SOUTHVILLE INTERNATIONAL SCHOOL AND COLLEGES

1281 Tropical Ave. Cor. Luxembourg St. BF International, Las Piñas City, 1740

Student’s Name: Maria Victoria Praxides Date Rotation: Oct 24,25 2022
Year and Section: BSN 4B Subject: NCM 118
Clinical Instructor: Miss Jet Lavarino Clinical Area: OR, NICU, EINC,Delivery Room

PATIENT-CENTERED CARE REPORT

Objectives:

After working on this PCCR, I was able to:

1. Identify the process and appropriate pharmacological and nonpharmacological approach

to the management and treatment of normal spontaneous delivery.

2. Recall and review maternal concepts about Normal Spontaneous Delivery regarding the
pathophysiology and its effects on the body. This interesting case was able to help me
improve my knowledge, skills, practice, and apply what I study. Previously I was only
able to imagine what it's like to have normal delivery and look at the book,internet
resources. I was able to experience first hand, saw how the baby delivered, even hold it
and assist the mother.
Case Description:

A. Baseline Information of the Patient:

MGP 30-year-old female, who is pregnant for 39 weeks, and is married arrived at
the emergency department of Osmun Hospital with his husband on Oct 24, 2022, at 3pm
due to uterine contractions and labor pain. She was conscious and coherent during
admission. Her BP was 100/60, pulse 87, G.A 39week, LMP 1/20/2022, and the EOD on
10/25/2022, G4P4A0.
She is a catholic with a brown complexion, stands 165cm, and weighs 80 kg. She
was born in Muntinlupa City and was third among three siblings. Her AOG is 39 weeks.
The patient had a previous 3 normal delivery. I was there during the normal delivery of
the baby. The baby came out in 2nd push and scream of the mother. I was able to
experience how to hold the baby after delivery and dry it. I was able to clean the mother's
vagina using saline water and betadine. I was able to put adult diaper to the mother after
vaginal delivery of the baby and the placenta. When the doctor got the baby Leila put it in
a baby crib with a lamp. I was able to dry the baby, apply erythromycin on his eyes, and
inject BCG and diphtheria vaccine through IM. I was very nervous at first because it's my
first time holding a baby but our CI Miss Jet guided and support me thoroughly. I was
able to help transfer the patient on her room and regulate her IV.

The patient had no history of asthma, no seizures, no diabetes mellitus, and no

hypertension. The patient had complete immunization and had no allergies to either food
or medications. The doctor's diagnosis was Normal Delivery. After normal delivery she is
conscious and looks very tired. The mother and baby are in good condition.
 B. Diagnostics and other procedures.

The doctor ordered the admission of the patient with informed consent for
admission and diet as tolerated. The physician in charge ordered the lab
diagnostics of CBC, Urinalysis, Covid 19 RT PCR test, , blood typing, NA, k, and
CL. Dr. P orders D5LR 1L to run for 8 hours. Lab diagnostic result was the
patient is negative for SARS COV2 Antigen (not detected). Based on the lab
result the patient has normal lab values.The lab diagnostic test was done once
and verified.

Lab Test:

Actual Normal
Procedure / Date Implications
Findings Findings
1. CBC

Hemoglobin 130 120 – 140

g/dL Normal Findings
Hematocrit 45 37.0-54.0 Overall

WBC 8.0 4 - 10

Lymphocytes 0.32 0.22 - 0.40

Eosinophils 0.02 0.01 - 0.04
Stab Cells 0.04 0.02 - 0.05
Platelets 320 150 – 400x9/L

URINE ANALYSIS

Microscopic Exam Chemical Exam

 Color: Yellow Albumin: Negative
Transparency: Hazel Sugar: Negative
pH: 6.0 (7.35 – 7.45)
Specific Gravity: 1.010 (1.010 – 1.025)
Epithelial Cells: Moderate
C. Brief Pathophysiology
MEDICATIONS:
The doctor didn’t prescribe any medication to the patient after giving birth.

D. Nursing Observation and Assessment

She's fully conscious, in good mood, tidy, has clean clothes and body, takes care of herself, no
bad odor, her weight, when she was pregnant, was 80kg, now her wt is 75kg Height: 165cm. The
patient's general condition is stable, with no headache, no epigastric pain, and no visual
disturbances. V/S taken and recorded, BP= 120/60mmhg,pulse90.Tem 36.5c. On the second day,
the uterus was well contracted. she has stable V/S, Pt out of bed, no dizziness, and passed
urine,lokia mild, episiotomy sutures no bleeding, no hematoma and a good approximation. the
baby is healthy, with normal vital signs and in good condition.

Physical Assessment:

Vital signs: Blood Pressure: 100/60

Pulse: 90
Temperature: 36.5 C
Respiration: 19 breathe per m.
 
Weight: Before delivery her wt was 80 kg ,  her wt now is 75kg.

Height : 165 cm.

 
Skin: Pink in color, smooth in texture, warm, no lesions, her skin is clear and free of
spots. vertical linea niagra extend from pubic area to umbilicus, striae gravidanum after delivery
is present

 
Heart: Lub-dub heart sound, regular rhythm 90 beat/ min. Apex beat is chentrally placed, no
murmur, no abnormal sounds, peripheral pulse is palpated. The Pt did not complain from heart
problems , no hypertension during pregnancy. Palpation is clear in the apical area, Jugular
veins are not visible. Peripheral pulses. Peripheral veins is normal, no tenderness on palpation of
limbs, radial pulse palpable in both arteries in the both hands.

 
Breast: Both are symmetrical, soft, no redness or swelling, the nipple is small inverted. no
congestion , Both are symmetrical, normal size ,soft, no redness or swelling or masses, lactated,
both nipples are normal, no abnormal discharge.

  
Abdomen: The uterus is in the mid line of umbilicus, uterus contracted,  transverse incision from
previous C/S , clean and dry, normal bowel habit, intact bowel sounds, central umbilicus, femoral
pulses are palpated.

Back: Has good postured shape, spinal vertebral is normal shape. no masses, or prominent
curves, no pain
 
Extremities: Both are symmetrical, have good reflexes, no edema, no varicose veins or DVT,
she can walk alone. full range of motion, no varicose veins are present to the both legs, no
deformities or scar tissue, will extension.

Pelvic area: Dark skin, soft and firm, no lesion, no congenital anomalies, no UTI, there is
moderate lochia ,no bleeding or tearing from episiotomy sutures.

Psycho/Social/Spiritual

During her stay, she was accompanied by her husband waiting outside who provides her care and
support all throughout. Every time the nurse and student nurse come into the room, the patient
always looks calm and cooperative. The patient is sharing a bed with another patient. The room
is fully occupied, crowded in a room with 2 to 5 patients in just 1 bed.
During every procedure like Vital signs and IV medication administration, the patient is very
cooperative and grateful. She’s a Roman Catholic and she always prays every day for her speedy
and successful recovery. She’s also scheduled for ligation tomorrow. She and her husband
decided to have family planning using a ligation procedure because she had 4 children already
and the doctor advise that her uterus can’t take it anymore if she became pregnant again within a
year. She’s very kind, approachable and friendly.
Current Plan of care:

A. Priority nursing Problems/Diagnosis

1. RISK FOR DEFICIENT FLUID VOLUME

2. RISK FOR INFECTION

B. Nursing Care Plan

CUES: PLAN .
1Note the client’s
SUBJECTIVE: level of consciousness
After normal delivery the and mentation
patient stated 1.After educating the Rationale: Blood flow
patient, she will identify to the nonessential
“Nanghihina ako, Wala organs gradually
kong gana uminom ng risk factors and stops to make more
tubig pagkatpos ko appropriate blood available for
interventions. vital organs,
manganak” specifically the heart
2. The patient will and brain. As blood
OBJECTIVE: demonstrate behaviors or loss continues, flow to
VITAL SIGNS: lifestyle changes to avoid the brain decreases,
progression of resulting in mental
changes, such as
BP: 100/70 dehydration. anxiety, confusion,
02: 99 3.Patient explains restlessness, and
measures that can be lethargy.
PR: 120 BPM
RR: 20 taken to treat or prevent
2.Measure and
fluid volume loss.
record the intake
WEAKNESS, and output balance.
CONCENTRATED Rationale Accurate
URINE,DECREASED documentation helps
SKIN TURGOR identify fluid losses
and replacement
needs and influences
the choice of
interventions. With
slow bleeding, the
client develops these
symptoms over a
period of hours; the
end result of
continued seepage,
however, can be as
life-threatening as a
sudden profuse loss of
blood. As blood flow
to the kidneys
decreases, they
respond by conserving
fluid. Urine output
decreases and
eventually stops.

3. Monitor vital
signs.
Rationale: Assess vital
signs every 15 minutes
until stable. Blood
loss from a laceration
or hematoma can be
significant, even
though it is less
obvious. The body
initially responds to a
reduction in blood
volume with increased
heart and respiratory
rate. Tachycardia is
usually the first sign of
inadequate blood
volume. The first
blood pressure change
is a narrow pulse
pressure. The blood
pressure continues
falling and eventually
. :.cannot be detected
4Assess for the presence of .
lacerations or hematomas.
Inspect characteristics of
.blood
Rationale:When the amount
and character of the lochia
are normal and the uterus is
firm, but signs of hypovolemia
are still evident, the cause
may be a large hematoma.
Excessive bright red bleeding
despite a firm fundus may
indicate cervical or vaginal
laceration.
5.Monitor skin temperature
and palpate peripheral
pulses.
Rationale: Cool or clammy
skin and/or weak pulses
indicate decreased peripheral
circulation and the need for
additional fluid replacement

Encourage the client to.6

resume oral intake
.gradually
Rationale: Increased intake of
oral fluids within the
provider’s advice helps
replenish fluid losses. If the
client underwent cesarean
birth due to precipitous labor,
provide clear liquids in small
amounts to reduce the risk of
gastric irritation and
vomiting to minimize fluid
loss

Weigh the client’s perineal

.pads to measure blood loss
Rationale: It is difficult to
estimate the amount of blood
a postpartal client is losing
because it is difficult to
estimate the amount of blood
it takes to saturate a perineal
pad. Be certain that when you
are counting perineal pads,
you differentiate between
saturated and used. Weighing
perineal pads before and
after use and then subtracting
the difference is an accurate
technique to measure vaginal
discharge; 1 g of weight is
comparable to 1 ml of blood
volume.
Be calm and advise the
client to remain calm, too,
and assure her of the baby’s
condition.
Rationale: The client is not
always aware of what is
happening at this point, but
she quickly senses something
is seriously wrong. Try to
maintain an air of calm and
assure her of the baby’s
condition and inform her
about the need to stay in the
birthing room a little longer
 than expected while the
healthcare provider places
sutures or packs.

Administer IV fluids as
prescribed.
Provide intravenous fluids to
maintain the circulating
volume and to replace fluids.
Intravenous infusions of
crystalloids and colloids
should be obligatory apart
from previously mentioned
drugs (Feduniw et al., 2020).

DIAGNOSIS: EVALUATION:
Goal Met: After Health
RISK FOR DEFICIENT Teaching, The client was able
FLUID VOLUME to identify individual risk
factors and appropriate
interventions.
She was able to demonstrate
behaviors or lifestyle changes
to prevent the development of
fluid volume deficits. She
encouraged herself to drink
water, i just support and
motivate her.

Recommendation for Improvement

For the client postpartum discharge plan, I educated the patient before discharging that after
pains or cramping are normal. This cramping means that the uterus is contracting to return to its
non-pregnant size. The uterus takes 5-6 weeks to return to its non-pregnant size. When it comes
to breastfeeding, she must wash her breast daily for cleanliness, airdry nipples after each feeding.
If nipple are sore, apply a few drops of breast milk after a feeding and let air dry. If breasts are
engorged, apply warm packs and express milk. Third, vaginal discharge last about 10 days to 4
weeks. The color will change from bright red to brownish to tan and will become less in amount
and finally disappear. When it comes to her menstruation, her period will resume in
approximately 6-8 weeks, unless breastfeeding. For caring for her episiotomy her stitches will
dissolve in 1-3 weeks. Sitz Bath can help, sitting in a tub of warm water for 15 minutes, 2-3
times per day, will help relieve the discomfort. Local agents, such as Tucks, Witch Hazel and
Lanacaine, may be applied to the stitches. She can use mild analgesic (Tylenol or Advil) for
breast engorgement, uterine cramping and episiotomy discomfort. For diet and nutrition, she
must still continue taking her prenatal iron and vitamin pills until her postpartum visit. It is
important to eat a well-balanced diet and drink plenty of fluids. Drink two liter of fluid per day if
you are breastfeeding. When it comes to emotional changes, she may get “baby blues”after
delivery. She may feel let down,anxious and cry easily but its normal. These feelings can begin
2-3 days after delivery and usually disappear in about a week or two. Prolonged sadness may
indicate Postpartum Depression. She must rest. Do not do heavy housework or heavy exercise for
two weeks. Avoid driving for 1-2 weeks. Avoid sexual activity, douching or tampons until her
postpartum visit. It is advisable as soon as she resume sexual intercourse. Foam and condoms
are safe and easy to use. Birth control methods will be discussed further at her postpartum visit.

She must call her doctor immediately if she experience a fever greater than 101 F, with or
without chills. If she have foul-smelling or irritating vaginal discharge and excessive vaginal
bleeding. She must report it immediately if there are recurrence of bright red vaginal bleeding
after it has changed to a rust color, Swollen area, painful area on the leg that is red or hot to the
touch. Burning sensation during urination or an inability to urinate. Pain in the vaginal or rectal
area. Lastly, if crying and periods of sadness is beyond the two weeks. Health teaching and
Health Promotion promote patient-centered care and increases adherence to medication and
treatments. An increase in compliance leads to a more efficient and cost-effective healthcare
delivery system. Educating patients ensures continuity of care and reduces complications related
to the illness.

REFERENCES:
Hartmann K, Viswanathan M, Palmieri R, Gartlehner G, Thorp J Jr, Lohr KN. Outcomes of routine episiotomy: a systematic review. JAMA. 2005;293(17):2141-2148.
American College of Obstetricians-Gynecologists. Episiotomy. Clinical Management Guidelines for Obstetrician-Gynecologists. ACOG Practice Bulletin. 2006;71.
Carroli G, Mignini L. Episiotomy for vaginal birth. Cochrane Database of Systematic Reviews. 2009;1:CD000081.
Cunningham FG, Leveno KJ, Bloom SL, et al. Normal labor and delivery. In: Cunnigham FG, Leveno KL, Bloom SL, et al, eds. Williams Obstetrics. 23rd ed. New
York, NY: McGraw-Hill;
2010:chap 17.
Vaginal Birth After C-Section (VBAC) | University of Maryland Medical Center
http://umm.edu/health/medical/pregnancy/labor-and-delivery/vaginal-birth-after-csection-vbac#ixzz2h7rvOuNr
University of Maryland Medical Center
Lenin (1995) pharmacology, Philadelphia, Lippincoot Company, fourth edition.
Pillitter, Adel, maternal and child health nursing, fourth edition.Gil Bert and human, manual of high risk pregnancy and delivery, third edition 2003