XAVIER

UNIVERSITY
ATENEO DE CAGAYAN
Corrales Ave., Cagayan De Oro City

COLLEGE OF NURSING

CLINICAL CASE SCENARIO: OB WARD (POST PARTUM CLIENT)

Patient NB, a 22 year old, 39.5 week pregnant woman, was admitted to J.R. Borja
Hospital last September 10, 2021 around 12:10 in the afternoon with a chief complaint of
labor pain. Her vital signs were taken and recorded as follows: temperature – 36.4 oC;
Pulse – 88 bpm; and blood pressure of 110/70 mmHg upon admission.
Around 12:50 in the afternoon, she spontaneously delivered a healthy baby boy
weighing 2.85 kg with a total duration of 40 minutes. Upon delivery. She had a right
mediolateral episiotomy. She had no complications during delivery and has a well
contracted uterus. After delivery, she was given Mefenamic Acid 500 mg administered
orally three times a day, Cephalexin 500 mg administered orally three times a day for
five days, Ferrous Sulfate one tablet administered orally once a day while
breastfeeding. The patient was diagnosed pregnancy uterine full term, in labor G2P0A1.
Her CBC results are as follows:
WBC Count – 20,078 Normal: 5,000-10,000
RBC Count – 4,39 Normal: 4.20-5.40
Hemoglobin – 11.3 Normal: 12.0-16.0
Hematocrit – 35.5 Normal: 37.0-47.0
Platelet Count – 415,000 Normal: 150,000-400,000
ABO Typing – A Rh +
Granulocytes – 88 Normal: 43.4-76.2
Lymphocytes – 8 Normal: 17.4-46.2
Monocytes – 4 Normal: 4.5-10.5
Eosinophil – 0 Normal 0-70
Basophil – 0 Normal 0-2.0
Stabs – 0 Normal: 1.0-2.0
Taking her history, last December 1, 2019 she had a total number of five visits in
the health center for her pre-natal check-up. During assessment she reports that there is
a presence of bright red blood fragments that covers only the center part of the adult
diaper. In past medical history, she said that she doesn’t have any past illnesses and
had a complication in her past pregnancy where she experienced miscarried on her first
pregnancy at three months.
The patient’s age menarche was 11 years old. According to the patient. The
amount of menstrual flow was moderate and uses 2-3 pads per day that usually last 3
days. The patient does not experience any menstrual discomfort. The discharges do not
smell foul and red in color. The patient does not experience any bleeding between
periods. She is sexually active and verbalizes that there is no change in her sexual
interest. She also uses family planning method namely IUD which was inserted two days
after the delivery of her first born. She has no familial history of cardiovascular disease,
hypertension, stroke but her mother is diabetic but controlled. She seldom eats
vegetables as she prefers meat or fish. She did not verbalize on financial difficulties as
her live-in partner has a stable job on the private company as a security officer.
 Upon assessment, vital signs were taken and recorded as follows: temperature
was 36.4OC, oxygen saturation of 98%, and blood pressure of 110/70mmHg on her right
are and 110/70 mmHg on her left arm while lying down. Pulse rate was 88 bpm on right
radial and respiratory rate of 20 cycles per minute (cpm) with shallow depth of 1-2 cm
and
XAVIER

UNIVERSITY
ATENEO DE CAGAYAN
Corrales Ave., Cagayan De Oro City

COLLEGE OF NURSING

uses no accessory muscles. She has a body mass index of 23.9, her weight 46.7 kg and
6.6 kg gained during pregnancy and her height is 144 cm. It was observed that the
patient was well-oriented, clean, and well groomed. Her hair was shiny, equally
distributed and kept properly, and her head and scalp are round, and symmetrical. She
has no problem on vision and hearing and does not experience headache, fainting
spells, or dizziness. She reported pain in the episiotomy site with the pain scale of 5/10.
She had dental caries
and her teeth is yellowish in color. She voids normally and defecates daily. She sleeps 5
hours a day and does not take naps. Throughout the assessment period, it was noted
that her level of development was suitable for her situation.

Guide Questions:
Assessment
1. Based on the case scenario, list down significant data that you observed. 2.
Identify the actual health problem, potential health problem and health risk. 3. Review
the laboratory findings and identify the abnormality and what is its significance?
4. What possible health risk may encounter during teen age pregnancy?

Planning
1. List down problems base on priority.
2. Formulate nursing diagnosis base on the problems assessed.

Intervention
1. Make a nursing care plan based on the problems assessed.
Evaluate Care Plan
Formulate a Drug study and Discharge Plan