
(delayed Answer: sa
response) pngalawa kasi mas Question: anong
maluwang lugar po yung
Place: bahay niyo?
Question: saan Answer: Zamorat
po yung asawa St., Brgy. Don
niyo? Domingo Maddela
(District I),
Answer: nasa Bayombong,
Riyadh, Saudi Nueva Vizcaya
Arabia (delayed
response)
The client’s The client’s The client’s The client is conscious and
memory is intact memory is intact memory is intact oriented
but delayed
Immediate:
response\\\\\\\\\\\
\\\\\\\\\\ Immediate: Immediate:
Memory
Questions: may Questions: may
sasabihin po sasabihin po
Page 24 of 84
Nursing Department
Immediate: akong mga akong mga

numbers maam, numbers maam,
Questions:
pagkatapos, pagkatapos,
may sasabihin
sabihin nyo rin sabihin nyo rin ( 5,
po akong mga
(6,2,3,5,8) 2, 8, 4, 6)
numbers maam,
pagkatapos, Answer: Answer: (5, 2,8 4,
sabihin nyo rin ( (6,2,3,5,8) 6)
7, 5, 6, 1, 2)
Immediate Immediate
Answer: ( 7, 5, memory is good memory is good
6, 1, 2) because she can because she can
follow my follow my
Immediate
instructions. instructions to
memory is good
repeat the
because she Recent:
numbers
can follow my
Question: Anong
instructions.
kinain mo kanina?
Recent:
Answer: yung may
Recent: sabaw Question: anong
kinain nyo po
Question: Remote:
kaninang umaga?
kailan po yung
Questions: Kailan
last nyong Answer: lugaw po
ang birthday mo?
dumi?
Recent memory is
Answer: March
Answer: good because she
10, 1989 can remember the
kaninang mga
alas sais ng Remote memory food that she ate
umaga was good because
she can recall the
Recent memory birthdate of her Remote:
is intact husband.
(delayed
response)
Page 25 of 84
Nursing Department
Questions: Kailan
ang kasal niyo ng
Remote:
asawa?
Question:
Answer: May 2,
kelan po
2019
birthday ng
asawa nyo? Remote memory
was good because
Answer: she can recall the
December 17, date of their
1987 wedding.
Remote
memory was
good because
she can recall
the birthdate of
her husband.
Speech Patient speak She speaks clearly She speaks clearly During the first assessment,
and response and easy to and easy to the client was crying due to
with crying due understand understand the labor contraction.
to labor
contraction In the Second and fifth
assessment, she was calm
and can speak
spontaneously
Nonverbal Nodding Facial grimace Facial grimace During the first assessment, Health teaching:
behavior the client facial grimace,
Facial grimace Can maintain eye Can maintain eye irritable and cannot maintain After assessing the condition of the client due to
contact contact eye contact due the labor discomfort using nonverbal cues. Encourage her
Irritability to express her feelings as the labor progress and
contraction.
provide assistant to during the first 3 days of
postpartum because the client is still exhaust
Page 26 of 84
Nursing Department
Cannot from giving birth. Also, provide positive

maintain eye reinforcement for the client effort during labor and
contact During the second minimize pain.
assessment, pain is seen in
her face because of the
cesarean delivery
she grimaces and irritable
due to the surgical incision to
her lower abdomen
During the, fifth assessment,

pain is seen due to the
incision in her lower
abdomen and can maintain
eye contact
ABDOMEN Rationale
LEOPOLD’
1st ASSESSMENT 2nd ASSESSMENT 3rd ASSESSMENT
S
January 12, 2020 January 13, 2020 January 16, 2020
MANEUVE
R
Bowel All quadrants have All quadrants have All quadrants have The uterus will decrease 1cm/ day until in the 10 th day it is not palpable.
sounds positive bowel positive bowel positive bowel sounds HEALTH TEACHING:
sounds sounds Encourage early ambulate to prevent paralytic ileus.
Fundal 37 cm Above the level of 2 finger breadth below the Encourage to do deep breathing and chin to chest exercise to
height Incision: 3-4 cm umbilicus umbilicus strengthen to abdominal muscle.
(transverse incision
of cesarean) NORMAL FINDINGS:
Contour Symmetrical around Protruding Protruding The abdominal wall is flabby due to the stretching it received during
the midline and pregnancy, and have a few silvery stretch marks. Exercise can help the
protruding patient to firm up the abdominal muscles after childbirth
Involution changes: size and weight by 5-6 weeks
Placental site is fully healed in 6-7 weeks
Not abdominally palpable by 10 days
Page 27 of 84
Nursing Department
Palpation One fetus Fundal area is feels Fundus is firm Encourage to void before performing fundal massage to the boggy
fetal lie: vertex boggy uterus
position
fetal presentation:
cephalic
presentation
fetal movement: 20
kicks over 2 hours
Lesions Absence of lesions Lesion in the lower Lesion in the lower
quadrant of quadrant of abdomen
abdomen (transverse incision)
(transverse incision)
With Without ascites Without ascites Without ascites
ascites
Leopold’s Leopold’s maneuver was performed during N/A
Manuever her 37 weeks AOG wherein she was
assessed with a fundal height of 37 cm. Her
baby is in longitudinal lie and is in cephalic
presentation where head is not engaged.
Fetal back was located in the left lower
quadrant of the abdomen.
Uterus In the beginning of labor, the client’s uterusThe uterus is palpated at After delivery the fundus of the uterus is palpated at the fundus is above
is oval and is mobile. During contractions, the fundus is 2 level of umbilicus. The uterus is mobile, regular, and non-tender. It feels
her uterus becomes hard. Each uterine fingerbreadths below the boggy so the client is encouraged to void and perform fundal massage
tightening lasts between 30-90 seconds and level of umbilicus. The until it firm in the second assessment. Then until the fifth assessment
contractions are coordinated. uterus is mobile, regular, the uterus feels firm.
and non-tender. It feels
During active labor, her uterine contractions firm.
intensified with each contraction lasting 60-
90 seconds with just 30 seconds to two
minutes rest between.
After delivery the fundus of the uterus is

palpated at the fundus is above level of
umbilicus. The uterus is mobile, regular, and
Page 28 of 84
Nursing Department
non-tender. It feels boggy so the client is

encouraged to void and perform fundal
massage until it firm
Bladder Before labor, she voided twice every 2 hours The estimated amount is to normalize the elimination pattern to become independent of her daily
with an estimated amount of 60ml. Bladder 60ml every 2 hours. living.
is not distended.
During labor, she was catheterized with an
estimated amount of 150 ml.
After emergency cesarean section bladder

training was done before the removal of the
catheter with estimated amount 450 ml and
through normal voiding the estimated
amount was 60ml every 2 hours.
After the removal of the catheter the voiding
normalize of 60 ml every 2 hours.
ELIMINATION
STOOL RESULTS Normal Value
Page 29 of 84
Nursing Department
Consistency Soft and well formed Soft and well formed

and Shape
HEALTH TEACHING:
The client can tolerate clear liquids and have soft diet such as broth, pudding, and porridge.
Minimal
Amount
Minimal
None
Presence of
unusual Odor None
Color Yellow to Brown

Yellow to Brown
LOCHIA Rubra (Red) First 3 days of For the first 1 hour after birth the amount of lochia flow is moderate which is less than 15 cm (6 inches).
postpartum period As the lochia progress the amount will decrease until it will turn white and scant in amount of lochia
called alba.
Serosa (Pinkish) 3- 10 days
No red flag
From 9 hrs:
HEALTH TEACHING:
3 maternity pads
Increase fluids, do not hold bowel
Lochia discharge: moderate movement
discharge less than 15 cm (6 Move around when it’s able
inches) Void every 2 hours
Change pad when using restroom and wipe it from front to back to prevent infection.
1st ASSESSMENT 2nd ASSESSMENT 3rd ASSESSMENT

URINE Normal Values
Page 30 of 84
Nursing Department
Amount 3000 ml 2500 ml 1500 ml 2000-3000ml during pregnancy

1,500-3,000ml during the 2nd- 5th day after birth
Aromatic
Presence of Aromatic Aromatic Aromatic

unusual Odor
Negative trace of protein
Presence of
protein Urine dipstick Urine dipstick Urine dipstick showed
showed result of +1 showed result of result of negative trace of
(15mg/dL) negative trace of protein (0mg/dL) Clear yellow
protein (0mg/dL)
Color Clear yellow Clear yellow

Clear yellow
No difficulty and no pain upon urination
No difficulty and no
With difficulty No difficulty and no pain upon urination No difficulty and no pain
or with pain pain upon urination upon urination
upon urination
1st ASSESSMENT 2nd ASSESSMENT 3rd ASSESSMENT Rationale

Page 31 of 84
Nursing Department
Upon admission, the Needs minimal assistance Can tolerate the pain but Health teaching:
Toileting client needs minimal due to surgical incision needs assistance when
ability assistance due to related to cesarean section getting out of the bed Encourage to ambulate to pass flatus
labor pain delivery
The incision wound in the lower abdomen should be kept dry, intact
and use of sterile dressing to prevent infection.
1st 2nd 3rd

REST AND
ASSESSMENT ASSESSMENT ASSESSMENT PHYSIOLOGICAL BASIS RATIONALE
ACTIVITY
Limited activity Limited activity due Moderate activity Encourage the client to Health teaching:
due to moderate to acute pain of with minimal pain ambulate to promote faster
Current Activity pain related to surgical incision of surgical incision healing Teach the mother to do Deep breathing exercises.
Level labor contractions related to cesarean related to cesarean breathing strategies can be taught to the mother
as evidenced by 8 section delivery as section delivery as in labor if she is not familiar with their advantages
pain scale evidenced by 6 evidenced by 3 before labor
pain scale pain scale.
Avoid lifting objects in first few weeks to prevent

evisceration and dehiscence of the surgical
wound.
ADL’S (THE CLIENT IS ABLE TO):

Groom Patient CT can’t Patient CT needs Patient CT can Cleaning the surgical wound would prevent
groom herself an assistance change clothes, accumulation of infection especially the client
independently when changing her clean her wound, undergone cesarean delivery.
such as tying her clothes, cleaning and go to the
hair and changing her surgical bathroom to do her
clothes due to wound, and going perineal routine
Page 32 of 84
Nursing Department
pain of labor to the bathroom to with support due to Proper hygiene is necessary to a postpartum
contractions do perineal routine healing process client undergone caesarean delivery prevent
due to the and relieve pain on infection.
emergency the surgical
cesarean section incision of
cesarean delivery
Feed herself N/A Patient CT can Patient CT can
feed herself feed herself
Communicate During the latent After the delivery After the delivery In the latent phase is where
phase the client the client is the client is a nurse can talk to the client
can still conscious and able conscious and able because the uterine
communicate but to communicate. to communicate. contraction is tolerable but
as the as it progress to active and
contractions transition phase the
progress to active contractions is increase
and transition wherein the mother become
phase it she was irritable and focus on the
able to pain that she is
communicate but experiencing.
delayed in
response due to
labor pain
Page 33 of 84
Nursing Department
Sleep SLEEP SLEEP HISTORY: SLEEP HISTORY: Sleep change due to pain HEALTH TEACHING:
HISTORY: she felt
At 9:30 pm she At 10:00 pm she Encourage the mother to sleep in a preferred
She sleeps early maintain bed rest, maintain bed rest, comfortable position and using a pillow in the
at 9:30 pm, and sleeping and sleeping and abdomen to support the wound
wakes up at 6:00 sometimes she sometimes she
feel pain due to feel pain due to Advise or caution the mother to avoid resting flat
am to cook for her on her back because supine hypotension
surgical incision of surgical incision of
family. syndrome (I.e. faintness, diaphoresis, and
emergency CS emergency CS and
wake up at 6:00am hypotension from the pressure of the expanding
uterus on the inferior vena cava)
DURATION: 7-9
hours of sleep DURATION: 7-8
DURATION: 4 hours of sleep Advise the mother to take some rest when the
hours of sleep baby is resting to regain energy to take of their
QUALITY AND child
CHARACTERIST QUALITY AND Administer paracetamol as prescribed by the
ICS: EasilyQUALITY AND physician
CHARACTERISTI
awaken because CHARACTERISTI CS: easily
of pain and CS: easily
difficulty in awakened
awakened because she feel
positioning forbecause she feel
sleep pain due to
pain due to contraction and
PATTERN: contraction and surgical incision
awakens more surgical incision
than 2 times at PATTERN:
night due to pain PATTERN: awakens at night
awakens at night due to pain of
due to pain of surgical incision
surgical incision
Obese Overweight Overweight 1st assessment Obese person have an excessive accumulation of
fats in the body wherein they are risk of stroke,
Body Frame BMI= kg/h(cm)2 BMI= kg/h(cm)2 BMI= kg/h(cm)2 patient CT is obesewith a diabetes and hypertension
BMI of 30.5
Page 34 of 84
Nursing Department
BMI=78kg/5’3(16 BMI=78kg/5’3(160. BMI=78kg/5’3(160. 2nd assessment (SOURCE: Healthline)

0.02cm) 02cm) 02cm)
The criterion in pre After the delivery most women lost 19 pounds (8.6
BMI=30.5 Weight loss of 19 Weight loss of 19 pregnancy weight loss is 19 kg) which include lochia, placenta, rapid diuresis
pounds after pounds after pounds from delivering in and diaphoresis and baby. The weight loss
delivery delivery associating loss of baby's dependent on the amount of weight gain during
weight, placenta, amniotic pregnancy or if the mother will be active to lose
BMI= 27 BMI= 27 fluid, lochia discharge, weight.
overweight overweight diuresis and diaphoresis.
From giving birth
Patient CT body frame
happened to lose weight due
to giving birth but there are
changes on her BMI which is
27. Typically will slightly
lose weight due to body
adjustment and sheds fluids.
Posture During her labor N/A because she is During the Patient is in normal posture As the weight shifts forward, the body's weight is
contraction the in bed rest assessment she she looks: carried more by the arch of the foot during
patient mantains has a good posture pregnancy than by the ankle. This, coupled with
good posture Lateral position Straighten neck, tuck chin, softening ligaments, often leads to the pregnant
which is lordosis Body lines up lift up through patient having foot discomfort and swollen feet.
likely feet slightly rib cage and pull back The specific changes in bony alignment include
wider than hip- shoulders roll arms out lumbar lordosis (back of waist curves in).
width apart, contract abdomen to flatten
shoulders back, back tuck buttocks under
and spine neutral. and tilt pelvis backbend to
Tilting the hips ease body weight over feet
and round the distribute body weight
lower back due to through center of each foot
contraction of her help for low back pain, keep
abdominal. She back aligned over hips avoid
makes different twisting and bending at waist
movements to wear comfortable, low-
cope with the pain heeled shoes avoid standing
i nthe latent phase for long periods get back
Page 35 of 84
Nursing Department
these include rubs use a firm mattress

walking with pelvic rocking exercises
assitance,
relaxing the feet
while sitting and
rocking exercise
Gait Before labor the After the operation After the operation Steady Gait- tends to move HEALTH TEACHING:
patient has a she has an she has an around to ease the uterine
unsteady gait unsteady gait due unsteady gait due contractions Encourage the mother ambulate or any
wherein she to pain of the to pain of the comfortable position to ease the uterine
moves around to incision site incision site contraction.
ease uterine
contractions
Balance Can stand with Needs assistance Needs assistance since the mother has fall for risk, advise the
assistance of her when going out of when going out of mother to ask for assistant to her significant others
mother to ease the bed the bed or nurse when going to the bathroom.
the pain due to
uterine
contractions
Muscle Increasing size on Increasing size on Increasing size on In all the assessments both
both sides of the both sides of the both sides of the the upper are scored +5
indicates full ROM against HEALTH TEACHING:
body body body
gravity and full resistance Encourage to engage to a light exercise to
Contractures is No tremors and No tremors and and for both lower
strengthen the muscle of the body such as yoga,
normal can handle the can handle the extremities full ROM against
walking and dancing
baby but she has baby gravity and some resistance
No malposition
passive behavior
body parts and it Minimal muscle
due to giving birth
has tremors due weakness due to
due to her 1st
to anxiety, surgical incision of
pregnancy
forgetful and emergency CS and
nervousness Muscle weakness acute pain but on
due to surgical the healing
Page 36 of 84
Nursing Department
Her body is well incision of process after days

coordinated whileemergency CS and regain muscle and
engaging to
acute pain but on rebuild strength
activity to ease the healing then maintain
the uterine
process after days healthy for the
contractions but regain muscle and baby’s condition
easily tired due to
rebuild strength
obesity then maintain
healthy for the
Muscle weakness
baby’s condition
due to pain
contraction and
acute pain
Motor Function GROSS: GROSS: can flex GROSS: can flex Having a good control of
and extend upper and extend upper motor function helps
The patient can extremities but not extremities but not strengthen the body muscle
able to flex and on lower on lower to be able to do all the daily
extend her upper extremities due to extremities due to activities.
extremities surgical incision surgical incision
without
assistance but FINE: can hold
spoon and can eat
needs assistance FINE: can hold
when walking to spoon and can eat
ease the pain due in a slow manner
to uterine
contractions
FINE:
she can hold a
cup of water
Legs: limited Legs: frequent Legs and arms: To regain daily activities HEALTH TEACHING:
movement, pain movement w/ can adduct and
Range of support Encourage to engage nonstrenuous exercises.
Motion
Page 37 of 84
Nursing Department
upon lifting on Arms: can adduct abduct extremities,

both legs and abduct flex & extend
extremities, flex &
Arms: can adduct extend
and abduct
extremities within
normal range
Pain Relief Bed rest/sleep Acetaminophen Acetaminophen

Measures
Quality: Labor Character: aching Character: aching
contraction pain pain
Rate: 8 pain scale Onset: post Onset: post
operation operation
Severity: severe
Location: pain Location: pain
Time: Frequent from incision from incision
Duration: Duration:
intermittent pain intermittent pain
Severity: 6/10 Severity: 3/10
Pattern Pattern
Associated Associated
Factors: difficulty Factors: difficulty
of sleeping due to of sleeping due to
the surgical the surgical
incision of incision of
emergency emergency
cesarean delivery. cesarean delivery.
Mobility and Crutches: None Need assistance of Patient use wheelchair for
Assistive significant other minimal assistance
Devices Walkers: None with an alternative
of assistive device
Page 38 of 84
Nursing Department
Wheelchair:
need the
assistance
Cane: None
SAFE 1st ASSESSMENT 2nd ASSESSMENT 3rd ASSESSMENT PHYSIOLOGICAL BASIS RATIONALE
ENVIRONMENT January 12, 2020 January 13, 2020 January 16, 2020
Allergies/Reaction Medication: None Medication: None Medication: None She has no allergy Changes in Hormones Affect Allergy
Food: None Food: None Food: None reaction when taking Symptoms
Environment: Environment: Environment: medicines, food and in
None None None environment. During pregnancy there is a change due to
increase of hormones which affects the body
system because it is possible that you become
sensitive to pathogens or different allergies.
Eyes/Vision She has normal She has normal She has normal PERLLA all assessed as
vision 20/20 vision 20/20 vision 20/20 normal (Pupils are equally
Color blindness: Color blindness: Color blindness: round and react to light
None None None and accommodation)
Pupils: P E R R L A Pupils: P E R R L A Pupils: P E R R L A -normal blinking of the
eyes (15-20 blinks per
min.)
-client can see clearly and
can see objects in the
periphery
Hearing/Hearing There were no There were no There were no In assessing the client’s
Aid lesions, or unusual lesions, or unusual lesions, or unusual response to a whispered
secretion noted on secretion noted on secretion noted on voice at 1-2 ft. Away. She
both ears. Patient both ears. Patient both ears. Patient is able to repeat non
doesn’t wear doesn’t wear doesn’t wear consecutive numbers.
hearing aid. hearing aid. hearing aid.
In performing a watch tick
Patient was able to Patient was able to Patient was able to test, she can hear the
answer in a low answer in a low answer in a low tickling on both ears.
tone questions. tone questions. tone questions.
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Nursing Department
Weber test:
Normal: vibration is heard
equally in both ears or the
midline
No disharge and no
swelling
Skin Minimal edema on Minimal edema on There is no Linea nigra: pigmentation Emergency CS is done to make sure that both
the bilateral upper the bilateral upper presence on the down middle line of the mother and baby are safe to prevent further
and lower limbs are and lower limbs are bilateral upper adomen, more notice in complications.
grade 2 grade 1 (2 and lower limbs darker skinned and
(4 millimeter slight millimeter barely patients color HEALTH TEACHING:
indentation the visible the rebound Post operative Striae gravidarum: Encourage to keep it clean, dry and intact to
rebound time is 15 time is immediate) site of incision: stretch marks of abdomen, prevent infection with the use of sterile
seconds) breasts, thighs and dressing.
There is no Appearance: no buttocks
presence on the redness Sweating these result from
bilateral upper stretching of the skin and
and lower limbs Bleeding: hormonal changes
negative bleeding Edema in the upper
Post operative site extremities:
of incision: Discharge: Women with preeclampsia
negative discharge there vessel become
Appearance: narrowed which increases
minimal redness the blood pressure and
respond differently to the
Bleeding: negative hormonal signals which
bleeding limits the flow of blood and
the fluid will accumulate
Discharge: causing swelling in the
negative discharge face, hands, feet and
weight gain.
Surgical Incision of
emergency CS:
Surgical incision in the
lower quadrant of the
Page 40 of 84
Nursing Department
abdomen during
emergency CS
Color Skin: Pinkish Skin: Pinkish Skin: Pinkish There is no pallor, no edema in the 2 nd – 5th
Conjunctiva: clear Conjunctiva: clear Conjunctiva: clear assessment but has a presence of surgical
Lips: Pale Lips: Pink Lips: Pink incision due to emergency CS. The skin turgor
Nailbeds: Pink Nailbeds: Pink Nailbeds: Pink was not assessed.
Palms: Pink Palms: Pink Palms: Pink
Mucous Moist and Intact Moist and Intact Moist and Intact
Oral cavity is moist and
Membrane intact. No indication of
dehydration
Temperature 37.2 C (Axillary 36.9 C (Axillary 36.8 C (Axillary Temperature may
Temperature) 8:00 Temperature) 8:00 Temperature) 8:00 increase up to 1F during Due to exhaustion after the labor it elevates the
am am am labor temperature
The client The client The client Encourage the mother to rehydrate if tolerated.
temperature is temperature is temperature is
within normal. within normal. within normal.
Normal: 35.37 to Normal: 35.37 to Normal: 35.37 to
37.35 C 37.35 C 37.35 C
OXYGENATION 1st 2nd 3rd 4th 5th PHYSIOLOGICAL RATIONALE

ASSESSMENT ASSESSMENT ASSESSMENT ASSESSMENT ASSESSMENT BASIS
January 12, January 13, January 14, January 15, January 16,
2020 2020 2020 2020 2020
Activity RR increase RR decrease RR decrease RR decrease RR decrease Due to acute pain HEALTH TEACHING:
tolerance due to significantly due significantly due significantly due significantly due and C-section Patient comfort and care by
contractions to normal bed to normal bed to normal bed to normal bed wound swaying from side to side,
and giving birth rest rest rest rest rocking, or other rhythmic
movements may also be
Normal color of comforting. If labor is
the skin after Normal color of Normal color of Normal color of Normal color of progressing slowly, ambulating
activity the skin the skin the skin the skin may speed it up again. Upright
positions such as walking,
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Nursing Department
heart rate does Heart rate and Heart rate and Heart rate and Heart rate and kneeling forward, or doing the
not exceed respiratory rate respiratory rate respiratory rate respiratory rate lunge on the birthing ball give a
baseline level does not exceed does not exceed does not exceed does not exceed greater sense of control and
and respiratory baseline level. baseline level. baseline level. baseline level. active movement than just lying
rate exceed . down.
baseline level
Totally Totally Totally Totally NURSING INTEVENTIONS
Normal RR: 8- dependent dependent dependent dependent FOR ROOMING IN:
24 (Green LJ, performing performing performing performing -The patient should wear such
et. Al, 2020) ADL’s. ADL’s. ADL’s. ADL’s. clothes in which there should
not hinder blood flow or oxygen
Shortness of supply.
breath -Make good breathing habits to
the patient and motivate him/her
to increase cardiovascular
functions and decrease stress
levels.
-Change in positions frequently
-Place most commonly used
things closer to bed
-Relax for one hour at least before
the new activity starts
Airway The patient is Patient is Patient is Patient is Patient is Implies here if there are
clearance experiencing abnormal changes in the airway
able to sniff able to sniff able to sniff able to sniff
shortness of clearance it may be related to
breath and each nostril each nostril each nostril each nostril factors such as obesity,
breathing malnourishment, side effects of
and no and no and no and no
through her medications (e.g., -blockers), or
mouth while occlusion occlusion occlusion occlusion emotional states such as
having labor depression or lack of confidence
while in bed while in bed while in bed while in bed
contraction and to exert one's self.
giving birth rest noted: rest noted: rest noted: rest noted:
HEALTH TEACHING:
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Nursing Department
-No -No -No -No Proper sitting position and

splinting of the abdomen
blockages or blockages or blockages or blockages or
promote effective coughing by
obstruction obstruction obstruction obstruction increasing abdominal pressure
and upward diaphragmatic
noted noted noted noted
movement.
-No -No abnormal -No abnormal -No abnormal Ambulation to promote lung
breath sounds breath sounds breath sounds expansion, mobilizes
abnormal
secretions, and lessens
breath atelectasis it defines a complete
or partial collapse of the entire
sounds
lung or area (lobe) of the lung.
Respiration Labor & Private room Private room Private room Private room 1st day The lungs have a bit more work
Delivery January 13, January 14, January 15, January 16, assessment to do during this stage of labor
birthing room 2020 2020 2020 2020 and delivery until postpartum
January 12, The client The respiratory rate implies
2020 3:00 AM 4:00 AM 6:00 AM 4:00 AM Respiration is Painful contractions may lead to
Rate: 18 Rate: 18 Rate: 18 Rate: 17 within irregular and maternal hyperventilation and
8:00 AM breaths/min breaths/min breaths/min breaths/min shallow breathing respiratory alkalosis, which in
Rate: 25 Rhythm: Rhythm: Rhythm: Rhythm: from ongoing turn shift the oxygen
breaths/min Regular Regular Regular Regular Assessment to hemoglobin dissociation curve
Rhythm: Erratic oscillating cycle oscillating cycle oscillating cycle oscillating cycle control intensity of to the left, decrease delivery of
Depth: of inspiration of inspiration of inspiration of inspiration contraction. It oxygen to the fetus. The pain of
Irregular and expiration and expiration and expiration and expiration means that client is labor is associated with reflex
shallow breath Depth: Regular Depth: Regular Depth: Regular Depth: Regular in shortness of increase in blood pressure,
breaths breaths breaths breaths breath from around oxygen consumption, and
9:45 AM 8 – 10 am liberation of catecholamine, all
Rate: 22 6:00 AM 8:00 AM 10:00 AM 8:00 AM due to labor and of which could adversely affect
breaths/min Rate: 19 Rate: 17 Rate: 18 Rate: 19 delivery uterine blood flow. Increased
Rhythm: breaths/min breaths/min breaths/min breaths/min carbon dioxide, peripheral
Regular Rhythm: Rhythm: Rhythm: Rhythm: Normal: 15 to 25 vascular resistance, and
Depth: Regular Regular Regular Regular Cpm increased oxygen consumption
Regular breaths oscillating cycle oscillating cycle oscillating cycle oscillating cycle in turn accompany this.
of inspiration of inspiration of inspiration of inspiration 2nd and 3rd day
and expiration and expiration and expiration and expiration assessment ABNORMAL FINDINGS:
Page 43 of 84
Nursing Department
Depth: Regular Depth: Regular Depth: Regular Depth: Regular Client is within Lost amount of blood with birth
breaths breaths breaths breaths normal range and is orthostatic hypotension,
decrease after dizziness, occurs on standing
10:30 AM 12:30 PM 2:30 PM delivering the the lack of adequate blood
Rate: 19 Rate: 18 Rate: 19 baby, having a volume to maintain nourishment
breaths/min breaths/min breaths/min normal relax of brain cells.
Rhythm: Rhythm: Rhythm: breathing (eupnea)
Regular Regular Regular as it heals HEALTH TEACHING:
oscillating cycle oscillating cycle oscillating cycle During labor notice pain so,
of inspiration of inspiration of inspiration doing upright and move in
and expiration and expiration and expiration different position
Depth: Regular Depth: Regular Depth: Regular Ambulation.
breaths breaths breaths
1:30 PM 7:00 PM
Rate: 19 5:00 PM Rate: 18
breaths/min Rate: 19 breaths/min
Rhythm: breaths/min Rhythm:
Regular Rhythm: Regular
oscillating cycle Regular oscillating cycle
of inspiration oscillating cycle of inspiration
and expiration of inspiration and expiration
Depth: Regular and expiration Depth: Regular
breaths Depth: Regular breaths
breaths
8:00 PM 11:30 PM
Rate: 18 9:00 PM Rate: 17
breaths/min Rate: 19 breaths/min
Rhythm: breaths/min Rhythm:
Regular Rhythm: Regular
oscillating cycle Regular oscillating cycle
of inspiration oscillating cycle of inspiration
and expiration of inspiration and expiration
Depth: Regular and expiration Depth: Regular
breaths Depth: Regular breaths
breaths
Page 44 of 84
Nursing Department
Peripheral Pulse Labor & Private room Private room Private room Private room 1st day Pulse rise during her labor and
delivery Janury 13, Janury 14, Janury 15, Janury 16, assessment delivery, and also as the uterus
birthing room 2020 2020 2020 2020 The client is having grows, it eventually will
January 12, a panic breathing compress the pelvic blood
2020 12:30 AM 12:00 AM 6:00 AM 4:00 AM (hyperventilation) vessels underneath it, and that'll
Rate:78 bpm Rate:92 bpm Rate:87 bpm Rate:83 bpm due to irregular obstruct venous return to the
8:00 AM peripheral pulse heart from the pelvis and the
Rate:90 bpm 3:00 AM 4:00 AM 10:00 AM 8:00 AM rate and labor due legs, and so among other
Rate:80 bpm Rate:92 bpm Rate:93 bpm Rate: 88 bpm frequency conditions, this can cause
9:45 AM contractions varicose vein to develop leg
Rate:90 bpm 6:00 AM 8:00 AM 2:30 PM cramps.
Rate:80 bpm Rate:92 bpm Rate:90 bpm Normal range:60-
11:00 AM 100bpm A decrease may indicate
Rate:90 bpm 10:30 AM 12:30 PM 7:00 PM bleeding after giving birth as I
Rate:84 bpm Rate:88 bpm Rate:89 bpm Active phase: monitor her vitals signs the
12:30 PM 8 am heart rate often decreases to a
Rate:85 bpm 1:30 PM 5:00 PM 11:30 PM rate of 50 to 60 beats/min
Rate:80 bpm Rate:95 bpm Rate:85 bpm 2nd and 3rd day (bradycardia, or slow pulse)
9:30 PM assessment
Rate:80 bpm 8:00 PM 9:00 PM Client is in the A fast pulse may be due to blood
Rate:92 bpm Rate:90 bpm normal range but loss, anemia, fever, or shock.
there are slight
changes after During labor and giving birth the
delivering the uterine contractions are regular,
baby. It means that strong, and coordinated the
she experienced intensity, frequency, and
intense pain due to regularity of contractions
urinary stress because of this extra blood
incontinence, volume
rectal tears and
anal sphincter
disruptions around
3:00pm because of
delivering the baby
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Nursing Department
Blood Pressure Labor & Private room Private room Private room Private room 1st day Oxytocis drugs frequently
Delivery January 13, January 14, January 15, January 16, assessment administered to achieve uterine
birthing room 2020 2020 2020 2020 Client blood contraction of all smooth muscle
January 12, pressure is above including blood vessels
2020 12:30 AM 12:00 AM 1:30 AM 4:00 AM the normal range consequently these drugs can
Rate: 130/100 Rate: 130/90 Rate: 130/90 Rate: 130/80 and continuously increase blood pressure.
8:00 AM mmHg mmHg mmHg mmHg increases due to (Source Piliterri book) This
Rate: 150/100 4:00 AM 6:00 AM fast implies that important to
mmHg 3:00 AM Rate: 130/90 Rate: 130/90 8:00 AM labour contractions measure first the blood pressure
Rate: 130/100 mmHg mmHg Rate: 130/90 nearly to giving before administering one of
9:45 AM mmHg mmHg birth these agents.
Rate: 130/90 8:00 AM 10:00 AM
mmHg Rate: 130/90 Rate: 130/900 Normal range: 110- The blood pressure should
6:00 AM mmHg mmHg 140/60-90 mmHg remain about the same as it was
11:00 AM Rate: 130/90 during labor, and the pulse will
Rate: 130/100 mmHg 12:30 PM 2:30 PM 2nd to 4th day gradually decrease. A high or
mmHg Rate: 130/85 Rate: 130/90 assessment low blood pressure can be
mmHg mmHg The blood helpful in diagnosing potential
12:30 PM 10:30 AM pressure is still complications such as
Rate: 130/100 Rate: 130/90 5:00 PM 7:00 PM above the normal hemorrhaging or hypertension.
mmHg mmHg Rate: 130/90 Rate: 130/80 range due to the
mmHg mmHg mother is In fact, they've gotta work about
6:00 PM 1:30 PM hypertensive. 50% harder, and this is to
Rate: 130/90 Rate: 130/90 9:00 PM 11:30 PM provide oxygen to all that extra
mmHg mmHg Rate: 130/90 Rate: 130/80 blood that patient got on board
mmHg mmHg for the fetus. But to sort of
9:30 PM 8:00 PM complicate things a bit, the
Rate: 130/100 Rate: 130/90 growing uterus pushes up on
mmHg mmHg patient's diaphragm, preventing
her from taking in full breaths.
So she might develop a bit of
shortness of breath. The uterus
puts a bit of pressure on the
stomach as well, and that can
cause some heartburn or gastric
reflux in patient, but luckily after
giving birth of the fetus sort of
Page 46 of 84
Nursing Department
descends a bit in the pelvis, and

that reduces the upward
pressure on the diaphragm, so
the patient can breathe a bit
better, and the heartburn
typically goes away as well. The
flip side of this, though, is that
the uterus, because it's dropped
a bit, it then puts even more
pressure on the urinary bladder,
and that leads to needing to
urinate a lot more frequently.
Apical Pulse 11:00 am 10:30 am 5:00 pm 2:30 pm 6:00 am Due to Basically, listening directly to the
Located on left Located on left Located on left Located on left Located on left contractions also heart. It’s a very reliable and
center of chest center of chest center of chest center of chest center of chest due to increased non-invasive way to evaluate
104 bpm due to 99 bpm 98 bpm 94 bpm 91 bpm circulation of cardiac function
contractions oxytocin and blood
(increased loss after giving HEALTH TEACHING:
circulation of birth it may affect Allowing some time and take
oxytocin) also insufficient care of any matter that needs
oxygen on her attention so that it will not be
normal range in transition interrupted.
adults 10 to 100 Wear loose fitting clothing
bpm) Empty your bladder
Find a comfortable position in
which your body is well
supported, using pillows as
necessary
Remember to evaluate pulse
rate conscientiously because
there’s a rapid and thread pulse
during this time which could be
a sign of hemorrhage.
Observe if there abnormal

findings:
Page 47 of 84
Nursing Department
It has presence of a pulse deficit

indicates that there may be an
issue with cardiac function or
efficiency. When a pulse deficit
is detected, it means that the
volume of blood pumped from
the heart may not be sufficient to
meet the needs of your body’s
tissues.
Fear or anxiety, fever, recent
physical activity, pain,
hypotension (low blood
pressure), blood loss and
insufficient oxygen intake
Additionally, a heart rate that is
consistently higher than normal
could be a sign of heart
disease, heart failure, or
an overactive thyroid gland.
When the apical pulse

is lower than expected, your
doctor will check for medication
that may be affecting your heart
rate. Such medications
include beta-blockers given for
high blood pressure or anti-
dysrhythmic medications given
for irregular heartbeat.
Oxygen 8:00 AM 10:30 AM 5:00 PM 2:30 PM 6:00 AM The patient’s It is necessary to check fo the
Saturation 90% 96% 98% 96% 100% oxygen saturation oxygen saturation to measure
was below the the amount or volume of blood
9:45 AM normal range bounded to oxygen that will
95% during admission perfuse the peripheral body
but became stable tissues
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Nursing Department
while she has been

oxygenated
Normal Range:
95% to 100%
Lung Sounds Anxious Normal breath Normal breath Normal breath Normal breath Changes in When hearing the lungs, your
breathing but it sounds due to sounds due to sounds due to sounds due to respiratory due to doctor compares one side with
is in the normal performing performing performing performing Increased the other and compares the
range ADL’s after ADL’s after ADL’s after ADL’s after progesterone front of your chest with the back
Sudden delivering the delivering the delivering the delivering the concentrations of your chest. Airflow sounds
changes level of baby baby baby baby during pregnancy contrarily when airways
mcL. Normal level of Normal level of Normal level of Normal level of likely stimulate are blocked, narrowed, or filled
Rhythm: Erratic mcL. mcL. mcL. mcL. increased with fluid. They’ll also listen for
Depth: Irregular respiration, even abnormal sounds such
shallow breath before an increase as wheezing.
in metabolic rate.
Oxygen Lung sounds can vary as much
consumption and as heart sounds. Wheezes can
carbon dioxide be either high- or low-
production pitched and can indicate that
increase. Vital mucus is preventing your lungs
capacity is from expanding properly. One
unchanged. Total type of sound your doctor might
lung capacity is listen for is called a rub. Rubs
only slightly sound like two pieces of
reduced because sandpaper rubbing together and
chest can indicate irritated surfaces
circumference around your lungs. (Source:
increases. Healthline)
Anatomic changes
One reason is that the uterus is
also accompany
expanding and pushing up into
pregnancy
the abdomen. This squeezes
the lungs a bit, reducing the
The respiratory
mucous
Page 49 of 84
Nursing Department
membranes space they have for oxygen

become vascular, exchange.
edematous. The
voice may deepen Shortness of breath is
and there is a progesterone, a hormone that
progressive increases during pregnancy.
increase in labor High progesterone levels cause
after the pregnant women to breathe
assessment the faster. The rise in progesterone
patient gain and begins early in pregnancy, and
coping which I the shortness of breath it causes
assess it is normal can come as a surprise.
breath sounds Although shortness of breath
which result to be can be bother, most of the time
good. it is harmless and due to the
normal changes of pregnancy.
(Source: Harvard Health Pub)
Skin integrity Color: Pinkish Color: Pinkish Color: Pinkish Color: Pinkish Color: Pinkish Patient are eager HEALTH TEACHING:
to take fluid, so Promote proper hygiene,
drinking a large provide well hydrated every day,
Nails: Pink Nails: Pink Nails: Pink Nails: Pink Nails: Pink quantity of fluid is moisturize dry skin to maximize
tones is seen in tones is seen in tones is seen in tones is seen in tones is seen in not a problem lipid barriers; moisturize at
the nails the nails the nails the nails the nails unless if the patient minimum twice daily. Avoid hot
Lips: light pink Lips: light pink Lips: light pink Lips: light pink Lips: light pink is nauseated from water during bathing; this will
without lesions without lesions without lesions without lesions without lesions a birth analgesic. increase dry, cracked skin.
or swelling or swelling or swelling or swelling or swelling Protect skin with a moisture
NORMAL lotion or barrier as indicated.
It is normal It is normal It is normal It is normal FINDINGS:
Normally goes which returns which returns which returns which returns Normally goes
back within 2 within 2 within 2 within 2 within 2 back within 2
seconds seconds seconds seconds seconds seconds
Capillary refill Return less than Return less than Return less than Return less than Return less than So that patient HEALTH TEACHING:
2 s means that 2 s means that 2 s means that 2 s means that 2 s means that assess that her The correct way is proper
client is client is client is client is client is Pressure is applied capillary nail refill test which is a
Page 50 of 84
Nursing Department
hydrated. The hydrated. The hydrated. The hydrated. The hydrated. The to the nail bed until quick test done on the nail beds.
normal must normal must normal must normal must normal must it turns pink. Once It is used to
return less than return less than return less than return less than return less than the tissue has monitor dehydration and the
3 seconds 3 seconds 3 seconds 3 seconds 3 seconds blanched, amount of blood flow to tissue.
pressure is So that patient assess that her
removed. I observe Pressure is applied to the nail
that the Capillary bed until it turns pink. This
refill is well good indicates that the blood has
normally return been forced from the tissue
less than 3 under the nail. It is called
seconds blanching.
ABCDE approach used by

nurses to assess and treat risk
factor 5 components namely
most especially for pregnant
and baby patient: important to
check
Airway, Breathing, Circulation,
Disability, and Exposure.
Edema Presence of Presence of There is no There is no There is no Usually this happe Swelling (aka "edema") in your
edematous edematous presence of presence of presence of n patient during feet, ankles, and hands
(upper edema in the edema in the edema in the labor and going throughout pregnancy and
color: Redness extremities) upper and upper and upper and through transition, especially as pregnancy nears
Temperature: lower lower lower the body produces the end is
Warm to touch Color: Redness extremities extremities extremities 50% more blood very common and normal.
Temperature: and bodily fluids, (Source: WHO)
Degree of Warm to touch There is a There is a There is a most of which is
identation or presence of presence of presence of created to meet Edema occurs when body fluids
pitting: +2 (4m Degree of surgical incision surgical incision surgical incision baby's needs. increase to nurture both you and
depression) few identation or due to due to due to your baby and accumulate in the
seconds pitting: +1 (2 emergency CS emergency CS emergency CS tissues as a result of increased
During labor the
millimeter and blood flow and pressure of your
body retains extra
barely growing uterus on the pelvic veins
water to support
detectable) The and your vena cava (the large
the baby, and this
vein on the right side of the body
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Nursing Department
rebound time is water is gradually that returns blood from your lower
immediate released through limbs to your heart).
sweating and
urination. In the
meantime, various HEALTH TEACHING:
home remedies Physical activity and low-impact
and exercises can exercise like walking can
reduce the swelling definitely help reduce swelling in
and associated your feet during pregnancy
symptoms. The
swelling usually
affects the legs,
feet, ankles, and
face. According to
the American
Pregnancy
Association, a
woman’s body
produces 50%
more blood and
body fluids during
pregnancy to
support the
developing baby.
Some research
suggests that a
woman may retain
more than,
swelling can occur
after abdominal or
vaginal delivery.
Homan’s Sign No pain felt in No pain felt in No pain felt in No pain felt in No pain felt in Implies that unable Varicose veins are swollen,
calf muscles calf muscles calf muscles calf muscles calf muscles to walk or put twisted veins that lie just under
weight on your leg. the skin and usually occur in the
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Nursing Department
Have pain, legs. Overview. Varicose

swelling, redness veins are a common condition
or warmth in caused by weak or
your calf. damaged vein walls and
The increased valves. Varicose veins may form
volume of the whenever blood pressure
uterus leads to increases inside your veins.
increased (Source: NIH)
pressure on the
main vein Painful involuntary muscle
responsible for contractions that typically affect
returning blood to the calf, foot or both
the heart. Blood are common during pregnancy,
circulation in the often striking at night during the
leg veins can be second and third trimesters.
considerably (Source: Piliterri Book)
disrupted. The
symptoms vary ABNORMAL FINDINGS:
significantly from hypercoagulability of the blood
ranging from experience of
simple discomfort -during pregnancy (hormonal
to disabling pain. changes)
Also we may -anemia
assess varicose -traumatic delivery
vein which is
common during HEALTH TEACHING:
pregnancy and that Homan’s sign assess to the
there is often patient is normal but if she
relief after giving complain of pain in calf of the leg
birth. This is due to upon dorsi- flexion of foot with
weight, sore leg extended is diagnostic of
feeling in Deep Vein Thrombosis
the affected leg(s) (DVT) of the area. It is positive
with or without Homan's sign is indicative of
swelling. Although DVT.
this is a normal
findings.
Page 53 of 84
Nursing Department
Pulse:popliteal, dorsalis pedis:

equal, bilateral, no edema
Ambulate
NUTRITION 1ST ASSESSMENT 2nd 3rd PATHOPHYSIOLOGICAL BASIS

January 12, 2020 ASSESSMENT ASSESSMENT
January 13, 2020 January 16, 2020
Hospital diet NPO, due to labor prior Clear fluid diet such as soup and jelly Lugaw, soft cook green beans,
to delivery ace chopped cooked spinach are good
source of vitamins A and C, iron
and dietary calcium.
Fluid intake A sip of water between 5-10mL 2 glasses of water Prevent dehydration and
constipation
IVF’s Site: Right Cephalic Vein Site: Right Cephalic Vein Provides calories, water and
electrolytes. To treat dehydration
D5LR/ L D5 LRS/ L and replace lost fluids and blood
IV infusion rate: IV infusion rate: 30gtts/min

30gtts/min
Rate: to treat dehydration and replace
lost fluids and bloods to run for 8 hours
Skin Turgor Not assessed due to her edema
HEIGHT AND WEIGHT 1ST ASSESSMENT 2ND ASSESSMENT 3rd ASSESSMENT

Blood Transfusion None
HEIGHT 5’3’’ 5’3’’ 5’3’’
Total Parenteral Nutrition (TPN) None WEIGHT 78 kg 69 kg 69 kg
BODY MAX INDEX RESULT NORMAL RANGE

1ST ASSESSMENT 30.5 A BMI of pre-pregnancy weight; 18.5-24.9 is considered normal; 25-29.9 is considered overweight;
2ND ASSESSMENT 26.9 30-39.9 is classified as obesity; and over 39 is very obese. The patient has BMI of below 18.5, it
3rd ASSESSMENT 26.9 implies that the patient is normal. Being normal in pregnancy it is essential to maintain weight for
baby's growth and development also the health of mother. BMI 4kg/m2
Page 54 of 84
Nursing Department
1ST ASSESSMENT 2ND ASSESSMENT 3RD ASSESSMENT

ABILITY TO:
A. CHEW  
B. SWALLOW  
C. TOLERATE FOOD  
D. FEED SELF  
CHAPTER VII
DRUG STUDY
Name of Medication Classification Complete Action Side Effects Adverse Effects Nursing Consideration
Doctor’s
Order
Generic Name: Second 500 mg BID Cefuroxime inhibits  Nausea Large doses can cause Assessment
Cefuroxime axetil Generation for 10 days bacterial cell wall  Vomiting  cerebral irritation History: Hepatic and renal
Cephalosporins synthesis by binding  diarrhea or convulsions impairment, lactation, pregnancy
to one 1 or more of stomach pain  erythema multiforme
Brand Name: the penicillin-binding  Dizziness and  Stevens-Johnson Physical: Skin status, LFTs, renal
Ceftin proteins (PBPs) drowsiness syndrome function tests, culture of affected
which in turn inhibit may occur less  epidermal necrolysis area, sensitivity tests
the final frequently,
Date Given: transpeptidation step especially with Potentially Fatal: Interventions
January 12, 2020 of peptidoglycan higher doses.  Anaphylaxis  Culture infection, and
synthesis in bacterial nephrotoxicity arrange for sensitivity tests
cell walls, thus  pseudomembranous before and during therapy if
Date Discontinued: inhibiting cell wall expected response is not
January 22, 2020 colitis.
biosynthesis and seen.
arresting cell wall  Give oral drug with food to
assembly resulting in decrease GI upset and
bacterial cell death. enhance absorption.
 Give oral drug to children
who can swallow tablets;
crushing the drug results in a
bitter, unpleasant taste.
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Nursing Department
 Have vitamin K available in

case hypoprothrombinemia
occurs.
 Discontinue if
hypersensitivity reaction
occurs.
Teaching points
Oral drug
 Take full course of therapy

even if you are feeling better.
 This drug is specific for this
infection and should not be
used to self-treat other
problems.
 Swallow tablets whole; do not
crush them. Take the drug
with food.
 You may experience these
side effects: Stomach upset
or diarrhea.
 Report severe diarrhea with
blood, pus, or mucus; rash;
difficulty breathing; unusual
tiredness, fatigue; unusual
bleeding or bruising; unusual
itching or irritation.
Parenteral drug
 Avoid alcohol while taking this

drug and for 3 days after
because severe reactions
often occur.
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Nursing Department
 You may experience these

side effects: Stomach upset
or diarrhea.
 Report severe diarrhea,
difficulty breathing, unusual
tiredness or fatigue, pain at
injection site.
Name of Medication Classification Complete Action Side Effects Adverse Effects Nursing Consideration
Doctor’s
Order
Generic Name: Antacids, 50mg IV Inhibits histamine at  headache  Rash Assessment & Drug Effects
Ranitidine Antireflux once H2-receptors of the  constipation  Dizziness
Agents & gastric parietal cells  diarrhea  Tiredness  Monitor creatinine clearance if renal
Antiulcerants thereby inhibiting  nausea and  Local pain dysfunction is present or
Brand Name: gastric acid vomiting  burning or suspected. When clearance is <50
Zantac secretion, gastric  stomach itching has been mL/min, manufacturer recommends
volume and reducing discomfort reported at the reduction of the dose to 150 mg
hydrogen ion or pain site of inj. once q24h with cautious and
Date Given: concentration. gradual reduction of the interval to
January 12, 2020 q12h or less, if necessary.
 Be alert for early signs of
hepatotoxicity: jaundice (dark urine,
Date Discontinued: pruritus, yellow sclera and skin),
January 12, 2020 elevated transaminases (especially
ALT) and LDH.
 Long-term therapy may lead to
vitamin B12 deficiency.
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Nursing Department
Name of Classification Complete Action Side Effects Adverse Effects Nursing Consideration
Medication Doctor’s
Order
Generic Antihypertensives 250mg/tab Methyldopa is  drowsiness  weight gain Assessment & Drug Effects
Name: 0D metabolised into α-  headache  reversible  Check BP and pulse at least
Methyldopa methylnorepinephrine,  lack of energy  granulocytopenia q30min until stabilized during
250 mg a false  weakness  thrombocytopenia, IV infusion and observe for
Brand Name: mixed in neurotransmitter that  dizziness  sedation adequacy of urinary output.
Aldomet 100 stimulates the central  lightheadedness  jaundice  Take BP taken at regular
milliliters inhibitory α-adrenergic  fainting  depression intervals in lying, sitting, and
(mL) of receptors resulting in standing positions during
Date Given:  weight gain  Edema
solution a decreased arterial period of dosage adjustment if
November 24,  Nausea and vomitting
(5% pressure. physician requests.
2019 dextrose)  Be aware that transient
sedation, drowsiness, mental
Date depression, weakness, and
Discontinued: headache commonly occur
January 12,
during first 24–72 h of therapy
2019
or whenever dosage is
increased. Symptoms tend to
disappear with continuation of
therapy or dosage reduction.
 Supervision of ambulation in
older adults and patients with
impaired kidney function; both
are particularly likely to
manifest orthostatic
hypotension with dizziness and
light-headedness during period
of dosage adjustment.
 Monitor fluid and electrolyte
balance and I&O. Report
oliguria and changes in I&O
ratio. Weigh patient daily, and
check for edema because
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Nursing Department
methyldopa favors sodium and

water retention.
 Lab tests: Schedule baseline
and periodic blood counts and
liver function tests especially
during first 6–12 wk of therapy
or if patient develops
unexplained fever; periodic
serum electrolytes.
 Be alert to and report
symptoms of mental
depression (e.g., anorexia,
insomnia, inattention to
personal hygiene, withdrawal).
Drug-induced depression may
persist after drug is withdrawn.
 Be alert that rising BP
indicating tolerance to drug
effect may occur during week 2
or 3 of therapy.
Patient & Family Education

 Exercise caution with hot baths
and showers, prolonged
standing in one position, and
strenuous exercise that may
enhance orthostatic
hypotension. Make position
changes slowly, particularly
from lying down to upright
posture; dangle legs a few
minutes before standing.
 Avoid potentially hazardous
tasks such as driving until
response to drug is known;
drug may affect ability to
perform activities requiring
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Nursing Department
concentrated mental effort,

especially during first few days
of therapy or whenever dosage
is increased.
 Do not to take OTC
medications unless approved
by physician.
 Do not breast feed while taking
this drug without consulting
physician.
Order
Generic Name: Vitamins & PO: 30 Facilitates oxygen  Contact irritation  Gastrointestinal (GI) Assessment & Drug Effects
Ferrous Minerals (Pre & mg/day for transport via Hb. It is  Diarrhea hemorrhage (rare)  Lab tests: Monitor Hgb and
Sulfate Post Natal) / 5 mos used as iron source  Dark stools  Gastrointestinal (GI) reticulocyte values during therapy.
Antianemics as it replaces iron  Nausea irritation Investigate the absence of
Brand Name: found in Hb,  Stomach pain  Gastrointestinal (GI) satisfactory response after 3 wk of
Slow Fe myoglobin and other  Superficial tooth obstruction (wax drug treatment.
enzymes. discoloration matrix products; rare)  Continue iron therapy for 2–3 mo
(oral solutions)  Gastrointestinal (GI) after the hemoglobin level has
Date Given: returned to normal (roughly twice
 Vomiting perforation (rare)
July 14, 2019  Urine discoloration the period required to normalize
 Constipation hemoglobin concentration).
 Monitor bowel movements as
constipation is a common adverse
Date effect.
Discontinued:
December 12, Patient & Family Education
2019  Note: Ascorbic acid increases
absorption of iron. Consuming
citrus fruit or tomato juice with iron
preparation (except the elixir) may
increase its absorption.
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Nursing Department
 Be aware that milk, eggs, or

caffeine beverages when taken
with the iron preparation may
inhibit absorption.
 Be aware that iron preparations
cause dark green or black stools.
 Report constipation or diarrhea to
physician; symptoms may be
relieved by adjustments in dosage
or diet or by change to another iron
preparation.
 Do not breast feed while taking this
drug without consulting physician.
Order
Generic Name: Hypertonic D5LRS 1L This pulls the fluid into  itching,  febrile response,  Do not administer unless solution is
D5LRS Nonpyrogenic at the vascular by  hives,  infection at the site clear and container is undamaged.
Parenteral fluid 30gtts/min osmosis resulting in  swelling of the of injection,  Caution must be exercised in the
Electrolyte to run for 8 an increase vascular face,  venous thrombosis administration of parenteral fluids,
Brand Name: Nutrient hours volume. It raises  puffy eyes, or phlebitis especially those containing sodium
replenisher Route: IV intravascular osmotic  coughing, extending from the ions to patients receiving
pressure and provides  sneezing, site of injection, corticosteroids or corticotrophin.
fluid, electrolytes and  sore throat,  extravasation and  Solution containing acetate should
Date Given: calories for energy.
 fever  hypervolemia. be used with caution as excess
January 12, administration may result in
2020  injection site
reactions metabolic alkalosis.
(infection,  Solution containing dextrose should
swelling, be used with caution in patients
Date
redness). with known subclinical or overt
Discontinued:
diabetes mellitus.
January 14,
 Discard unused portion.
2020
 In very low birth weight infants,
excessive or rapid administration of
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Nursing Department
dextrose injection may result in

increased serum osmolality and
possible intracerebral hemorrhage.
 Properly label the IV Fluid
 Observe aseptic technique when
changing IV fluid
Order
Generic Vitamins & 400 Folic acid is essential  abdominal  Cardiac disorders: Assessment
Name: Minerals (Pre & mcg/day for for the production of cramps, Flushing.  History: Allergy to folic acid
Follic Acid Post Natal) / 45 days coenzymes in many  diarrhea,  Gastrointestinal preparations; pernicious,
Antianemics metabolic systems  rash, disorders: Anorexia, aplastic, normocytic anemias;
Brand Name: such as purine and  sleep nausea, abdominal lactation
Folvite pyrimidine synthesis. disorders, distention, flatulence.  Physical: Skin lesions, color; R,
It is also essential in  irritability,  Immune system adventitious sounds; CBC, Hgb,
nucleoprotein  confusion, disorders: Allergic Hct, serum folate levels, serum
Date Given: synthesis, vitamin B12 levels, Schilling test
 nausea, reactions.
June 9, 2019 maintenance of 
 stomach Nervous system
erythropoiesis and disorders: Malaise. Interventions
upset,
stimulation of WBC
 behavior  Respiratory, thoracic  Administer orally if at all
and platelet and mediastinal possible. With severe GI
Date changes,
production in folate- disorders: malabsorption or very severe
Discontinued: deficiency anemia.  skin
reactions, Bronchospasm. disease, give IM, IV, or
July 21, 2019
 seizures,  Skin and subcutaneous subcutaneously.
tissue disorders:  Test using Schilling test and
 gas,
Erythema, pruritus, serum vitamin B12 levels to rule
 excitability
skin rash, out pernicious anemia. Therapy
hypersensitivity.burning may mask signs of pernicious
or itching has been anemia while the neurologic
reported at the site of deterioration continues.
inj.  WARNING: Use caution when
giving the parenteral
preparations to premature
infants. These preparations
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Nursing Department
contain benzyl alcohol and may

produce a fatal gasping
syndrome in premature infants.
 WARNING: Monitor patient for
hypersensitivity reactions,
especially if drug previously
taken. Keep supportive
equipment and emergency
drugs readily available in case of
serious allergic response.
Teaching points
When the cause of megaloblastic
anemia is treated or passes (infancy,
pregnancy), there may be no need for
folic acid because it normally exists in
sufficient quantities in the diet.
Report rash, difficulty breathing, pain
or discomfort at injection site.
Order
Generic Beta-Blockers 250 mg PO, Labetalol non-  dizziness.  shortness of Assessment & Drug Effects
Name: twice a day selectively  tingling scalp or breath or wheezing  Monitor BP at 5 min intervals for
Labetalol for 42 days antagonizes beta- skin.  swelling of the feet 30 min after IV administration;
adrenergic receptors,  lightheadedness. and lower legs then at 30 min intervals for 2 h;
Brand Name: and selectively  excessive  sudden weight then hourly for about 6 h; and as
Trandate antagonizes alpha-1- tiredness. gain indicated thereafter.
adrenergic receptors.  headache.  chest pain
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Nursing Department
Date Given: Antagonism of alpha-  upset stomach.  Monitor diabetic patients

January 13, 1-adrenergic  stuffy nose closely; drug may mask usual
2020 receptors leads to cardiovascular response to
vasodilation and acute hypoglycemia (e.g.,
decreased vascular tachycardia).
Date resistance.3 This  Convert from IV to PO therapy
Discontinued: leads to a decrease only when supine diastolic
February 24, in blood pressure that pressure rises about 10 mm Hg.
2020 is most pronounced  Maintain patient in supine
while standing. position for at least 3 h after IV
Labetalol leads to administration. Then determine
sustained patient's ability to tolerate
vasodilation over the elevated and upright positions
long term without a before allowing ambulation.
significant decrease Manage this slowly.
in cardiac output or
stroke volume, and a Patient & Family Education
minimal decrease in  Note: Postural hypotension is
heart rate. most likely to occur during peak
plasma levels (i.e., 2–4 h after
drug administration).
 Make all position changes
slowly and in stages, particularly
from lying to upright position.
Older adult patients are
especially sensitive to
hypotensive effects.
 Do not drive or engage in other
potentially hazardous activities
until response to drug is known.
 Note: Most adverse effects
(e.g., scalp tingling) are mild,
transient, and dose related and
occur early in therapy.
 Be sure to keep follow-up
appointments. Get liver and
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Nursing Department
kidney function tests

periodically during therapy.
 Discontinue drug gradually over
1–2 wk period after chronic
administration. Close
monitoring during this time is
very important.
Order
Generic Name: Analgesics 500 mg According to its FDA  Rash  Hypersensitivity Assessment
Acetaminophen (Non-Opioid) & every 8 labeling,  Nausea reactions  History: Allergy to
Antipyretics hours for 5 acetaminophen's  headache  Serious skin acetaminophen, impaired
days exact mechanism of reactions hepatic function, chronic
Brand Name: action has not been  Kidney damage alcoholism, pregnancy, lactation
Tylenol fully establishedLabel  Anemia  Physical: Skin color, lesions; T;
- despite this, it is  Reduced number of liver evaluation; CBC, LFTs,
often categorized platelets in the renal function tests
Date Given: alongside NSAIDs blood
January 12, (nonsteroidal anti- Interventions
(thrombocytopenia)
2020 inflammatory drugs)  Do not exceed the
due to its ability to recommended dosage.
inhibit the  Consult physician if needed for
Date cyclooxygenase children < 3 yr; if needed for
Discontinued: (COX) pathways. longer than 10 days; if continued
January 17,
fever, severe or recurrent pain
2020
occurs (possible serious
illness).
 Avoid using multiple
preparations containing
acetaminophen. Carefully check
all OTC products.
 Give drug with food if GI upset
occurs.
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Nursing Department
 Discontinue drug if
hypersensitivity reactions occur.
 Treatment of overdose: Monitor
serum levels regularly, N-
acetylcysteine should be
available as a specific antidote;
basic life support measures may
be necessary.
Teaching points
 Do not exceed recommended
dose; do not take for longer than
10 days.
 Take the drug only for
complaints indicated; it is not an
anti-inflammatory agent.
 Avoid the use of other over-the-
counter preparations. They may
contain acetaminophen, and
serious overdosage can occur.
If you need an over-the-counter
preparation, consult your health
care provider.
 Report rash, unusual bleeding
or bruising, yellowing of skin or
eyes, changes in voiding
patterns.
Order
Generic Name: Local 10-20 ml of Local anesthetics  Burning,  continuing ringing Assessment & Drug Effects
Bupivacaine Anesthetics, 0.25% or such as bupivacaine itching, or buzzing or other  Monitor for signs of inadvertent
Amides; Local 0.5% block the generation numbness, intravascular injection, which can
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Nursing Department
Brand Name: Anesthetics, and the conduction of prickling, unexplained noise produce a transient "epinephrine
Marcaine Parenteral; nerve impulses, "pins and in the ears response" (increased heart rate
Local presumably by needles", or  hearing loss or systolic BP or both, circumoral
Anesthetics, increasing the tingling  seizures pallor, palpitations, nervousness)
Date Given: Dental threshold for electrical feelings  trouble breathing within 45 seconds in the
January 12, excitation in the nerve,  change or  unusual bleeding or unsedated patient and an
2020 by slowing the loss of taste bruising increase by 20 bpm or more in
propagation of the  chest pain or  unusual tiredness heart rate for at least 15 seconds
nerve impulse, and by discomfort or weakness in sedated patient.
Date reducing the rate of  decrease in  Vasoconstrictor-containing
Discontinued: rise of the action the frequency solution should be administered
January 12, potential. Bupivacaine and amount cautiously, if at all, to areas with
2020 prevents of urine end arteries (e.g., digits, penis) or
depolarization by  diarrhea to areas that have a
bindng to the  difficult or compromised blood supply;
intracellular portion of painful ischemia and gangrene can
sodium channels and urination result. Inspect areas for evidence
blocking sodium ion  dizziness of reduced perfusion because of
influx into neurons.  dry mouth vasospasm: pale, cold, sensitive
 fever, skin.
headache  Note: Systemic reactions
 increased (toxicity) are more apt to occur in
thirst children or older adults and may
develop rapidly or be delayed for
 loss of
as long as 30 min after
appetite
administration.
 mood
 Monitor for toxicity: CNS
changes
stimulation (unusual anxiety,
 muscle pain
excitement, restlessness) usually
or cramps
occurs first, followed by CNS
 nausea or depression (drowsiness,
vomiting unconsciousness, respiratory
 sleepiness or arrest). Monitor BP and fetal
unusual heart rate continuously during
drowsiness labor because maternal
hypotension may accompany
regional anesthesia. Place
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Nursing Department
 slow or mother on left side with legs

irregular elevated.
heartbeat  Monitor cardiac and respiratory
status continuously in patients
receiving retrobulbar and dental
blocks.

 After spinal anesthesia,
sensation to lower extremities
may not return for 2.5–3.5 h.
Order
Generic Laxatives, 15 mg Bisacodyl stimulates  Stomach/abdominal  Anaphylactic Assessment & Drug Effects
Name: Purgatives peristalsis of the pain or cramping, reactions,  Evaluate periodically patient's
Dulcolax colon and promotes  Nausea and  angioedema, need for continued use of
accumulation of vomiting,  hypersensitivity; drug; bisacodyl usually
Brand Name: water in the colonic  diarrhea,  dehydration; produces 1 or 2 soft formed
Bisacodyl lumen which leads to  or weakness  dizziness, stools daily.
stimulation of  syncope;  Monitor patients receiving
defecation, reduction  haematochezia, concomitant anticoagulants.
Date Given: of transit time and Indiscriminate use of laxatives
January 13,  abdominal &
softening of stool. results in decreased
2020 anorectal
discomfort, absorption of vitamin K.
 ischaemic colitis.
Date  Add high-fiber foods slowly to
Discontinued: regular diet to avoid gas and
January 13, diarrhea. Adequate fluid intake
2020 includes at least 6–8
glasses/d.
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Nursing Department
CHAPTER VIII
COURSE VISIT
Date and time Doctor’s Order Nurse Order
January 12,2020 please admit patient to OB D - Admitted a female, 32 years

8:00 am LR/DR under the service old, 37 weeks pregnant woman
of Dr. TC with chief complaint of labor pain ,
-pls secure consent for blurry vision and shortness of
admission and breathing and edema is evidence
management Dr. TC, Vital Signs has follows:
-Temperature: 37.2 C
-Pls insert Ivf nd hook
D5LRS 1L to run for 30 -Pulse rate: 90 bpm
drops -Respiratory rate: 25 bpm
-pls hook to oxygen at 5 L
/min -Blood pressure: 150/100
-pls monitor vs q 15mins
until stable A- nursing intervention in her labor
-pls hook to ctg and pain is massage the mothers back
monitor to reduce the pain
-request lab for CBC with
A-Nursing intervention shortness of
hbsag, urinalysis, etc.
breathing teach breathing
-pls prepare magnesium
sulfate 25mg and calcium technique slowly deep breath and
gluconate in the bed side slowly breath out)
incase of emergency A-nursing intervention on her
edema is told the mother to elevate
-PIH with mild pre
her hand above the heart
eclampsia and edema
upper extremities A- laboratory request forwarded
A - consent for hospitalization
Medications; secured, kept monitored
Methyldopa 250mg/ mixed A- hooked to oxygen at 5L per min
in 100 milimiters of for the mother and monitor fetal
solution for hypertensive heart rate
A-Check tendon reflex
Ranitidine 50mg/IV A - inserted IVF aseptically
-referred to dr. further A -Prepare magnesium sulfate
management 25mg and gluconate in bedside
R – Cooperated
9:45 am -Emergency CS the D- Emergency CS due to her BP

patient under the service 150/100mmHG and diagnosed PIH
of DR. TC operation start with mild pre eclampsia the patient
at 10:00 am is now 4cm dilated
- Please prepare to insert Assessment was done and her BP
IV line and Foley catheter is 130/90 RR- 22
-Please prepare the
abdomen as prescribed A- Inform the delivery
-Please monitor the A-Prepare to insert IV line and
mother and the baby Foley catheter
-Please administer A-Prepare the abdomen as
preoperative medication prescribed
as prescribed A-Monitor the mother and the baby
Nursing Department
Marcaine10-20ml for A-Administer preoperative

anesthesia medication as prescribed
A-Contact anesthesiology
A-Prepare the patient
R-Cooperated
10:50 am -Monitor the mother and D-Successfully delivered the baby
the baby A-Skin to skin contact, Drying,
-Administration of identity tag sa baby , proper time
Vaccine, Vit. K and cord clamping, administration of
prophylaxis vaccine prescribed by the doctor ,
Cesarian in a low Vit. K and prophylaxis
transverse or bikini
incision A-Placenta delivery
A- Ensure the mothers safety
R- cooperated
11:00 am D- Assesssment
A- Get the infant’s vital signs:
-temperature: 36.6℃
-AP: 147 bpm
-RR: 48 cpm
-BP: 70/50
-Weight: 2900g
-Length: 54 cm
-APGAR Score: 8/9
A- Get the mother’s VS
-Temperature: 36.7C
-PR: 104 bpm
-RR: 90 bpm
-BP:130/100 mmHg
R- Cooperated
11:30 D-Observation Room
A- Monitor the VS of the mother
R- Cooperated
4:30 pm D- Transferred to OB ward

A- Refer to the OB ward Nurse
A- Placed in a comfortable position
A- Bed Rest
R-Cooperated
7:00 pm D- Rooming In
A- Assist the mother for
breastfeeding
A-counsel mother on positioning,
attachment and suckling on
breastfeeding and for the benefits
of breastfeeding, frequency of
feeding
R- Cooperated
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Nursing Department
8:00 pm D-Assessment:
A-Breast full, firm and engorged
due to lactation process
A-Uterus - fundus is above level of
umbilicus ,uterus mobile,,regular
and non tender boggy
A-Bladder - not distented and non-
palpable
A-Bowel - patient did not defacate
yet
A-Lochia (rubra) - red with small
clots; no foul odor; patients
consumes 3 pads per day
A-Homan’s sign - Negative
A-Emotion - taking-in phase; well
acquainted during rooming in
A-Diet as tolerated
R-cooperated
9:00 pm D-Edema
A-Nursing management in her
edema Elevate her hand above her
heart
A-Request the mother to have a
stress ball for hand exercise
A-Applying icepacks from 10-15
min affected area
A- Told the mother to limit sodium
intake
A—Vs monitored
R-cooperated
January
13,2020
7:00 am D-Catheter removal

A-Told the mother that her catheter
will be remove
A-Assist the mother on how she can
cooperate
A- Asses the urine output
A-Health teach the mother about
perineal care
A-told the mother to ensure
adequate intake of fluid
R-Cooperative
8:00 am Doctors Visitation
12:00 pm D-First meal

A-Assess gag reflex and bowel
movement
A-Gave mother Jelly Ace and told
the mother to have clear fluid only
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Nursing Department
A- Laxative was given so that the

stool will be soften
R-Cooperative
12:30 pm D-Bathing the baby
A-Baby bath tell the motor on how to
position the baby and use gentle
baby bath
A- Include the support system in the
health teaching and advice to assist
the mother in bathing the baby at
home
R-Cooperative
1:30 pm D-Check Surgical Incision
A-Check the surgical incision
A-Assist the mother in changing the
gauze pad
A-Health teach the mother on how to
properly clean the surgical incision
to prevent infection
A-Gave pain reliever because the
mother complains pain due to
surgical incision
A-Heath teach the mother the
importance of taking antibacterial
med
R-Cooperative
5:30 pm D- Defacate
A- Mother defacate already
this means that the digestive system
is now condition ready to take her
soft diet
A- Asses the amount texture of the
stool
R-Cooperated
January 14, D-Breastfeeding complains
2021 A-The mother fed her baby and
complain that it is slightly painful and
3:00 am advice the mother to try it in the
other breast instead
R-Cooperative
7:00 am D-Soft diet and Assess the mother

A-Soft diet for mother
A-The mother told that she already
ate lugaw
A- Check her surgical incision
A-change the gauze and clean
properly the surgical inscision
A- Told the mother that she should
clean and change the gauze and on
what are the proper cleaning
A-Gave her medicines
R-cooperative
10:30 am D- D5LRS removal

A- D5LRS was now removed
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Nursing Department
A-Told the mother that she will now

take her medicines orally
A-Educate the mother that she
should also take a rest if the baby is
sleeping she can also take her nap
R-Cooperative
12:00 am D-Newborn screening and

assessment Mother ate her lunch
A-Newborn screening told that the
ambulatory is to detect potentially
fatal or disabling conditions in
newborns as early as possible
A-Record the lunch of the mother
R-Cooperative
6:00 pm Medication: D-Medication and Dinner

Oral Medication: D-Quaker oats
-Cefuroxime axetil 500 mg 2x a A- Cefuroxime axetil to reduce the
day incidence of infection
A-Labetalol- for hypertension
-Tylenol A-Laxative for her tool
-Labetalol 250mg PO, Twice a A-Tylenol pain reliever
R-Cooperated
day
January 15, 2020 D-Breakfast and monitor mother and

7:30 am baby
A-Check the mother’s emotional state
A-Allow her to talk her experience
A-Gave her medicine
R-Cooperated
10:00 am D-Health improvement
A-Health teaching about the health
improvement, Tell the mother about
the proper diet and and some
exercise
A- Eat more vegetable and fruits like
having vegetable salads limit eating
in a fast food chain
A- Practice a healthy Lifestyle
R-Cooperated
January 16, D- assessment

2020 A-Asses the VS of the mother
8:00am R-Cooperative
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Nursing Department
11:00 am Discharge D-Health teaching

-Birth spacing
-Family planning
-Immunization
-Surgical Incision care
-Daily hygiene
R-Cooperative
D-Billing
A-Told the parents that can now
settle their account, before going
home, the patient’s significant other
settled their hospital bills.
R-Cooperative
D-Discharge health teaching
A-Mother and significant other was
counseled on the continuity of care
and medications at home and
application of health teaching and
self care improvement including
baby bath and proper sunlight
exposure for the baby , after 1 week
there will be follow check up
A-Advice the mother to always
monitor her BP
R-Cooperative
Page 74 of 84
Nursing Department
CHAPTER IX
NURSING CARE PLAN
NCP 01
ASSESSMENT DIAGNOSIS SCIENTIFIC PLANNING IMPLEMENTATION RATIONALE EVALUATION
EXPLANATION
Date of Assessment: “INEFFECTIVE TISSUE Spiral arteries in the uterus After 1-2 hours of INDEPENDENT: After 1-2 hours of
January 12, 2021 – 8:00 PERFUSION RELATED does not increase in size implementing care: 1. Checking the vital implementing care the
AM TO 1. Monitor the vital signs signs of the patient goals are met as
VASOCONSTRICTION SHORT TERM: every 15 minutes prior to giving birth evidenced by:
SUBJECTIVE: OF THE BLOOD Placenta will become - Check the Blood will help the health
“Medyo nahihirapan po VESSELS ischemic 1. The patient’s Pressure care providers to SHORT TERM:
akong huminga” as SECONDARY TO MILD oxygen saturation - Respiratory and monitor if there are
verbalized by the client. PRECLAMPSIA AS will be stable Pulse Rate any alleviations or it 1. The patient’s
EVIDENCED BY BP OF Placenta reacts to the - Temperature is within the normal oxygen saturation
OBJECTIVE: 150/100 mmHg, +2 stress that’s why it releases 2. The patient’s range. became 95%
 Irritability EDEMA, +1 substances like respiration and 2. Monitor fetal heart
 Restlestness PROTENURIA” inflammatory mediators blood pressure will tone and rate 2. Checking the fetal 2. The patient’s
 BP – 150/100mmHg that affects the endothelial be stable prior to heart tone/rate is respiration became
 PR – 90 bpm cells lining in the blood cs delivery 3. Monitor neurological necessary to check 22bpm and blood
 RR – 25 bpm vessels status if the baby receives pressure became
 Temp – 37.2 C 3. The patient will enough oxygen and 130/90 mmHg.
 +2 Edema (Upper engage in actions 4. Assess for bleeding - nutrients, and if
Extremities Tone and Permeability to improve tissue Check the perineal there is alterations 3. The patient
function of the endothelial perfusion area for bleeding that may result to engaged in actions
 +1 Protenuria
cells are damage fetal distress to improve tissue
 Oxygen Saturation:
5. Encourage bed rest perfusion like bed
90%
and provide good 3. Changes to rest and positioning
- Vasospasm = positioning neurological status
Hypertension may indicate
6. Use pulse oximetry to cerebral hypoxia or
- Permeability issue = monitor oxygen impending seizures
Protein leakage saturation and pulse
causing proteinuria rate
and water goes into 4. It is necessary to
the interstitial tissues 7. Check the laboratory check if there is any
causing edema results for any signs of bleeding in
changes the perineal area
because patient
Less blood is being able to DEPENDENT: who was diagnosed
perfuse organs especially 8. Provide oxygen with preeclampsia
the kidneys, liver, brain and administration to the has a higher risk of
heart patient as ordered by abruptio placenta
the physician and disseminated
intravascular
9. Administer coagulation DIC
antihypertensive drug
as prescribed by the 5. Encouraging bed
physician rest to the patient
with preeclampsia is
10. Prepare Magnesium necessary to reduce
Sulfate and 10 ml of fluctuations of blood
100% Calcium pressure and
Gluconate during the providing good
position like lateral
Page 75 of 84
Nursing Department
labor as ordered by promotes good

the physician circulation and
perfusion to the
11. Assess hyperreflexia organs and semi
prior in administering fowler’s position to
magnesium sulfate promote alveolar
via IV gas exchange
6. Pulse oximetry is a
useful to detect
changes in
oxygenation
7. Checking the
laboratory tests is
necessary to check
if the results are not
elevated and it is
within normal
ranges.
8. Oxygenation will
help the patient to
stabilize respiration
and promote good
oxygen level in the
body
9. Giving
antihypertensive
medication to the
patient will help to
low the blood
pressure but it
should not be
lowered
dramastically
because placental
perfusion may be
compromise
10. Prepare magnesium

sulfate to prevent
seizures and
calcium gluconate
for MgS04 toxicity
just in case the
condition of the
patient will get
worst.
11. Assess the need of

magnesium sulfate
by checking the
patellar reflex
Page 76 of 84
Nursing Department
NCP 02
Assessment Diagnosis Scientific explanation Planning Intervention Rationale

Date of Acute pain related C-section delivery Short term goal: Independent nursing  The pain might be because
assessment to incision site After three hours of nursing intervention: of abdominal distention or
through interview: secondary to intervention from the incision.
January 12, 2020 cesarian section Abdominal and uterine  The patient will be 1. Determine the Determining the location of
6:00 PM delivery incision able to verbalize the characteristics and the pain can help to provide
decrease of pain location of discomfort. proper intervention.
Subjective: from the incision site 2. Assess for verbal and  The client may not be
“Masakit ung sugat Tissue trauma with pain scale 5/10. non-verbal cues such as verbally reported pain and
ko lalo na pag grimacing, stiffness and discomfort directly.
gagalaw ako”  The patient will be limited movement.  Repositioning the patient
Prostaglandin release + able to move and 3. Provide comfort and providing good
C – aching pain Uterine contraction + Loss ambulate without measures by helping the environment can give
O – March 12, 2020 of anesthetic effect discomfort. mother in repositioning comfort to the patient
5:30 PM and providing good  Early breastfeeding can help
L – Lower abdomen environment. alleviate the pain and
D – 30 minutes Sensation of pain 4. Promote breastfeeding. promotes healing of the
S – 8/10 5. Apply ice pack on the incision.
P – The pain wound  Applying ice pack to the
increases when 6. Encourage the patient to wound promotes comfort by
moving ambulate. decreasing the pain
A – Activity and 7. Instruct the patient to use  Early ambulation improves
movement supportive material such blood flow, which in turn can
as binder. speed up the process of
Objective: 8. Provide the patient with wound healing and it helps
 Grimace with deep breathing exercises to lower gas formation and
pain scale of 9. Encourage the mother to increase the peristaltic
8/10 increase fluid intake movement of the intestine to
10. Encourage the mother to relieve discomfort due to gas
 Limited have diversional activities accumulation.
movement such as listening to  Binder helps to reduce pain
music, watching tv and when moving
talking to her significant
 Periodic deep breathing
other.
exercises full aerate the
11. Placing pillow on her lap
lungs and help prevent the
or abdomen while
accumulation of mucus in
breastfeeding.
the lungs that could lead to
infection.
Dependent nursing intervention:
 CS patients has more blood
Doctor’s order
loss compare to NSD
 Administration of
patients; the patient needs to
antibiotics, Cefuroxime
increased her fluid intake
axetil 1.5mg ld then 500
because of excessive blood
mg BID
loss after birth.
 Administration of pain
reliever, Acetaminophen
 To distract attention from the
500 mg every 8 hours
pain and reduce tension of
 Dulcolax 15mg the incision.
Page 77 of 84
Nursing Department
 It could give comfort to the

patient by decreasing the
pressure on the suture line.
 Antibiotics is used for
infection prophylaxis.
 Pain reliever medicines can
help to lessen the pain.
 Stool softener is prescribed
by the doctor if needed to
help to soften the stool of the
patient.
Page 78 of 84
Nursing Department
NCP 03
Assessment Diagnosis Scientific Planning Intervention Rationale Evaluation

explanation
Date of Risk for postpartum C- section delivery Short term goal: Independent nursing  Temperature Short term goal:
assessment hemorrhage After 3 hours of intervention: higher than 38 C, After 3 hours of nursing
through interview secondary to nursing intervention  Assess vital signs rapid respirations, intervention
January 13, 2020 cesarian section Abdominal and  Asses for bladder continuous
07:00 AM delivery uterine incision  Patient will be distention and decrease in blood  Patient was able to
able to palpate the pressure and a verbalize the signs
Subjective: verbalize the fundus of the rapid or weak of postpartum
Tissue trauma signs of uterus thready pulse rate, hemorrhage.
Objective: postpartum  Assess for blood are indicative signs  The patient was
 Laceration hemorrhage. loss of possible able verbalize the
due to Non contracted  The patient will  Assess the bleeding. importance of
surgical uterus and blood be able to incision site and  Always check the being aware about
incision vessels are not verbalize the provide good bladder before the consumption of
Obtained vital signs yet securely close importance of hygiene palpating the perineal pads
 36.9 C being aware  Encourage early fundus of the during the
(Axillary about the ambulation after uterus to provide postpartum period.
Temperature) Elevated vital consumption the anesthesia comfort and full
 RR 19 cpm signs of perineal wears of. bladder predispose Therefore, the goals were
 PR 84 bpm pads during  Teach the patient the woman to met.
 BP 130/90 the postpartum on how to uterine atony.
mmHg Risk for bleeding period properly wash Palpating the
perineum. fundus helps to
 Encourage the contract the uterus.
patient to  Assess for blood
increased fluid loss by counting
intake perineal pads
 Encourage early because just like
breastfeeding. NSD, cs patients
also discharges
Dependent nursing normal pattern of
intervention: lochia, foul smelling
Doctor’s order discharge and the
 Administration absence of it may
oxytocin. 10 units also indicate
intramuscularly or bleeding.
20 units diluted in  The patient needs
500 mL normal to be reminded to
saline always maintain
intravenously. aseptic technique
 Blood transfusion specially things that
will be using to
dress the wound to
avoid infection.
 To allow good
circulation in the
body and prevent
blood clotting
Page 79 of 84
Nursing Department
formation in the
lower extremities.
 Teach the patient
to wash the
perineum from front
to back in order to
avoid introducing
other
microorganisms to
the perineum.
 Increased fluid
intake can help
soften stool and
stimulate bowel
movements.
 Breastfeeding
releases hormone
called oxytocin
helps to contract
the uterus.
 If the uterus does

not remain
contracted,
administer oxytocin
to help the uterus
to contract.
 Blood transfusion is
needed in order to
compensate for
blood loss.
Page 80 of 84
Nursing Department
CHAPTER X
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Saint Mary’s University

School of Health and Natural Sciences

PRE ECLAMPSIA, G1P0 (0000) 37 weeks AOG s/p “e” CS

Weight before Pregnancy: 68 kg

Admitting Diagnosis: Pre-eclampsia, G1P0 (0000) 37 weeks AOG s/p “e” CS

II. History of Past Illness

III. Gynecologic History

IV. Family Health History

V. Social Health History

VI. Environmental History

VII. Lifestyle and Health Practices

 Weight gain over 1 or 2 days because of a large increase in bodily fluid

 baby has developmental conditions

9. Administer preoperative medications as prescribed

Discharge teaching to our client:

PHYSIOLOGICAL CHANGES DURING PREGNANCY

CARDIOVASCULAR SYSTEM Cardiac output is assumed to be mediated early

During pregnancy there is actually a drop in blood

In the case of Mrs. CT, she was in pain due to the

ENDOCRINOLOGICAL CHANGES The endocrinology of human pregnancy is

FEMALE REPRODUCTIVE SYSTEM The main pregnancy hormones are oestrogen

Breast The mammary glands undergo changes during

The mammary glands are the first source of food

Mrs. CT begin producing milk weeks before her

Fetal and Maternal Circulation

Several conditions make a Cesarean delivery more likely. These include:

Physiological Processes of Placental Separation and Expulsion

Placenta delivery after a cesarean

Controlled Cord traction

Modifiable Non Modifiable

Spiral Arteries in Placenta will become

Affect the endothelia

Permeability Leakage of protein and H2O

Tone and permeability

Tone issue Vasospasm

Less blood is able to

SIGN AND SYMPTOMS NURSING MANAGEMENT

 Increase blood pressure  Promote bed rest

A. 2nd Urinalysis: November 24, 2019, 9:00 am, 30 weeks AOG

Examination Result Normal Nursing Implication

Appearance/Tran Clear and Clear and Normal

Specific Gravity 1.020 1.010-1.025 Normal

Protein 15mg/dL Negative Abnormal

There must be no protein or a small

For the nursing action, the patient is

Glucose Negative Negative Normal

Epithelial Cells Few Few Normal

Bacteria Rare No Bacteria Normal

B. 3rd URINALYSIS: January 12, 2020, 8:00 am, 37 weeks AOG

Examination Result Normal Nursing Implication

Specific Gravity 1.020 1.010-1.025 Normal

pH 4.6 4.5-8 Normal

Protein 30mg/dL Negative Abnormal

There must be no protein or a small

Glucose Negative Negative Normal

Epithelial Cells Few Few Normal

Bacteria Rare No Bacteria Normal

Examination Result Normal Nursing Implication

Hemoglobin 14 12-16 Normal

In the case of Mrs. CT, her hemoglobin is adequate in red

WBC 9.0 5.0-10.0 Increased

. For white blood cell count is to verify infections in the body.

Platelet 289 150-450 Normal

Primary Tagalog and Tagalog and Tagalog and