NORMAL SPONTANEOUS VAGINAL DELIVERY; G1P1 (1,0,0,1); PREGNANCY UTERINE

TERM DELIVERED CEPHALIC VIA NORMAL SPONTANEOUS VAGINAL DELIVERY WITH

RIGHT MEDIOLATERAL EPISIOTOMY AND REPAIR TO A LIVE BABY GIRL

A Case Study Presented to the College of Nursing

St. Jude College Dasmariñas Cavite, Inc.

Dasmariñas Cavite, Philippines

In Partial Fulfillment of the requirements for

Care of the Mother, Child & Adolescent (Well Clients)

Presented by:
Olavario, Irish Faye N.
Operiano, Kristine A.
Sabino, Allyna Lohan B.
Sambo, Clark A.
Saramines, Jazzlyn Mae C.
Shackleton, Angeline L.

Group 2V
BS Nursing Level 2

Presented to:
Ms. Baby Dela Cruz, RN, MANc
Ms. Crisaline Baculi, RN, MANc
Ms. Nicole Santos, RN, MANc
Reymart B. Bolagao, RN, MAN, PhDc

Batch of 2025

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 TABLE OF CONTENTS

CHAPTER I: INTRODUCTION 3
A. Background of the Study 3
B. Biographical Data 4
C. Genogram 5
D. History of Past Illness 6
E. Obstetric History 6

CHAPTER II: GENERAL ASSESSMENT 8

A. Vital Signs 8
B. Review of System 9
C. Gordon’s Functional Pattern of Assessment 15
D. Diagnostic & Laboratory Findings 23

CHAPTER III: ANATOMY AND PHYSIOLOGY 29

CHAPTER IV: DRUG STUDY 39

CHAPTER V: NURSING CARE PLAN 45

A. Prioritization 45
B. Actual Problem 52
C. Potential Problem 59
D. Health Promotion 69

CHAPTER VI: NEWBORN ASSESSMENT 78

A. Anthropometric Data 78
B. Apgar Scoring 79
D. Prophylaxis & Vaccines 86
E. Nursing Care Plan for Newborn 88

CHAPTER VII: DISCHARGE PLAN 97

A. Medications 97
B. Environment 97
C. Treatment 97
D. Health Teaching 97
E. Observable S/Sx 98
F. Diet 98
G. Spirituality 98

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 CHAPTER I
INTRODUCTION

A. Background of the Study

Normal spontaneous delivery is a childbirth process often referred to as "normal" as it does
not usually require any medical procedures or interventions to occur. It is the most common type
of delivery that accounts for nearly all births. Normal spontaneous delivery is associated with a
lower risk of complications than other delivery methods. According to Tsukerman & Desai
(2022), it is the safest option for both the fetus and the mother when the newborn is full-term at
37 to 42 weeks gestation. It is preferable since the morbidity and mortality associated with
cesarean births have risen over time. This process typically occurs after the mother has entered
labor and the cervix has dilated to at least 8 to 10 centimeters. Labor is a series of continuous,
progressive uterine contractions that help in the dilation and effacement of the cervix (John
Hopkin Medicine, 2021). Labor allows the fetus to go through the birth canal. It normally begins
two weeks before or after the expected delivery date.

Patient K.D is a 15-year-old young primigravida who delivered a live birth baby girl via
Normal Spontaneous Delivery and underwent a right mediolateral episiotomy and repair
procedure. Episiotomy is a procedure that is intended to lessen the prevalence of severe
perineal tears and relieve pressure on the perineum during birth (Barjon & Mahdy, 2022). As
reported by the Philippine Statistics Authority (2023), adolescent pregnancy among Filipino
women aged 15 to 19 years has declined from 8.6 percent in 2017 to 5.4 percent in 2022 and
1.4% of women began childbearing when they were 15 years old. The patient was admitted in
Pagamutan ng Dasmariñas (PD) with the chief complaint of labor pain and admitting diagnosis of
G1P0 pregnancy uterine term 39 weeks of gestational age cephalic in labor; young primigravida
with the chief complaint of labor pain on January 7, 2023 at 12:15 A.M. Patient K.D. labor and
delivery happened the same day, expulsion of the baby occurred at exactly 6:23 A.M. of January
7, 2023.

On January 9, 2023, student nurses handled Patient K. D and interviewed to gather

information for this study. Before conducting the interview and obtaining the patient’s consent to
use her case for this study, student nurses informed the patient that the interview was done to
fulfill a course requirement. The student nurses handled the patient two days after the delivery.

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B. Biographical Data

Name : Patient K.D.

Age : 15 years old

Date of Birth : December 30, 2007

Address : Brgy. San Juan, Dasmariñas, Cavite

Religion : Roman Catholic

Civil Status : Single

Educational Attainment : Grade 9

Last Menstrual Period : April 02, 2022

Date & Time Admitted : January 07, 2023, 12:15 A.M.

Chief Complaint : Labor pain

GPTPAL Score : G1P1T1P0A0L1

Admitting Diagnosis : G1P0 Pregnancy Uterine Term 39-40 weeks

AOG Cephalic in Labor; Young Primigravida

Final Diagnosis : G1P1 Pregnancy Uterine Term Cephalic

delivered live birth via Normal Spontaneous
Delivery; Young Primigravida (Girl, BW 2840g,
AS: 9,9) with Right Mediolateral Episiotomy

Source of Information

Primary Source : Patient K.D.

Secondary Source : Patient’s Chart

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C. Genogram

The first generation includes the grandparents of patient K.D who died due to old age.
According to her, she was not able to meet her grandparents as they live far away from them.
Her grandparents are located in the province of Albay, while they are situated in the City of
Dasmariñas. However, she was able to know them through her parents who were able to tell
stories about them. The second generation includes patient K.D’s parents. In 2022, both of her
parents passed away. The father died at the age of 55 from pulmonary edema, while the mother
died at the age of 52 from bacterial gastroenteritis. Pulmonary edema is an excessive buildup of
fluid in the lungs (Chen, 2022). Bacterial gastroenteritis, on the other hand, is a digestive
problem caused by a bacteria. They died only a month apart which led her brother to be her
parental figure. Furthermore, there are no known hereditary disease that could be pass down
from the first and second generation.

The third generation includes patient K.D and her two siblings. The patient has a full sibling
on her parents' side and a half-sibling on her mother's side. She have a 30-year-old sister who
lives in Batangas, which is her full-sibling and one brother who is 25-year-old, which is her
half-sibling also guardian as of the moment due to the death of her parents. The patient is the
youngest member of the family; her half-brother is the second oldest, and her full-sister is the
oldest of the three. The most recent generation includes the patient’s newborn, which is a baby
girl. The baby girl was born on January 7, 2023 at 6:23 A.M.

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D. History of Past Illness

Patient K.D. stated that she is healthy and has no history of past illness. According to her,
she had completed her immunizations when she was a child including Bacillus Calmette–Guérin
(BCG) vaccine, Hepatitis B vaccine, Pentavalent vaccine, Polio vaccines, Pneumococcal
vaccine, and Measles, Mumps, and Rubella (MMR) vaccine. Aside from that, she also received a
COVID-19 vaccination in the brand of Pfizer-BioNTech last 2021. Patient K.D also mentioned
that no genetic illness had been passed down via her family and that she had no prior history of
surgery or other procedures.

E. Obstetric History

Patient K. D. is a primigravida. Prior to pregnancy, the patient's menstrual cycle was 28 days
long, with a moderate flow and a duration of 3-4 days. She had her menarche at the age of 11.
During menstruation, she uses three to five pads per day. Her last menstrual period was April 02,
2022‌ and the expected date of delivery was on January 9, 2023 based on Naegele’s rule.
According to John Hopkins Medicine, Naegele's rule is used to calculate a woman's estimated
delivery date by adding one year and seven days to the last menstrual period (April to
December) and then subtracting three months. The patient began sexual activity at the age of 14
with a single male partner in the absence of contraception. She has no history of any sexually
transmitted disease.

During the course of pregnancy, she completed prenatal examinations and was able to take
her supplements such as ferrous sulfate, calcium, and vitamins on a regular basis. Prior to
admission, Patient K.D. had painful contractions for 3 hours. She had a good fetal movement
and dilation of 3 cm upon arrival. She was admitted in Pagamutan ng Dasmariñas on January 7,
2023 at 12:15 a.m. with a chief complaint of labor pain. Upon admission, a standard testing
method for SARS-CoV-2, nasopharyngeal swab, was performed to the patient and the result
was negative. On the same day, the patient delivered a live baby girl with a cephalic presentation
via normal spontaneous vaginal delivery at 6:23 a.m. with a final diagnosis of G1P1 Pregnancy
Uterine Term Cephalic delivered livebirth via Normal Spontaneous Delivery; Young Primigravida
(Girl, BW 2840g, AS: 9,9) with Right Mediolateral Episiotomy. Her current obstetric score is now
G1P1T1A0L1.

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 Date/Time Doctor’s Order

January 7, 2023 Admitting Orders

1:30 A.M. ➢ Start IVF D5LR 1L x 8 hours
➢ Urinalysis
➢ EPO 4 softgels per vagina every 6 hours
Postpartum Orders
➢ Oxytocin 10μ IM now
January 7, 2023 ➢ To follow IVF: D5LR 1L + 10μ Oxytocin x 8hrs then to consume
6:37 A.M. if no profuse bleeding
➢ Start oral meds:
1. Cefuroxime 500mg/cap PO BID to complete for 7 days
2. Mefenamic acid 500 mg/cap PO TID PRN for pain
3. Ferrous sulfate 100 mg/cap PO OD
➢ Methergine 1 amp IM now

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 CHAPTER II
GENERAL ASSESSMENT

A. Vital Signs
Initial Vital Signs
Date: January 7, 2023 Time: 12:20 A.M.

Height Weight Temperature Pulse Rate Respiratory Blood O2

Rate Pressure Saturation

162 cm 72.9 kg 36.6 °C 109 bpm 20 bpm 120/80 mm 99%

Hg

Body Mass Index: 27.8 Fetal Heart Tone: 152 bpm

The initial vital sign assessment of Patient K.D. was taken and documented by the staff
nurse on duty on January 7, 2023 at 12:20 A.M. The patient has a pulse rate of 109 bpm,
respiratory rate of 20 bpm, temperature of 36.6°C, blood pressure of 120/80 mm Hg, and oxygen
saturation of 99%. The fetal heart tone was 152 bpm, which is normal. Patient K.D. stands 5’4 ft
(162 cm) with a weight of 72.9 kg (160.7 lbs). Pulse rate was slightly elevated due to increased
fetal movement. As explained by Rice (2020), heart rate alterations do not always indicate a
problem. Some are natural as a result of fetal movement or a contraction. These changes are
viewed as markers of the baby's health.

In terms of weight pre-pregnancy, patient K.D. has a weight of 60 kg and a body mass index
of 22.9, indicating a healthy weight. Prior to delivery, the patient's BMI was 27.4, indicating she
is overweight for her age group. However, Jacobson (2020) stated that most pregnant women
gain between 25 and 35 pounds (11.5 to 16 kilograms) during the course of pregnancy. This
implies that the patient's weight gains throughout pregnancy is normal and part of the physiologic
changes of maternal adaptation to pregnancy.

Postpartum Vital Signs

Date: January 9, 2023 Time: 2:17 P.M.

Height Weight Temperature Pulse Respiratory Blood O2

Rate Rate Pressure Saturation

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 162 cm 67.3 kg 36.8 °C 88 bpm 19 bpm 100/70 mm Hg 96%

Body Mass Index: 25.5

On January 9, 2023 at 2:00 P.M., student nurses received patient K.D. in bed with her
newborn. The student nurses were able to obtained vital signs and assessed the patient and her
newborn upon arrival. All vital signs noted were normal. Prior the assessment, the student
nurses introduced themselves to the patient and asked permission to conduct an interview with
her and utilize her case in this study. The patient was advised by student nurses that the data
gathered from the interview will be used to accomplish a course requirement and that all data
gathered, especially her identity, would be kept confidential and treated with the utmost respect.

B. Review of System
Physical Assessment
Date: January 9, 2023 Time: 3:28 P.M.

System Normal findings Actual findings Analysis

Skin Hyperpigmentation Linea nigra and Linea nigra, melasma, and

of certain parts of striae gravidarum stretch marks are physiologic
the body such as are still visible. skin alterations that may
the face, neck, and appear as the pregnancy
midline of the progresses. Hormonal
abdomen is changes can cause the skin
common during to become slightly darker and
pregnancy (Datta et more likely to get stretch
al., 2010). Stretch marks. This is because the
marks may also be body produces extra pigment
present. as a result of pregnancy
hormones. Stretch marks can
be observed, especially
around the abdomen where
the middle layer of skin
(dermis) becomes stretched
and broken in places to make

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 room for the developing baby
during pregnancy. After
childbirth, the marks may
gradually fade into paler scars
and become less noticeable
and the pregnancy-related
pigment changes often go
away six to eight weeks
(Chauhan & Tadi, 2022).

Hair American Academy Patient stated that A few months after having a
of Dermatology she is baby, many new mothers
(2010), hair loss experiencing hair notice considerable hair loss.
after pregnancy is fall and her hair is This is not actual hair loss.
common caused by dry. This is referred to by
falling estrogen dermatologists as excessive
levels. hair shedding. Falling
estrogen levels cause the
increased shedding. This
excessive shedding is only
temporary, and it does need
any remedy (American
Academy of Dermatology,
2010).

Eyes The altering level of Patient stated A woman’s body experiences

hormones and fluids vision changes so many changes during and
within the body can like blurry vision. after pregnancy, and
lead to vision hormones cause these
changes and cause changes. One such
blurry vision and dry unexpected change is that
eyes after childbirth most new moms notice
(Samuels, 2021). changes related to their
vision, with approximately
50% of women being

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 susceptible to these changes
(Pillai & Samajder, 2023).
After childbirth, the fluid
retention capacity of the eye
ducts are extremely
hampered. As a result, the
cornea cannot sustain its
normal shape, and the vision
may get blurred or highly
distorted.

Nose No signs of rhinitis No discharge and The mother displays normal

or nasal congestion, the bridge of the findings and no discharge or
discharges and the nose is in midline. congestion are noted.
bridge of the nose
should be at According to Toronto
midline. Metropolitan University
(2021), External nose is
symmetrical with no
discolouration, swelling or
malformations. Nasal mucosa
is pinkish red with no
discharge/bleeding, swelling,
malformations or foreign
bodies.

Mouth and Lips and tongue are Lips are Patient K.D. displays normal
Teeth reddish or pigmented, moist, findings on both mouth and
pigmented and have and plumped. teeth. There are no sores on
no signs of dryness. Tongue is pinkish the lips or the mouth, and
There should be no to reddish. Mouth there is no discomfort or pain
lesions. is free from any when eating.
form of lesions.
Teeth are more Teeth are
sensitive, which complete and

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 causes severe pain, somewhat
discomfort, and yellowish in
poor eating. Have appearance.
an appearance of
teeth discoloration.

Neck Smooth, The patient can Patient K.D. displays normal

coordinated freely move her findings on the neck. She
movement with no head. have no discomfort with
discomfort. Size and movement.
strength are equal.

Chest and The chest wall The chest wall The mother have normal
Lungs should be intact, and abdomen findings on the chest and
without any masses move outward on lungs. There are no abnormal
or tenderness, and inspiration and breath sounds.
deformities. inward on
expiration in a
coordinated
action.

Breast Warm, full, and It is engorged as Breasts change after

heavy, and have well as warm and childbirth to facilitate the
signs of tender due to milk baby's feeding. The
engorgement, production and hormones in the body ay alter
including fullness. fullness is also and make the areola darker.
present. Nipples The color may or may not
are protruding and lighten after childbirth. Full
erected. breasts are a regular part of
the postdelivery experience.
The color of the When milk starts to flow in,
areola and nipples breasts get full, which is
are dark brown. known medically as
engorgement. (Johnson,
2022).

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Abdomen Abdomen is soft, It does have The abdominal muscles are
symmetric, and stretch marks and overstretched during
non-tender without loose skin. Uterus pregnancy and strained
distention. There is located at the during labor and are slow to
are no visible midline and 2 cm regain their normal tone and
lesions or scars. below the elasticity, returning to
The aorta is midline umbilicus. It is still pre-pregnancy levels by 6 to
without bruit or palpable. 8 weeks. It may appear
visible pulsation. bloated or "deflated." After
(ThriveAP, 2016) birth, stomach may have
stretch marks. The linea nigra
may also be present. (Zapata,
K., 2022)

The uterus is situated

between the pubic symphysis
and umbilicus after delivery. It
descends by roughly one to
two cm daily. The uterus
regains its pre-pregnancy size
and weight in around six
weeks (Cleveland Clinic,
2022).

Extremities Swelling in the Presence of mild After giving birth, the body
ankles and feet are postpartum will continue to hold on to
common after birth. edema is noted in water because of an increase
the legs, feet, and in progesterone. Swelling in
ankle. the hands, arms, feet, ankles,
and legs may be obserbed.
Edema shouldn’t last much
longer than a week after
delivery. (WebMD, 2021).

Genitalia Vaginal discharge There is a Labor and delivery place a lot

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 (lochia rubra). presence of of strain on the vagina, anus,
Vaginal soreness, vaginal soreness and perineum. This results in
and discomfort in and vaginal vaginal soreness, which is
the perineal area. discharge called normal following vaginal
lochia rubra. It is delivery, and the pain can
bright red, and no linger for several weeks.
foul odor is noted. Furthermore, following
Episiotomy site is delivery, the endometrium
still intact. begins to shred, resulting in
According to the lochia rubra, a vaginal
patient, pain is discharge composed of blood,
tolerable ranging fetal membrane shreds,
7/10. decidua, vernix caseosa,
lanugo, and membranes. Its
color is red because of the
enormous amount of blood it
contains. For the first few
days, the discharge will be
red and heavy (Mayo Clinic,
2022).

Rectum Postpartum Patient reported Constipation is common after

constipation, pain, feeling giving birth. Characterized by
and rectal itching is constipated after difficult or infrequent bowel
common. giving birth. movements, many people
experience constipation
during pregnancy, and it can
continue after delivery, or it
may occur for the first time
after delivery (White, 2022).
Patient K.D’s stool passage
may still be delayed due to
the presence of relaxin in the
bowels and it may still be

14
 difficult for the patient to
defacate due to the pain of
the episiotomy.

Neurological Baby blues on 2 to Patient stated that Hormone changes that

3 days after the she’s having happen after birth may cause
baby is born. They difficulty sleeping, the baby blues. After delivery,
can last up to 2 fatigue, and mood the amount of the hormones
weeks, usually go swings, but have estrogen and progesterone
away on their own, the readiness to suddenly decreases, causing
and don’t need any enhance her mood swings. For some
treatment. parenting skills people, the hormones made
and knowledge for by the thyroid gland may drop
newborn care. sharply, which can make
them feel tired and
depressed.
(MarchofDimes.org, 2021)

C. Gordon’s Functional Pattern of Assessment

GORDON’S BEFORE DURING ANALYSIS
ASSESSMENT HOSPITALIZATION HOSPITALIZATION
Health Perception “Okay lang naman “Normal pa rin po Both remarks are
Health po yung kalusugan lahat ngayon, wala significant because
Management ko at wala rin akong namang they indicate that the
Pattern mga bisyo. Mahilig binabanggit yung patient is avoiding
rin akong kumain ng doktor ko na may health concerns that
gulay.” as patient sakit ako. Paborito could harm her and
verbalized. ko pa ring kainin the baby by
ang gulay.” as consuming nutritious
patient verbalized. foods such as
vegetables and not
engaging in vices.

Eating a nutritious diet

15
 and having healthy
lifestyle during
pregnancy has been
linked to healthy brain
development and birth
weight, as well as
lowering the risk of
many birth defects. A
healthy lifestyle will
also aid in the
prevention of anemia,
as well as other
unpleasant pregnancy
symptoms such as
fatigue and morning
sickness (Stickler,
2020).
Nutritional “Kadalasan po, “Sa pagkain ko po, This is a good
Metabolic Pattern paborito kong mas babantayan at indicator for the
kinakain ang gulay. magiging maingat patient because she
Kumakain din ako ako para iwas sa wants to live a better
ng karne.” as patient sakit. Magiging lifestyle by being more
verbalized. mapili na rin siguro conscious in her
ako sa pagkain dietary choices for the
para sa health rin ni sake of herself and
baby.” as patient her baby.
verbalized.
According to
MedlinePlus (2021),
consumption of
nutrients are more
important than ever
during pregnancy.
Making healthy food

16
 choices every day will
help in providing the
baby what she needs
to develop. It will also
help in gaining proper
birthweight.
Elimination “Wala naman pong “Ngayon po, During hospitalization,
Pattern problema sa pag-ihi inaalam ng mga patient K.D reported to
at pag-tae ko. Hindi nurse kung ilang have a postpartum
naman ako beses ako umihi at constipation, which
nahihirapan.” as dumudumi. manifested as
patient verbalized. Nahihirapan lang discomfort and firm
ako dumumi, stool. Postpartum
constipated ata constipation is a
ako.” as verbalized common condition that
by the patient. affects mothers
(Turawa et al., 2015).
Postpartum
constipation might be
exacerbated by
episiotomy site pain
and pregnancy
hormones. Nurses
must help patients
maintain healthy
elimination patterns,
such as regular soft
bowel movements and
adequate urination, as
well as identifying
abnormal patterns
such as constipation,
diarrhea, polyuria, and
other abnormalities

17
 that may be signs of
underlying medical
condition (Sharma &
Bhutta, 2022).
Activity Exercise “Ang nagiging “Ngayon po, medyo This is a good
Pattern exercise ko po sa naglalakad-lakad indication since the
araw-araw ay na po ako ulit kahit patient is aware and
paglalakad-lakad medyo masakit pa knowledgeable about
pati na rin yung po yung tahi pero the importance of
pag-akyat at yung pagbaba at exercise and on how
pagbaba ko ng pag-akyat sa to take care of her
hadgan namin.” as hagdan baka health.
patient verbalized. mahirapan pa ako
dahil According to Johnson,
magpapagaling pa (2022), following a
ako, pero mahalaga regular exercise
pa rin na regimen can help in
gumalaw-galaw staying healthy and
para may exercise feeling great. Exercise
kahit papaano.” as on a regular basis
patient verbalized. during pregnancy can
improve posture and
ease some common
discomforts such as
backaches and
exhaustion.
Sleep - Rest The patient stated, The patient This indicates that the
Pattern “Nakakatulog po verbalized, “Ngayon patient is having
ako mga alas onse po, hindi ako difficulty getting rest
na ng gabi tapos masyadong due to the infants
nagigising ako ng nakakatulog at crying and is still
alas siyete ng paputol-putol dahil adjusting to her new
umaga.” sa pag-iyak ni baby routine.
pati nung mga baby

18
 then added, sa kabilang room.” According to Lewis
“Maayos naman po (2014), mothers
ang pagtulog ko at This happens become more
hindi naman ako because the patient sensitive to the
nahihirapan.” is transferred to the sounds of babies
OB ward together crying, preparing them
with the newborn to care for an infant.
babies. Sleep loss is a
common, normal
experience after the
arrival of a baby
(Swanson, 2016).
Cognitive “Wala naman po The patient stated, The patient’s
Perceptual Pattern akong problema sa “Ngayon po medyo statement during
mata at pandinig. anxoius at nafifeel hospitalization
Pati yung memorya kong paiba-iba rin indicates a normal
ko po ay okay parin yung mood ko pero findings and changes
naman.” the patient tolerable naman po after giving birth. Her
stated. at hindi nadadamay statement also
yung baby ko.” indicates that she is
taking control of her
emotions so that her
baby will not be
affected by it.

The transition from

pregnancy to
parenthood is a major
life adjustment — both
physically and
emotionally. During
your baby's first few
days of life, it's normal
to feel emotional highs

19
 and lows, something
commonly referred to
as the "baby blues."
(Ben-Joseph, 2018)
Self - The patient “Okay pa rin naman This suggests that
Perception/Self – verbalized, “Okay po ako ngayon at patient K.D. have no
Concept Pattern lang naman po ako masaya dahil altered body image as
at masaya kahit nakaraos na ako sa a result of the
nag-iba yung pagbubuntis ko lalo changes that occur
katawan ko, na sa paglabas ng throughout her
tumaba. Normal baby ko.” as pregnancy. She
lang naman siguro verbalized by the deemed these
yon sa patient. changes as normal
nagbubuntis.” and part of the
process of pregnancy.

According to Zaltzman
et al., (2015), studies
reviewed found that
the majority of
pregnant adolescents
had positive body
image and positive
attitudes towards
weight gain.
Role Relationship The patient The patient stated, As per patient’s
Pattern verbalized, “Kasama “Sa ngayon po, remarks, she
ko po sa bahay yung boyfriend ko anticipates having a
yung half-brother yung kasama ko lot of duties as a new
ko. Siya na rin yung dito nagbabantay mother and student.
tumatayong sakin. Pagkauwi ko Since the patient is
magulang sa siguro ay ibang-iba still young, it is vital to
bahay.” and added, na yung routine ko support and
“Ako naman ay dahil nanay na ako encourage her as she

20
 nag-aaral pa, third at estudyante rin. transitions from an
year high school na Mas dadami narin adolescent to a
ako at marami rin yung mother.
akong mga kaibigan responsibilidad ko.”
sa school.” According to Mangeli
et al., (2017), study
showed that teenage
mothers are facing
many physical,
mental, psychological
and social challenges.
Achieving such results
shows that teenage
mothers need
comprehensive
support.
Sexually “First baby ko po si The patient stated, As stated by the
Reproductive baby. Active rin “Wala na po akong patient, she realized
yung sexual life ko planong magbuntis the importance of
bago ako mabuntis.” pa dahil mahirap using contraception,
as verbalized by the po. Pinaplano ko na especially long-term
patient. ring magpa-implant contraception such as
at pag na-expired an implant, as well as
na iyon ay the difficulties she
magpapalagay po faced after her
ulit ako ng delivery, which led her
panibago.” to decide not to
become pregnant
again.

According to Rapaport
(2019), long-acting
contraceptives work
well in preventing

21
 pregnancy. Increased
usage of implant and
other kinds of
long-acting
contraception has
been associated to
reduced adolescent
pregnancy and birth
rates, indicating the
efficacy of this
approach.
Coping - Stress The patient stated, “Ganoon pa rin According to Unicef
“Pag naiistress po naman po, mahilig (2019), It is proven
ako, paborito ko pa rin akong that music has a role
yung pakikinig ng makinig ng mga in brain development
music katulad ng hillsong lalo na before birth. Listening
hillsong.” ngayon habang to music during
nagrerecover sa pregnancy will not
hospital.” as only have a soothing
verbalized by the and uplifting effect on
patient. the pregnant woman,
but also a positive
influence on the
unborn baby.
Values - Belief As per the patient, “Nagdasal po ako According to Callister
Pattern “Roman Catholic po talaga na gabayan et al., (2010), women
ako, pero hindi ako ako ni Lord lalo na described how their
pala simba, pero nung bago ako religious beliefs and
importante sa akin manganak dahil accompanying rituals,
yung pagppray.” kinakabahan ako at such as prayer, served
first time din.” as as helpful coping
verbalized by the mechanisms during
patient. labor and childbirth.

22
D. Diagnostic & Laboratory Findings
Hematology
Hematology involves the diagnosis and treatment of patients who have disorders of the blood
and bone marrow. According to John Hopkins Medicine (2020), Hematology tests are performed
to aid in diagnosing anemia, certain cancers of the blood, inflammatory diseases, and to monitor
blood loss and infection.

Hematology (Smear and Blood Typing)

November 3, 2022 8:44 P.M.

Test Results Analysis

Blood Type “A” The Rh antibodies screening test is performed during pregnancy
to determine whether or not the infant is at risk for Rh disease.
This can happen if the mother is Rh-negative and the infant is
Rh Positive
Rh-positive. When Rh-negative and Rh-positive blood combine,
the immune system produces antibodies to fight the Rh-positive
blood (Staff, 2022). As per the laboratory results, Patient K.D is
Rh positive with a blood type “A” and therefore, will not make
anti-Rh antibodies.

Hematology
November 3, 2022 8:44 P.M.

Test Normal Results Analysis

WHITE BLOOD CELL 5-10 12.30 The physiologic stress

COUNT generated by pregnancy
causes an increase in white
blood cell count (Chandra et
al., 2019). Since the patient
was pregnant, the results for
Patient K.D are acceptable.

23
Lymphocytes 20.0 - 45.0 14.0 Lymphocyte count
decreases during the first
and second trimesters of
pregnancy and increases
during the third trimester.
There is absolute
monocytosis throughout
pregnancy, particularly in the
first trimester, although this
reduces as the pregnancy
progresses (Chandra et al.,
2019). This suggests that
Patient K.D.'s result was
low, which is normal during
pregnancy.

Monocytes 1.0 - 7.0 3.0 Monocytes are transient

cells that form in the bone
marrow and mature in the
circulation. They are thought
to be necessary for healthy
pregnancy because they
play an important role in
immunological responses.
By entering the decidual
tissue (7th-20th week of
gestation), monocytes aid to
reduce fetal allograft
rejection (Chandra et al.,
2019). The result for patient
K.D was within the normal
range.

Eosinophils 1.0 - 5.0 2.0 Eosinophils are a type of

white blood cell that help

24
 ward off bacteria, viruses,
parasites, and other
possible causes of infection.
Eosinophil levels may rise
when a person has an
allergy, an infection, or
leukemia. (Biggers., A.
2023) This indicates that the
patient has a normal
findings.

Neutrophils 40.0 - 75.0 81.0 The quantity of neutrophils

in the blood normally rises in
response to the additional
stress that pregnancy places
on the body. (Madormo,
2022) Since the patient was
pregnant, the neutrophils
were higher than normal.

RED BLOOD CELL COUNT 4.0 - 5.4 4.60 Red blood cell mass does
not increase until about 20
weeks of pregnancy, and it
increases by about 30%
above the non-pregnant
state. By 6 weeks
postpartum, red blood cell
mass will return to normal
levels (Chen, 2021). The
result signifies normal
findings, indicating that the
result is within a normal
range.

HEMOGLOBIN 120 - 160 141 All pregnant women are at

25
 HEMATOCRIT 0.37 - 0.47 0.41 risk of becoming anemic
because they require more
iron and folic acid than
usual. Measuring
hemoglobin and hematocrit
levels can be used to help
diagnose blood disorders
such as anemia, a condition
in which there aren't enough
red blood cells (Johnson,
2022). Patient K.D's findings
indicate that her values are
within the normal range.

Serology
The National Cancer Institute defined serology as laboratory test that checks for the presence of
antibodies or other substances in a blood sample. Antibodies are proteins made by the body’s
immune system in response to a foreign substance or microorganism, such as a virus. Serology
tests look for certain antibodies to see whether a person has been exposed to or infected with a
virus or other infectious agent.

Serology
November 3, 2022 8:44 P.M.

Test Result Analysis

HBsAg Screening Nonreactive The laboratory results

indicates that Patient K.D.
VDRL/RPR Nonreactive
does not have any

Anti HIV ½ (Screening) Nonreactive evidence of HIV, syphilis,

and Hepa B infection.

26
Fasting Blood Sugar Test
FBS is a type of laboratory test that measures the amount of glucose in the blood to test for
diabetes or prediabetes. The typical fasting time is at least 8 hours Centers for (Disease Control
and Prevention, 2022).

Fasting Blood Sugar Test

November 4, 2022 7:30 P.M.

Test System International Conventional Analysis

Result Reference Result Reference Fasting blood sugar levels are used
to screen for diabetes, prediabetes,
FBS 4.24 3.9 - 5.8 76.40 70 - 105
and gestational diabetes. Gestational
mmol/l mmol/l mg/dl mg/dl
diabetes is a kind of diabetes that
occurs during pregnancy when blood
sugar levels become abnormally
high. It normally emerges between
the 24th and 28th week of pregnancy
(Cleveland Clinic, 2019). Patient
K.D's blood sugar levels were
confirmed to be within the normal
range, as seen above.

Urinalysis
A urinalysis involves checking the appearance, concentration and content of urine. It's used to
detect and manage a wide range of disorders, such as urinary tract infections, kidney disease
and diabetes (Mayo Clinic, 2021).

Urinalysis
January 7, 2023 7:48 A.M.

Findings Analysis

Color Yellow Urinary tract infection (UTI) is common during

pregnancy, owing to urinary stasis caused by

27
 Transparency Hazy hormonal ureteral dilatation, hormonal ureteral
hypoperistalsis, and pressure of the enlarging uterus
pH 6.0
against the ureters (Friel, 2022).

Reaction Acidic
Urine analysis of Patient K.D. revealed yellow hazy
Specific Gravity 1.025 urine appearance with an average pH of 6.0. Hazy
urine is one of the sign of a urinary tract infection.
Protein Trace
There is also a trace of protein in the urine, also
(10mg/dL)
known as proteinuria. In most women, proteinuria will
Sugar Negative resolve by 6 months postpartum (Roberts et al., 2014
). Moreover, there is also a presence of white blood
WBC/Pus Cells 10-25/HP
cells, red blood cells, and epithelial cells in the urine
F
which signifies the urinary tract infection. Postpartum
Red Blood Cells 2-5/HPF urinary tract infections are simple urinary tract
infections that occur in the days or weeks following
Epithelial Cells Moderate/ childbirth.
LPF

Most commonly, they are the result of receiving a

Amorphous Rare/LPF
catheter, which can introduce bacteria into the urinary
Urates/Phosphates
tract, leading to an infection. Urinary tract infections
occurs in any part of the urinary system. They mainly
occur in the bladder or urethra, although they can
also damage the kidneys. Urinary tract infections can
occur when pathogenic bacteria enter the urinary
tract. The majority of urinary tract infections begin in
the lower urinary system, when bacteria enter through
the urethra and travel to the bladder.

Postpartum urinary tract infections aren’t necessarily

more harmful or uncomfortable compared to urinary
tract infections that happen at any other time.
However, as with all urinary tract infections, it is
critical to pay attention to the symptoms and seek
treatment as soon as possible. (Propst, 2021).

28
 CHAPTER III
ANATOMY AND PHYSIOLOGY

The female reproductive system consists of internal and external organs, which are involved
in all stages of fertility, conception, pregnancy, and childbirth. The reproductive system is a
collection of organs and a network of hormone production in both men and women that allows a
man to impregnate a woman who then bears a child. During conception, a woman's egg cell and
a man's sperm combine to generate a fertilized egg (embryo), which implants and develops in
the uterus throughout pregnancy. Humans, like all living things, pass on some characteristics to
the next generation. It is accomplish through genes, which are the specific carriers of human
characteristics. The genes that parents pass down to their children are what make their kids
similar to others in their family, but also what distinguishes each child. These genes are found in
both female eggs and male sperm.

The external female genitalia are collectively called the vulva. The vagina is the pathway into
and out of the uterus. The man’s penis is inserted into the vagina to deliver sperm, and the baby
exits the uterus through the vagina during childbirth.

The ovaries produce oocytes, the female gametes, in a process called oogenesis. As with
spermatogenesis, meiosis produces the haploid gamete (in this case, an ovum); however, it is
completed only in an oocyte that has been penetrated by a sperm. In the ovary, an oocyte
surrounded by supporting cells is called a follicle. In folliculogenesis, primordial follicles develop
into primary, secondary, and tertiary follicles. Early tertiary follicles with their fluid-filled antrum will

29
be stimulated by an increase in FSH, a gonadotropin produced by the anterior pituitary, to grow
in the 28-day ovarian cycle. Supporting granulosa and theca cells in the growing follicles produce
estrogens, until the level of estrogen in the bloodstream is high enough that it triggers negative
feedback at the hypothalamus and pituitary. This results in a reduction of FSH and LH, and most
tertiary follicles in the ovary undergo atresia (they die). One follicle, usually the one with the most
FSH receptors, survives this period and is now called the dominant follicle. The dominant follicle
produces more estrogen, triggering positive feedback and the LH surge that will induce ovulation.
Following ovulation, the granulosa cells of the empty follicle luteinize and transform into the
progesterone-producing corpus luteum. The ovulated oocyte with its surrounding granulosa cells
is picked up by the infundibulum of the uterine tube, and beating cilia help to transport it through
the tube toward the uterus. Fertilization occurs within the uterine tube, and the final stage of
meiosis is completed.

30
 The uterus has three regions: the fundus, the body, and the cervix. It has three layers: the
outer perimetrium, the muscular myometrium, and the inner endometrium. The endometrium
responds to estrogen released by the follicles during the menstrual cycle and grows thicker with
an increase in blood vessels in preparation for pregnancy. If the egg is not fertilized, no signal is
sent to extend the life of the corpus luteum, and it degrades, stopping progesterone production.
This decline in progesterone results in the sloughing of the inner portion of the endometrium in a
process called menses, or menstruation.

Internal Female Reproductive System

Vagina
The vagina is a hollow, muscular tube that connects the vaginal opening to the uterus. The
vagina can expand and shrink due to its muscular walls. The vagina's flexibility to expand and
contract allows it to accommodate objects as small as a tampon and as large as a newborn. The
muscular walls of the vagina are coated by mucous membranes, which keep it protected and
moist.

Cervix
The cervix protects the growing baby by increasing in size and strength from conception until
just before birth, helping to keep the infant safe and secure in the uterus.

Uterus
The uterus ('womb') is pear-shaped and contains a thick muscular wall. The uterus' major
role throughout pregnancy is to shelter and nourish your growing baby.

Parts of the Uterus

● Fundus is the widest and uppermost portion of uterus. It is connected to the fallopian
tubes.
● Corpus is the main body of the uterus. During pregnancy, a fertilized egg implants here.
● Isthmus is the area of uterus between the corpus and cervix.
● Cervix is the base of the uterus. The cervix connects to the vagina.

Layers of the Uterus

● Perimetrium is the outermost, protective layer is known as the perimetrium.
● Myometrium is the middle layer, which is quite muscular. This grows during pregnancy
and contracts to expel the baby.

31
 ● Endometrium is the innermost layer, which serves as het uterine lining. Throughout
menstrual cycle, this layer sheds.

Fallopian Tubes
Fallopian tubes are small tubes attached to the top region of the uterus that serve as
passageways for the sperm. The transfer of an egg (ovum) from the ovaries to the uterus. The
fallopian tubes are the tubes that carry eggs from the ovaries to the uterus. Fertilization usually
takes place in the fallopian tubes.

Parts of the Fallopian Tube

● Interstitium gives access to the uterine cavity, where an embryo can implant and mature
into a fetus.
● Isthmus serves as a sperm reservoir, where sperm bind transiently to the epithelium
before being released during ovulation.
● Ampulla is the part at which the ovum and sperm are fertilized.
● Infundibulum catches and channels the released eggs.

Ovary
The ovary's major job during pregnancy in humans is endocrine support during implantation
and the first trimester, after which the placenta takes over. The corpus luteum of the ovary is
primarily responsible for this early pregnancy support.

Ovarian Cycle
The ovaries play a crucial role in both menstruation and fertilization. They produce the
estrogen hormones as well as progesterone and eggs for fertilization. Ovulation happens when
an ovary creates an egg laying an egg during the menstrual cycle (about day 14 of a 28-day
cycle).

Each ovaries has thousands of ovarian follicles. Ovarian follicles are little sacs found in the
ovaries in the ovaries that hold growing eggs. Each month, between days six and fourteen of
menstruation, follicles in one of the ovaries are stimulated to mature by follicle-stimulating
hormone (FSH) cycle. On day 14 of the menstrual cycle, a rise in luteinizing hormone (LH)
causes theegg production by the ovary (ovulation).

The fallopian tube, a small, hollow structure, is where the egg begins its trip to the uterus.

32
Progesterone levels rise as the egg travels through the fallopian tube, assisting in the
preparation of the uterine lining for pregnancy.

External Female Reproductive System

Labia majora
The labia majora are soft tissue folds that enclose and protect the other external genital
organs. Sweat and sebaceous glands create lubricating fluids in the labia majora.

Labia minora
The inner folds are referred to as the labia minora. These skin folds protect the urethral and
vaginal openings. The urethra is the tube that transports pee from the body. The inner folds of
the vulva produce a skin hood known as the prepuce or clitoris hood.

Clitoris
Clitoris serves only one purpose: to provide you with sexual pleasure. Your entire vulva is an
erogenous zone, which means it gets sexually excited when touched. The most sensitive portion
of your vulva is the clitoris.

Vagina Opening
During a woman's monthly period, the vaginal canal transports blood and mucosal tissue from
the uterus, accepts the penis during sexual intercourse and retains the sperm until it enters the
uterus. allows for delivery to occur.

33
 Hymen
Hymen is a piece of tissue covering or surrounding part of your vaginal entrance. It's
generated during development and present during birth. It thins over time and tears. Some
people will experience pain or bleed when their hymen ruptures, but the majority will not.

Urethra
The urethra is the tube that allows urine to exit your bladder and body. If you were born male,
your urethra runs past your prostate and into your penis. Your urethra is substantially shorter if
you were assigned female at birth. It runs from your bladder to your vaginal opening.

Breast
The breasts are accessory sexual organs that are utilized after the birth of a child to produce
milk in a process called lactation. Birth control pills provide constant levels of estrogen and
progesterone to negatively feed back on the hypothalamus and pituitary, and suppress the
release of FSH and LH, which inhibits ovulation and prevents pregnancy.

34
 FETUS DEVELOPMENT

FETUS IN UTERO
Placenta
The placenta attaches to the uterine wall and gives rise to the baby's umbilical cord. It is a
developing organ in the uterus during pregnancy. A growing baby gets oxygen and nutrients from
this structure.

Umbilical Cord
A rope-like cord that connects the fetus to the placenta. A baby in the womb relies on an
umbilical cord for survival. It usually contains three blood vessels which are 2 arteries and 1 vein.

Amniotic Sac
A thin-walled sac that surrounds the fetus during pregnancy. The sac is filled with liquid made
by the fetus (amniotic fluid) and the membrane that covers the fetal side of the placenta
(amnion). This protects the fetus from injury. It also helps to regulate the temperature of the fetus.

35
Fetus
An unborn baby from the 8th week after fertilization until birth.

STAGES OF LABOR
The first stage: This is the longest part of labor and the latent phase may last up to 20 hours. It
begins with the onset of the true contractions and lasts until the cervix is dilated to 10cm.
The second stage: It lasts from cervical dilation until the delivery of the baby.
The third stage: The process of childbirth ends with the delivery of the placenta.

36
 MECHANISM OF LABOR
The cardinal movements of labor describe the passage of the fetus through the birth canal.
These movements consist of engagement, descent, flexion, internal rotation, extension,
restitution and external rotation, and expulsion of the infant.

Engagement
The movement of the baby's head into
the pelvis is referred to as
engagement.

Descent
The descent of the fetus through the
pelvis indicates the progressive
movement of the fetal presenting part
through the pelvis to prepare for birth.

Flexion
This mechanism allows the baby's
head to move through the outlet with a
smaller diameter.

Internal Rotation
The fetal shoulder enters the pelvis in
the transverse diameter.

Extension
As the fetus moves through the
vaginal opening for birth, the head
extends pushing the occiput out first
followed by the face and chin.

37
External Rotation
When the fetus's head is outside the vaginal opening, it rotates about 45° to realign the head
with the shoulders and back, allowing the shoulders to move out of the opening.

Expulsion
After the fetus' head is delivered, the anterior shoulder descends to the pubic symphysis. The
anterior shoulder is then rotated under the symphysis, followed by the posterior shoulder and the
rest of the fetus.

38
 CHAPTER IV
DRUG STUDY

EVENING PRIMROSE OIL

Drug Mechanism of Indicatio Side Adverse Nursing

Action n Effects Reaction Responsibilities

DRUG Action: Evening Stomach Postpartu Assess if the patient

Evening Stimulate the primrose discomfor m is taking any
Primrose Oil body's oil is t bleeding anticoagulant drug
(EPO) production of widely Headach problems. as it may worsen
prostaglandins, used by e Newborn the bleeding and if
BRAND hormones that many bleeding there is any history
Primdin help ripen the midwives problems of allergies.
cervix and can to hasten
ROUTE bring on cervical Inform the pt about
PV contractions. ripening the purpose of
in an administering the
DOSAGE Therapeutic effort to drug and discuss
4 Softgel Effects: Hasten shorten possible side
Capsule cervical ripening. labor effects.

CLASSIFICA Ask for consent and

TION administer the drug
Fatty Acid
Gamma-linol
enic Acid
(GLA)

39
 METHYLERGONOVINE

Drug Mechanism of Indication Side Adverse Nursing

Action Effects Reactio Responsibilitie
n s

DRUG Stimulates Methergine is Headac Severe Assess

Methylergonovi uterine, vascular, administered in he Hyperten baselines for
ne and smooth the postpartum Nausea sion vital signs and
muscle, thereby period to help Vomiting Seizure history of
BRAND: causing bleeding deliver the allergies.
Methergine and arterial placenta and
vasoconstriction. to help control Inform the pt
ROUTE: bleeding and about the
IM Therapeutic other uterine purpose of
Effect: problems after administering
DOSAGE: Produces childbirth. the drug and
0.2 mg/ml sustained. discuss possible
contractions, side effects.
which shortens
CLASSIFICATI third stage.of Raise side rails.
ON labor, reduces
Semi-synthetic blood loss. Monitor VS
ergot alkaloids especially blood
pressure. Report
immediately if
any unusual vital
signs are
recorded.

40
 OXYTOCIN

Drug Mechanism Indicatio Side Adverse Nursing

of Action n Effects Reaction Responsibilities

DRUG . Oxytocin Oxytocin Sudden Postpartum Assess baselines for

Oxytocin increases is drop of hemorrhag vital signs and history
the sodium administe blood e of allergies.
BRAND permeability red pressur Anaphylact
Pitocin of uterine immediat e oid Inform the pt about
myofibrils, ely in the reactions the purpose of
ROUTE indirectly postpartu Water administering the drug
IM, IV stimulating m period intoxication and discuss possible
contraction to side effects.
DOSAGE of the prevent
IM: uterine excessiv Raise side rails.
10 units smooth e
immediately muscle. bleeding Monitor vital signs
after delivery. by and uterine
Therapeuti helping contractions.
IV: c Effect: the
10 units in D5LR Stimulates uterus to Maintain careful I&O;
1L at 41-42 uterine contract. be alert to potential
gtts/min to contractions water intoxication.
consume for 8 . Check for blood loss.
hours if no
profuse bleeding

CLASSIFICATIO
N
Oxytocic agent

41
 MEFENAMIC ACID

Drug Mechanism Indication Side Adverse Nursing

of Action Effects Reaction Responsibilities

DRUG It works by Mefenamic Diarrhea Chest pain Assess patients

Mefenamic acid stopping the is used for Constipati Trouble who develop
body's the relief of on breathing severe diarrhea
BRAND production of pain Dizziness Slurred and vomiting for
Mefenamic a substance following an speech dehydration and
Ponsteli that causes episiotomy. electrolyte
pain, fever, imbalance.
ROUTE and
PO inflammation Give with meals,
. food, or milk to
DOSAGE minimize GI
500 mg Therapeutic adverse effects.
Effects:
FREQUENCY Mefenamic Advised the pt to
TID PRN acid is used not use drug for a
to treat mild period exceeding
CLASSIFICATIO to moderate 1 week.
N pain.
NSAIDs . Notify physician if
persistent GI
discomfort, sore
throat, fever, or
malaise occur.

42
 FERROUS SULFATE

Drug Mechanism of Indicatio Side Adverse Nursing

Action n Effects Reaction Responsibilities

DRUG Replenish iron To Loss of Stomach Advise to take

Ferrous stores and prevent appetite cramps, medication
Sulfate promote iron Constipati Nausea between meals with
hemoglobin deficiency on Diarrhea orange juice or
BRAND synthesis anemi Black or vitamin C
Slow FE and help green stool supplement
Therapeutic build up
ROUTE Effects: Used to body’s Instruct to remain
PO treat or prevent iron upright for at least
low blood levels supply 30 minutes after
DOSAGE of iron such as administration
1 tablet those caused by
(300mg) anemia or Advise patient that
pregnancy. the drug have side
FREQUENC effects such as
Y stools that may
Once a day become dark green
or black and that
CLASSIFIC this change is
ATION harmless.
Iron
Supplement Instruct patient to
s Hematinics follow a diet high in
iron such as dark
leafy greens,lean
red meats, and
fortified cereals.

43
 CEFUROXIME

Drug Mechanism of Indication Side Adverse Nursing

Action Effects Reaction Responsibilities

DRUG Inhibition of Cephalosp Vaginal Thromboc Inform the pt about

Cefuroxime bacterial cell orins are itching ytopenia the purpose of
wall synthesis usually or Anaphyla administering the
BRAND by binding to considered discharg xis drug and discuss
Ceftin one or more of safe during e possible side effects.
the pregnancy. Nausea,
ROUTE penicillin-bindin Minor lower Vomitin Give oral drug with
PO g proteins urinary g food to decrease GI
(PBPs) which tract upset and enhance
DOSAGE turn inhibits the infections absorption.
500mg final are
transpeptidatio frequent Have vitamin K
FREQUENC n step of during available in case
Y peptidoglycan pregnancy hypoprothrombinemia
Two times a synthesis in and occurs.
day for 7 bacterial cell cefuroxime Discontinue if
days. walls. is a hypersensitivity
first-line reaction occurs.
CLASSIFIC Therapeutic treatment.
ATION Effects: It Teach the pt to take
Cephalospor works by killing full course of therapy
in bacteria or even if you are
preventing feeling better.
their growth.
Teach the pt to
swallow tablets
whole; do not crush
them. Take the drug
with food.

44
 CHAPTER V
NURSING MANAGEMENT
A. Prioritization

ACTUAL PROBLEMS

NURSING DIAGNOSIS RANK JUSTIFICATION

Acute pain related to surgical 1st Pain might cause poor

procedure (Right mediolateral healing and also cause
Episiotomy) as evidenced by further complication. It
pain scale of 7/10. is important to control
postoperative pain to
fulfill physiological
needs.

Fatigue related to sleep 2nd . Fatigue related to lack

deprivation as evidenced by of sleep during the
drowsiness and lack of energy. postpartum period is a
common issue for many
new mothers. The
physical and emotional
demands of caring for a
newborn can make it
difficult to get enough
sleep, leading to
feelings of exhaustion
and fatigue. To help
alleviate postpartum
fatigue related to lack of
sleep, it is important to
prioritize self-care and
to get help from family
and friends when
possible.

45
Ineffective Breastfeeding r/t
lack of knowledge on proper
breastfeeding as evidence by
incorrect position of the baby
while breastfeeding
Constipation related to
surgical manipulation as
evidenced by absence of
stool.
Disturbed sleeping patterns
related to environmental
barrier by ambient noise and
unfamiliar setting
3rd Inproper breastfeeding
position can lead to
difficulties with milk
transfer, decreased milk
production, and other
breastfeeding
problems.
4th An increase in
progesterone, a
pregnancy hormone,
can cause the gut to
operate less efficiently
and food to travel more
slowly through the
intestines. This is
referred to as
decreased stomach
motility.
5th Lack of sleep can
weaken the immune
system, making the
patient more
susceptible to
infections. Adequate
sleep can be helpful in
healing and promote
fast recovery.
46
 POTENTIAL PROBLEMS

NURSING DIAGNOSIS RANK JUSTIFICATION

Risk for Postpartum 1st It can interfere with a

Depression r/t lack of support mother's ability to take
system as evidenced by care of and bond with
verbalization of “Wala na po her baby, as well as
kasi yung magulang ko, harm the child's
maaga pa po akong nabuntis development and
at wala pang trabaho. safety. In rare cases,
Inaasahan ko lang po yung new mothers have
kuya kong nag aalaga saakin.” harmed themselves
and/or their babies. For
the good of the mother
and her new baby, it is
crucial to identify and
treat PPD as quickly as
possible.

Risk for imbalanced nutrition 2nd Having an imbalanced

less than body requirements nutrition can increase
related to inability to ingest or an individual's risk for
digest food or to absorb other problems as well
nutrients because of biologic, such as: Weaker
psychologic, or economic immune system. Poor
factors as evidenced by wound healing. Muscle
verbalization of “Wala po weakness and
akong gana kumain hindi decreased bone mass.
kagaya dati na madami pa Also, when a person
yung kaya kong kainin.” gains weight, it can
indicate poor nutritional
practices or a side
effect of a medication
they might be taking

47

Risk for sleep deprivation
postpartum related to
challenging life transitions as
evidenced by asking “Ano po
pwedeng gawin kapag hindi
ako nakakatulog ng maayos
kahit tulog o hindi naman po
kailangan ni baby dumede.”
Risk for ineffective coping r/t
situational and maturational
crisis as evidenced by
verbalization of “Naiistress rin
ako kasi halo halo na yung
mga nararamdaman ko lalo na
ngayon kakapanganak ko
lang, minsan naiiyak nalang
(Padilla et al., 2021). In
pregnant women,
having low
pre-pregnancy weight
and inadequate weight
gain can indicate
growth problems and
potential low birth
weight for babies.
3rd New mothers are also
at risk for insomnia,
daytime sleepiness,
anxiety, depression,
non-refreshing sleep,
and fatigue. Sleep
deprivation can worsen
symptoms of
postpartum depression,
which affects one in
eight mothers. Being a
new parent requires
navigating through a
number of sleep
decisions and
challenges.
4th Ineffective coping is the
inability to assess a
stressful situation or
event comprehensively
and therefore fail to
make sound decisions
using inappropriate
resources or none at
48
 ako kung paano rin yung all. Coping
kinabukasan ng anak ko.” mechanisms break
down due to stress and
build pressure that
eventually exceeds
problem-solving skills.

Risk for impaired Parenting r/t 5th It is important to know

unplanned pregnancy as your well-being and
evidenced by verbalization of avoid burnout as a
“hindi po planado yung parent because burnout
pagbubuntis ko kaya feel ko can have a negative
rin na kulang pa ako ng impact on your physical
kaalaman sa pagiging and mental health. It
magulang. can also affect your
ability to parent
effectively, leading to a
negative impact on the
well-being of your
children.

HEALTH PROMOTIONS

NURSING DIAGNOSIS RANK JUSTIFICATION

Readiness enhanced self- 1st Any alteration or disruption to

health management related the immune system's defences
to the postoperative can allow microorganisms to
procedure (Right enter the body, which can
mediolateral Episiotomy) as result in various diseases.
evidenced by surgical Several nursing interventions
wound can be needed, depending on
the kind and degree of danger.

49

Readiness for enhanced 2nd
breastfeeding as evidenced
by “Gusto ko pong
matutunan ang tamang
paraan ng pagbbreastfeed.”
Readiness for enhanced 3rd
parenting as evidenced by
deficit knowledge about
child development
Nurses should educate the
patients on how to recognize
the symptoms of infection and
how to reduce their risk.
Breastfeeding helps the
growth and development of a
baby and has benefits for the
mother too.Breast milk
provides all the nutrients that a
baby needs for the first six
months of life to grow and
develop. Nurses should
educate the patient on how to
properly breastfeed their
newborn and explain to the
patient that breastfeeding
must continue for up to 6
months before introducing
other food in addition to breast
milk.
Impaired parenting can occur
when a parent has inadequate
knowledge about child
development, as this can lead
to poor decision making and a
lack of understanding of the
needs of the child. This can
result in a variety of negative
outcomes for the child, such
as developmental delays,
behavioral problems, and poor
academic performance.
Additionally, inadequate
50

Readiness for enhanced
nutrition as evidenced by
asking “Ano po ba mga
pagkain na masustansiya
ang pwede kainin?”
Readiness for enhanced
knowledge related to
different methods of
contraceptives as evidenced
by patient verbalized “balak
ko po mag pa - IUD”
knowledge about child
development may also put the
child at risk for physical or
emotional abuse, neglect, or
other forms of maltreatment.
As a nurse it is important to
ensure that the parents has a
good understanding about
child development in order to
provide appropriate care and
support for their children.
4th Lactating mothers may be
motivated to enhance their
nutrition in order to provide
adequate milk for their baby, to
support their own recovery
and healing postpartum, and
to prevent nutrient deficiencies
that may affect their own
health and the health of their
baby.
5th Enhancing one's knowledge
about contraception motivates
one to prevent unintended
pregnancies, protect
themselves from sexually
transmitted infections (STIs),
or regulate their menstrual
cycles. The nurse needs to
assess the ability of the patient
to learn related to different
methods of contraceptives as
it can help in providing
51
 accurate, comprehensive and
effective contraceptive
counselling.

ACTUAL PROBLEM #1

ASSESSME DIAGNOS PLANNING INTERVENTION RATIONALE EVALUATIO

NT IS N

Subjective Acute pain SHORT INDEPENDENT Vital signs SHORT

Data: related to TERM Monitored vital are altered TERM
“Nakirot po surgical GOAL: signs during acute GOAL:
yung tahi” as procedure Within 4 pain. After 4hours
verbalized by (Right hours of Explained to the of nursing
the patient. mediolater nursing patient that the The patient intervention
al intervention discomfort and may fix her the Goal was
Pain scale is Episiotomy s, The pain usually last mindset met, The
8/10 ) as patient will more than 3 days. about the patient would
evidenced experience pain and will experience
Objective by pain less pain DEPENDENT be lessen the less pain and
Data: scale of and above Administered perception relieve and
Facial 8/10. a tolerable Mefenamic acid about pain reach its
grimace as level as as ordered by and possible tolerable level
seen manifested. physician anxiety. as
Irritable manifested to
Discomfort LONG COLLABORATIV Assist in alleviate the
TERM E alleviation of pain.
GOAL: Instruct the pain and LONG TERM
Medication: The patient patient to do deep facilitate GOAL:
Mefenamic will breathing relaxation The patient
acid 500mg verbalized exercise. breathing would
decreased exercise verbalized
pain scale Distract self by that the pain
into 1/10 doing things that To relieve the was
patient will enjoy. pain. decrease,

52
 ACTUAL PROBLEM # 2

ASSESSM DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATION

ENT

Subjectiv Ineffective After 1 to 2 INDEPENDENT The patient After the of

e Data: Breastfeedin hours of Assessed the must perceive a nursing
“Nahihirap g related to nursing mother's need or a cause intervention,
an po ako lack of intervention motivation and for learning The mother
magpaded knowledge the patient eagerness to everything there would have
e, Di po on proper will know learn about is to know about enough
kasi ako breastfeedin the proper breastfeeding. breastfeeding knowledge
marunong” g as positioning and the crucial about proper
evidence by and have Demonstrated, things that the positioning
Objective incorrect knowledge explained, and mother must and
Data: position of about offered hands-on understand. techniques
Improper the baby importance assistance with prior to
positioning while of breastfeeding The patient breastfeeding.
of the breastfeedin breastfeedi positions such would have
infant g. ng. as cradle hold, basic
football hold, and understanding
sidelying position of what to
expect with
COLLABORATI breastfeeding.
VE It is the most
Refer to a vital aspect of
breastbeeding effective
support group breastfeeding is
proper
positioning and
attachment. It
easier for them
to breastfeed
and mother

53
 would relax.
This practice
will assist the
mother to build
confidence.

This practice
assist the
mother in
meeting her
psychological
and educational
need about
importance of
breastfeeding.

54
 ACTUAL PROBLEM # 3

ASSESSME DIAGNOSI PLANNING INTERVENTIO RATIONALE EVALUATIO

NT S N N

Subjective Disturbed After three INDEPENDENT It will prevent Short Term

Data: sleeping hours of Advised the the patient Goal met,
“Medyo patterns receiving patient to refrain from getting after
hindi lang related to nursing care, from consuming up to use the rendered
po ako environment the patient a lot of liquids restroom in nursing
makatulog al barrier by will be able to right before the middle of intervention,
ng maayos ambient get enough night. the night. the patient
sa ingay ng noise and sleep, which take her to
ibang mga unfamiliar will lessen Introduced To induce rest and
baby” setting irritation. calming relaxation and manifest
practices like distraction in -sleepy voice
Objective calming music. order to get after
Data: the body and sleeping.
Low enegy Prompted the mind ready for
Irritability patient to sleep.
Sleepy consume milk.
voice Casein tryptic
hydrolysate is
a milk
component
that relieves
stress and
enhances
sleep.

55
 ACTUAL PROBLEM # 4

ASSESSMEN DIAGNOSI PLANNIN INTERVENTION RATIONALE EVALUATIO

T S G N

Subjective Constipatio After 8 INDEPENDENT The patient After 8 hours

data: n related to hours of Encourage sitz will know how of nursing
The client surgical nursing bath before stools to take the intervention
stated procedure interventio if indicated to relax prescribed the goal was
“Nahihirapan as ns, the sphincter for medication met. As a
po ako evidenced patient will cleansing and when she’s result of the
dumumi, hindi by absence establish soothing effect to constipated. pain
pa ako of stool. or return to rectal area. medication,
nakakadumi normal The patient the patient
ngayong pattern of Instruct and will have a had
araw.” bowel encourage broad decreased
functioning balanced diet (e.g,, knowledge pain, relief,
. fruits, vegetables, about the and reached
whole grains) in bowel a bearable
diet and fiber techniques. level.
supplements.
To relieve
DEPENDENT discomfort in
Educate the the perineal
patient to take region and to
prescribed lessen the
medications to hemorrhoid
prevent pain.
constipation by
discharge.

56
 ACTUAL PROBLEM # 5

ASSESSME DIAGNOSI PLANNING INTERVENTION RATIONAL EVALUATIO

NT S E N

Subjective Fatigue Short term: INDEPENDENT The impact After 4 hours

data: related to after 4 hours Examined the of of receiving
“Pagod na sleep of receiving patient's capacity intervention effective
pagod po ako deprivation efficient to do tasks, taking selection nursing
at parang as nurse note of claims of assistance interventions,
wala akong evidenced intervention weakness, The patient
lakas para by s.The exhaustion, and Improve rest was able to
bumangon.” drowsiness patient will difficulty to minimize cope with
and lack of be able to completing tasks. the body's fatigue as
Objective energy. cope with oxygen shown by
data: weariness DEPENDENT demand and verbalization
The patient and Recommended the strain on of emotions
looked frail. enhance peaceful the heart of comfort.
activity environment; bed and lungs
Incapable of participation rest if stress is Within 2 days
doing certain indicated—need Maximizes of giving
movements Long-Term to monitor and oxygenation nursing
Objective: restrict visitors, for cellular intervention,
Spends the Within two phone calls, and absorption the patient
majority of days of unscheduled by was able to
her time in receiving disruptions increasing do simple
bed nurse As tolerated, raise lung activities of
treatments, the head of the expansion daily living
the patient bed.
will be able Although
to COLLABORATIV assistance
demonstrate E may be
an increase Gave/recommend required,
in activity ed assistance with self-esteem

57
tolerance by activities/ambulati is increased
performing on as needed, when the
simple allowing as much patient does
activities of as feasible things for
daily living. himself.

58
 POTENTIAL PROBLEM # 1

ASSES DIAGNOSIS PLANNING INTERVENTI RATIONALE EVALUATION

SMENT ON

Subject Risk for After 7 INDEPENDE INDEPENDENT: The GOAL

ive impaired hours of NT: Helps identify WAS MET after
Data: Parenting r/t nursing Note family problem areas and 7 hours of
“Ngayon unplanned intervention constellation; strengths to formulate nursing
, pregnancy , the for example, plans to change interventions,
nafi-feel as patient will two-parent, situation that is the patient was
ko po na evidenced be able to: single, currently creating able to:g
nanay by Verbalize extended difficulties for the
na verbalization awareness family, or parents. Recognized
talaga of “hindi po of individual child living ith individual risk
ako planado risk factors other relative, These maturational factors like her
ganon. yung such as crises bring changes age, finacial
Na pagbubuntis Verbalize grandparent. in the family that can status,
marami ko kaya feel realistic be stressful to unplanned
na ko rin na information Determine parents and the pregnancy, and
akong kulang pa and development family. Provides educational
responsi ako ng expectation al stage of direction forimproving level.
bilidad kaalaman s of the family parenting skills and
na sa pagiging parenting (e.g., new family interactions. Participated in
dapat magulang.” role baby, discussing role
gawin. adolescent, Parents with in realistic
Pero Demonstrat child leaving significant manner such
hindi po e behavior or returning impairments may as how will she
planado and lifestyle home) need more education able to adapt to
yung changes to and support. her new role as
pagbub reduce Assess Ineffective parenting a mother and
untis ko potential for parenting skill and unrealistic also as a
kaya developme level, taking expectations student.
feel ko nt of into account contribute to

59
 rin na problem or the problems of abuse Demonstrated
kulang reduce or individual’s and neglect. appropriate
pa ako eliminate intellectual, behavior and
ng effects of emotional, Demands of working lifestyle change
kaalama risk factors and physical long hurs, out of such as using
n sa strengths and town, multiple contraceptive
pagiging Identify weakness. responsibilities such like implant to
magulan own as working and avoid
g.” strengths, Note absence attending educational unwanted
individual from home classes will affect pregnancy.
Objecti needs, and setting or lack relationship between
ve method and of child parent and child and Identified own
Data: resources supervision ability to provide the strengths,
Age: 15 to meet by parent. care and nurturing needs, and
years them. necessary for method like
old COLLABOR children to grow and finding a
Single Demonstrat ATIVE: prosper. source of
3rd e Refer COLLABORATIVE: income that is
year appropriate adolescent A study indicated that appropriate to
high attachment parents for a comprehensive her situation
school and comprehensi psychoeducational like work from
parenting ve parenting class can home jobs so
behaviors. psychoeducat be effective in that sh can
ional changing parenting sustain her
parenting attitudes and beliefs baby’s needs.
class (Thomas & Looney,
2004) Demonstrated
appropriate
attachment and
parenting
behaviors.

60
 POTENTIAL PROBLEM # 2

ASSESSMEN DIAGNOSI PLANNING INTERVENTIO RATIONALE EVALUATI

T S N ON

Subjective Risk for After 8 hours INDEPENDENT INDEPENDENT: After 8

Data: ineffective of nursing : Client may not hours of
“Naiistress rin coping r/t intervention, Ascertain the understand nursing
po ako kasi situational the patient client’s situation, and intervention
halo halo na and will be able understanding being aware of , the GOAL
yung mga maturationa to: of the current these factors is WAS
nararamdama l crisis as situation and its necessary to PARTIALLY
n ko lalo na evidenced Assess the impact on life planning care MET. The
ngayon by current and work. and identifying patient was
kakapangana verbalizatio situation appropriate able to:
k ko lang.” n of accurately Active-listen interventions.
“Naiistress and identify the Reflected
Objective rin ako kasi Identify client’s Reflecting on her
Data: halo halo ineffective perceptions of client’s thoughts thoughts
Age: 15 years na yung coping what is can provide a and
old mga behaviors happening. forum for understand
nararamda and understanding perceptions
3rd year high man ko lalo consequenc Encourage perceptions in in relation
school na ngayon es verbalization of relation to reality to reality or
kakapanga fears and for planning care her current
nak ko Verbalize anxieties and and determining situation.
lang, awareness expression of accuracy of
minsan of own feelings of interventions Able to
naiiyak coping denial, needed. verbalized
nalang ako abilities depression, and her feeling
kung paano anger. Let the First time to the
rin yung Verbalize client know that mothers, student
kinabukasa feelings these are especially nurse but
n ng anak congruent normal adolescent tend with

61
ko.” with reactions. to keep their hesitation
behavior. feelings to and
Meet Assist the client themselves. limitation to
psychologic in the use of Verbalizing their her words.
al needs as diversion, emotions to
evidenced recreation, and health care
by relaxation provider can be
appropriate techniques. a therapeutic
expression way and
of feelings, COLLABORATI relationship for
identification VE: them.
of options, Emphasize the
and use of importance of Learning new
resources. follow up care. skills can be
helpful for
reducing stress
and will be
successful in the
future as the
client learns to
cope more
successfully.
COLLABORATI
VE:
Checkups verify
that regimen is
being followed
accurately and
that healing is
progressing to
promote a
satisfactory
outcome.

62
 POTENTIAL PROBLEM # 3

ASSESSM DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATION

ENT

Subjectiv Risk for After 2 days Encourage patient Determining THE GOAL
e Data: imbalanced of nursing participation in the kind, WAS MET
“Wala po nutrition less intervention, recording food quantity, and After 2 days of
akong than body the patient will intake using a pattern of nursing
gana requirement be able to: daily log. food or liquid intervention,
kumain, s related to intake is The patient
parang lagi inability to Verbalize and Document actual made easier was able to:
akong ingest or demonstrate weight using when the
busog. digest food the selection weighing scale; do patient or Demonstrated
Minsan or to absorb of foods or not estimate. caregiver meal choices
kumakain nutrients meals that will accurately that stopped
lang ako because of stop weight Provide records the weight loss
paunti-unti biologic, loss and for companionship intake as it and can
para kay psychologic, having during mealtime. happens express
baby at or economic satisfaction in because understanding
pag factors as food for daily Create and memory is verbally.
nakaramd evidenced eating. convince an insufficient.
am na ng by inviting dining The patient
pagkahina. verbalization Have weight environment. Patients may gained at least
” of “Wala po within 10% of Prepare meals in be unaware 10% of the
akong gana ideal body a pleasant setting of their actual ideal body
Objective kumain hindi weight. that is weight or weight.
Data: kagaya dati well-ventilated, weight loss
Poor na madami leisurely, and in due to The patient
muscle pa yung the company of estimating learned how
tone kaya kong kind people. weight. to avoid
kainin.” unhealthy
Low body During foods and
weight aggressive learned about

63
 nutritional nutritious,
Evidence support, healthy diets
of lack of patients can and having a
food. gain up to 0.5 good appetite.
lbs per day.
Variety of
unhealthy Attention to
foods the
social
aspects of
eating is
important in
both the
hospital and
home setting.

64
 POTENTIAL PROBLEM # 4

Assessment DIAGNOSI PLANNING INTERVENTION RATIONALE EVALUATIO

S N

Subjective Risk for Short Term: Independent: THE GOAL

To assess a
Data: Postpartum After 7 hours Advise the mother WAS
client's
“Wala po Depression of nursing to make time for PARTIALLY
coping
akong gana r/t lack of interventions, herself every day MET , After 7
abilities and
kumain, at support the patient to take a break hours of
evaluate her
parang system as will be able to from her routine therapeutic
ability to
palagi po evidenced explain the baby care. nursing
understand
akong by importance of interventions,
the present
kinakabahan, verbalizatio having a Encourage the the patient
situation.
madaming n of “Wala healthy diet mother to was able to:
bagay pa na po kasi for herself maintain contact Regular
akong alam yung and a healthy with her social interactions
sa pag magulang lifestyle for circle as they Expressed
with other
aalaga kay ko, maaga her child’s could act as a her feelings
adults or
baby.” pa po akong healthy source of support and
close friends
nabuntis at development. for her. insecurities
can help
Objective wala pang and can
prevent
Data: trabaho. finally
feelings of
Overall Inaasahan Long Term: Collaborative: evaluate her
loneliness.
feeling of ko lang po After 1 day, Assist the patient ability to
sadness yung kuya the patient in making plans Discussed understand
kong nag will recognize for her daily the realities the present
Extreme aalaga the value of activities, of parenting situation..
fatigue saakin.” taking time including her diet, and the fact
for herself to exercise routine, that it may be
Poor Eating boost her and sleep. exhausting. Performed

Habits self-esteem her activities

and make her of daily living
feel happier easily and

65
and more know the
fulfilled. significance of
socializing
with her close
friends and
family.

Recognized
the
importance of
counseling
and regularly
attends one.

66
 POTENTIAL PROBLEM # 5

ASSESSMEN DIAGNOSI PLANNING INTERVENTION RATIONALE EVALUATIO

T S N

Subjective Risk for Short Term: Independent: Helps to Goal was

Data: sleep After 5 hrs of Take note of identify her partially met
The mother deprivation nursing observations of sleeping after 5 hrs of
verbalized her postpartum interventions, sleep-wake patterns and nursing
problems as related to the patient behaviors. Take provides interventions,
she challenging will be able down notes on baseline data the patient
sometimes life to: the number of for evaluating was able to:
cannot sleep transitions hours the patient means to
at night. as Verbalize the is asleep. improve the Recognized
“Minsan po evidenced importance of patient’s the
talaga hindi by asking restrictions Evaluate the sleep. significance
ako “Ano po on caffeine, patient’s of having
makatulog, pwedeng alcohol, and knowledge on the Provides daily physical
kapag pinipilit gawin other cause of sleep guidelines or activity and
naman po kapag hindi stimulating problems and basis for the other risk
sumasakit ung ako substances potential relief evaluation of factors.
ulo ko.” nakakatulog from late measures to sleep
ng maayos evening facilitate deprivation. Identify the
Objective kahit tulog o meals, as it is treatment. behaviors
Data: hindi naman the reason to The patient and needs to
Lack of po disrupt sleep Observe and may have control
Energy kailangan ni patterns. evaluate the insights sleeping
baby timing or effects about the patterns.
Tired dumede.” Identify the of medications existing
health risk that can affect problems Determined
Unmotivated factors of sleep. (e.g., anxiety the potential
sleep or fear about positive effect
Irritable deprivation. Collaborative: a certain of 8hrs of
Advised the situation in sleep every

67
Long Term: patient to life). This night.
Within 2 days determine data will
of nursing patterns of sleep determine Evaluate the
interventions, in the past few appropriate effects of
the patient days such as the therapy. each
will be able amount, bedtime medication
to: routines, depth, Determining related to
length, positions, the following sleep
Promote aids, and other medication deprivation.
adequate interfering factors. schedules
physical that require
exercise attention may
activity during affect the
daytime to patient's
enhance sleeping
expenditure pattern,
of energy and especially in
release of the hospital
tension so setting.
that the
patient feels
ready for
sleep or rest.

Know to
manage
controllable
sleep-disrupti
ng factors
such as
noise, light,
and room
temperature.

68
 HEALTH PROMOTION # 1

ASSESS DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATION

MENT

Subjectiv Readiness Short term: Independent: Hand washing Short term:

e Data: for After 2 hours Teach the reduces the GOAL WAS
The enhanced of intervention patient to wash risk for MET after 2
patient self- health the patient hands often, infection hours of nursing
verbalized managemen would be able especially before interventions,
“Medyo t related to to and after Changing the client was
kumikirot the demonstrate toileting pads can able to
po yung postoperativ at least 3 reduce demonstrate at
tahi sakin e procedure ways on how Discuss with the irritation and least 3 ways on
pag (Right to prevent the patient why bacteria how to prevent
umiihi” mediolateral infection. changing pads build-up that infection.
Episiotomy) every 2-4 hrs can lead to
Pain scale as Long term: and proper infection. Long term:
8/10 evidenced After 3 days cleaning of the While keeping GOAL WAS
by surgical of intervention perineum area the perineum PARTIALLY
Objective wound the patient will important. area clean MET after 3
Data: be able to be can prevent days of nursing
Facial free from Educate the foul odor. intervention the
Grimace infection and patient about the patient was able
would be able following signs To inform the to be free from
to urinate with of infection; patient when infection and
minimal pain. redness, the would the patient
swelling and become verbalised a
increased pain. infected and pain scale of
when to seek 5/10 when
medical care. urinating.

69
 HEALTH PROMOTION # 2

ASSESSM DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATION

ENT

Subjective Readiness Short term Independent: This provides Goal met

Data: for enhanced goals: Assessed the information within 6 hours
The patient breastfeedin mother’s for of nursing
verbalized, g AEB After 4 hours desires/plan for developing a intervensions
“Gusto ko verbalizing of nursing feeding infant. plan of care AEB
po “Gusto ko intervention, verbalized
matutunan pong the client will Provided health To increase understanding
ang matutunan be able to: education about mothers' of proper
tamang ang tamang the benefits of knowledge breastfeeding
paraan paraan ng Understand breastfeeding and and skills, techniques
nang pagbbreastfe the proper breast milk: help them and benefits
pagbbreast ed.” way of view of breast milk,
feed para breastfeeding Student nurse breastfeeding “Nag-improve
mapakain and the explained that that as normal, na po yung
nang benefits of breastmilk and develop pagdede ni
maayos the contains positive baby, hindi na
yung baby breastmilk. antibodies that attitudes po ako gaano
ko. Paano help the baby fight toward nahihirapan
po ba ang Demonstrate off viruses and breastfeeding nung sinunod
tamang effective bacteria and . ko po yung
pagpapabr breastfeeding necessary tinuro niyo.
eastfeed?” behaviors nutrients for the To help the Aware na rin
baby's growth infant obtain po ako na
Objective Breastfeed including milk importante
Data: her infant vitamins, protein, effectively magbreastfee
(+) successfully and fat. The from the d hanggang 2
Eagerness with student nurse also breast. years old si
to enhance satisfactory mentioned babies baby, para
ability to who are breastfed There is an iwas sakit at

70
exclusively Long term exclusively for the increased lumakas
breastfeed goal: first 6 months, need for resistensya ni
without any maternal baby.”
Demonstrate formula, have energy,
wellness in fewer risk for protein, Exhibited
the illnesses. minerals, and effective
breastfeeding vitamins, as breastfeeding
process Provided well as behaviors
techniques to get increased fl AEB proper
a good latch: uid intake demonstration
during of
Encouraged lactation. breastfeeding
skin-to-skin and techniques,
eyet-to-eye Burping helps and the
contact and hold to get rid of acknowledge
the baby against some of the ment of
the chest while air that expectations
breastfeeding. babies tend of the
to swallow breastfeeding
Advised the during process.
mother to let the feeding. Not
baby lead while being burped Breastfed
supporting the often and infant
neck, shoulders, swallowing successfully
and hips with the too much air and
hands. can make a satisfactory
baby spit up AEB the
Advised mother or gassy. absence of
not to withdraw nipple
immediately her This provides soreness, the
nipples. practice and ability to
the distinguish
Provided opportunity to early infant
information about correct hunger cues,

71
 early infant misunderstan and the infant
feeding dings and is content
cues (e.g., rooting, add additional after
lip smacking, information to breastfeeding.
sucking on fi promote the
ngers/hand) optimal
versus the late experience
cue of crying. for
breastfeeding
Encouraged the .
mother to follow a
well-balanced diet
containing an
extra 500
calories/day,
continue her
prenatal vitamins,
and increase OFI
least 2,000 to
3,000 mL day.

Demonstrated to
the mother how to
properly position
the infant to burp.

Observed and
evaluated
mother's
return
demonstration

72
 HEALTH PROMOTION # 3

ASSESSM DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATION

ENT

Subjective Readiness Short term Independent: Independent: Goal partially

Data: for goal: Determined the Provides met within 1
The patient enhanced After 1 hour of client’s knowledge baseline for hour of
verbalized, nutrition nursing of current further nursing
“Ano po ba AEB asking intervention, nutritional needs. teaching and intervensions
mga “Ano po ba the client will interventions. AEB
pagkain mga pagkain be able to: Provided health verbalized
ang dapat ang dapat education about To increase understanding
kainin kainin Verbalize importance of mothers' of he
ngayong ngayong understanding proper nutrition knowledge importance of
nagbbreast nagbbreastf of proper especially during about proper proper
feed na eed na nutrition and her breastfeeding nutrition and nutrition
ako? ako?” her nutritional period: nutrional especially
Mahilig po needs. needs during during her
kasi ako sa Student nurse lactation. breastfeeding
gulay e, Explain the discussed that period, “Mas
may importance of breastfeeding There is an magiging
suggestion proper uses a lot of increased mapili na po
pa po ba nutrition energy and need for ako sa
kayong especially nutrients. It is maternal kakainin ko
dapat during her important to have energy, lalo na at
kainin?” breastfeeding well-balanced diet protein, nagpapadede
period. to meet extra minerals, and ako. Dahil
Objective nutrient needs vitamins, as kung anong
Data: Long term and the demands well as kinakain ko,
Consumes goal: of caring for a new increased parang ayon
adequate Demonstrate baby. Since fluid intake na rin kinakain
liquid mindfulness breastmilk is the during ni baby.
and behaviors best food for lactation. Kailangan ko

73
 Eat and appropiate to newborns and kumain ng
finish her maintain infants, eating . mga
meal on proper food rich in Collaborativ masusutansya
time nutrition calcium, e: ng pagkain
carbohydrates, Dietitian para maging
(+) Exhibit ability and protein will helps the healthy si
Eagerness to develop provide energy to patient in baby atsaka
to enhance nutritious support the regards of uminom
nutrition meal plan. growth and nutritional diet palagi ng
development of / meal plans. tubig para
the baby. maayos din
pagpproduce
Student nurse ng gatas.”
also explained the
nutritional needs
of lactating
mother, which
includes a
balance
diet that supplies
at least 1800 kcal
per day, with
moderate fat,
variety of dairy
products, fruits,
vegetables, and
whole grains.

Encouraged the
mother to
increase OFI least
2,000 to 3,000 mL
day to encourage
milk production.

74
 Dependent:
Referred to
physician
regarding
postpartum
vitamins and
minerals
supplements.

Collaborative:
Consulted a
dietician regarding
diet and nutrition
for postpartum
women.

75
 HEALTH PROMOTION # 4

ASSESS DIAGNOSI PLANNING INTERVENTIO RATIONALE EVALUATION

MENT S N

Subjectiv Readiness Short term: Determine the To determine Short term:

e Data: for After 1 hr of patient’s ability the patient’s GOAL WAS MET,
enhanced nursing to learn ability to after 1 hr of
No parenting as intervention understand the nursing
verbalizati evidenced the patient Discuss normal health intervention the
on by deficit will be to infant teaching. patient was able
knowledge understand characteristics to understand the
Objective about child the appropriate to Provide normal infant
Data: developmen development the infant's age. anticipatory characteristics
Patient t al milestones guidance about and was able to
education of a child. Encourage developmental verbalize the
al patient to changes during developmental
attainment Long term: participate in the first year of milestone of a
: Grade 9 After 3 days care behavior life. child during the
/ 3rd year of nursing such as putting first year of life.
high intervention on diapers, To promote
school. the patient proper familiarity with Long term:
will exhibit breastfeeding, behaviors and GOAL WAS MET,
Shows adequate and bathing. decrease after 3 days of
manifestat knowledge parental nursing
ions of about child anxiety and intervention the
eagerness development also to patient was able
and al enhance the to exhibit
willingnes milestones. parental feeling adequate
s to of contribution knowledge about
cooperate as newborn’s child
. primary developmental
caretaker/s milestones

76
 HEALTH PROMOTION # 5

ASSESSM DIAGNOSIS PLANNING INTERVENTION RATIONAL EVALUATION

ENT E

Subjectiv Readiness Short term: Determine the To Short term:

e Data: for After 30 patient’s ability determine GOAL WAS
The enhanced minutes of to learn the patient’s MET, after 30
patient knowledge nursing ability to minutes of
verbalized related to intervention Discuss the understand nursing
“Hindi po different the patient will different the health intervention the
ako aware methods of be able to methods of teaching. patient was able
sa mga contraceptiv verbalize contraceptives to verbalize
contracepti es as understanding (natural, This helps understanding of
ve bago evidenced of different artificial, and the patient different methods
ako mag by patient methods of permanent to of
buntis” verbalized contraceptive contraceptives) understand contraceptives.
“balak ko po and be
Objective mag pa - Long term: Include the aware of Long term:
Data: IUD” After 2 days family member other GOAL WAS
(+) of nursing in the teachings. methods of MET, after 2
Eagerness intervention contraceptio days on nursing
to learn the patient will n. intervention the
be able to patient was able
verbalize at The family is to verbalize more
least 3 the number than 3
contraceptive one contraceptives
s and influence in and was able to
understand the patient’s differentiate their
the difference compliance uses and
and importance of the
importance of verbalized
contraceptive contraceptive.
s.

77
 CHAPTER VI
NEONATAL ASSESSMENT
A. Anthropometric Data
Anthropometry is a critical aspect of assessing the nutritional status of children. Casadei and
Kiel (2022) characterized anthropometric measurements as quantitative, noninvasive body
measurements. Length, weight, and head circumference are widely used as markers of growth
and development in neonates. The anthropometric measurements of children reflect their
general health, dietary adequacy, and growth and development across time.

ANTHROPOMETRIC DATA

Weight 2840 grams The anthropometric data of the newborn

is appropriate for gestational age with a
Length 48 cm
birth weight of 2840 grams, length of 48

Head Circumference 33 cm cm, head circumference of 33 cm, chest

Chest Circumference
Abdominal Circumference
circumference of 31 cm, and abdominal
31 cm circumference of 30 cm. These results
indicate the overall health of the infant,
30 cm
which is healthy and normal.

CLASSIFICATION WEIGHT LENGTH HEAD CIRCUMFERENCE

Large for Gestational Age (LGA)

(>90th percentile)

Appropriate for Gestational Age X X X

(AGA)
(10th to 90th percentile)

Small for Gestational Age (SGA)

(<10th percentile)

Place an “X” in the appropriate box (LGA, AGA, and SGA) for weight, length, and head circumference.

78
B. Apgar Scoring
The medical encyclopedia Medlineplus defined apgar score as a rapid test performed on a
baby between 1 and 5 minutes after birth. The baby's tolerance for the birthing process is
determined by the 1-minute score. The 5-minute score informs the doctor about how well the
baby is doing outside of the mother's womb. In exceptional circumstances, the test will be
performed 10 minutes after birth.

Criteria Assess 0 1 2 Points

Pulse Cardiac rate Absent <100 >100 2

Respiration Cry Absent Weak, slow, Strong, 2

irregular regular

Activity Muscle tone Limp, floppy Some flexion Well 2

tone flexed-fetal
position

Grimace CNS, response No response Some Gagging, 2

to stimulus, grimace crying,
reflex irritability sneezing, pull
away from
the stimulus

Appearance Color Pale/blue all Pink body, Pink/Red all 1

over blue over
extremities

Score 1 min: 9 5 mins: 9

Analysis:
Upon apgar assessment, the newborn has a vigorous cry, a heart rate of 120 beats per
minute, active muscle tone, and blue hands and feet, indicating acrocyanosis. Acrocyanosis is
common in babies as long as there is no cyanosis in the core region of the body (Bretz, 2021).
According to Saint Luke’s Health System, the baby's hands and feet are blue when they have
acrocyanosis. This happens frequently soon after birth. It affects the majority of neonates during

79
the first few hours of life and occurs as a result of blood and oxygen being sent toward the body's
most vital organs such as the brain, lungs, and kidneys instead of the hands and feet. The higher
the score, the better the baby's postnatal health. The apgar score during the first minute is 9,
which is the same as the 5 minute score. A score of 9 is considered normal and indicates that
the newborn is in good health.

Vital Signs
Date: January 7, 2023 Time: 6:27 A.M.

Length Weight Temperature Pulse Rate Respiratory Rate

48 cm 2840 g 36.9 °C 149 bpm 48 bpm

Date: January 9, 2023 Time: 2:21 P.M.

Length Weight Temperature Pulse Rate Respiratory Rate

48 cm 2840 g 36.5 °C 143 bpm 44 bpm

C. Review of System Physical Examination

The initial inspection within the first 24 hours of birth is crucial in establishing infants' general
well-being and detecting any red flags that may necessitate additional evaluation.

General Appearance
Newborn is alert, pinkish, and has an active reflex. Respiration are normal as evidenced by 44
breaths per minute. Pulse rate was within normal, 143 beats per minute. No signs of respiratory
distress include tachypnea, nasal flaring, grunting, retractions, and cyanosis. Temperature is
warm to touch. No significant abnormalities are noted.

Physical Assessment
Date: January 9, 2023 Time: 3:28 P.M.

System Normal Findings Findings Analysis

Skin Milia are tiny, white, Skin is pinkish, dry, According to

bumps on a and slightly peeling. Raising Children

80
 newborn's nose, Milia is present at the Network (2021),
cheeks, chin and bridge of the nose. milia are very
forehead. Milia form common and it
from oil glands and does not need any
disappear on their treatment. Milia
own. are tiny lumps or
blisters that
sometimes come
up on babies’
faces soon after
birth. They
happen when the
sweat glands get
blocked. The
glands get
blocked because
they aren’t yet
fully developed.

Head, Face, and The head should be Fontanels feels soft According to Mayo
Neck symmetrical. The and flat. No signs of Clinic (2022),
fontanelles should be retraction and babies are born
soft and flat. bulging. Head with soft areas on
circumference is their heads called
Eyes - Movement adequate for fontanels. The
usually gestational age. Hair skull bones in the
uncoordinated. is thin, soft, and soft spots haven't
Strabismus or black. yet grown
crossed eyed or together. The soft
“Doll’s eye” reflex spots allow a
Eyes - slightly open
baby's relatively
and pupils are black.
Ears - The newborn’s large head to
The cornea appear
external ear is not yet move through the
round and
fully formed, and the narrow birth canal.
proportionate in size.

81
 top part of the
external ear should Ears - pinna is Their eyes are
be on a line drawn smooth and it recoils sensitive to bright
from the inner when pinched. The light, so they're
canthus to the outer top of the external ear more likely to
canthus of the eye is in line with the open their eyes in
and back across the inner canthus to the low light.
side of the head. outer canthus of the Sometimes the

eye. baby's eyes cross

Nose - Newborn's or drift outward
nose should be (go "wall-eyed").
Nose - no signs of
located in the middle This is normal
discomfort or distress
third of the baby's until the baby's
in breathing. The
face. Both nares vision improves
nose is patent and
should be patent. and eye muscles
appropriately small in
strengthen (Kids
size.
Mouth - The inside of Health, 2022).
the mouth should be
pink, moist and the Mouth - palate are The same goes
mucous membranes intact. Lips are for noses,
intact. completely pink. cartilage can be
Mouth is open evenly soft, and a baby’s
Neck - Short and when crying. nose can get a bit
covered with folds of squished during
tissue Neck - neck is short delivery. Again, all
and creased skin should return to
folds are visible. Hed normal within the
lag is present. first week (Having
A Baby, 2012).

Normally the neck

looks short in
newborns
because it tends

82
 to get lost in the
chubby cheeks
and folds of skin
(Kids Health,
2018).

Chest and Chest - Shape should Chest - appears According to Kids

Abdomen be cylindrical. head symmetrical side to Health (2022),
circumference slightly side. Chest Also, both male
exceeds that of the circumference is and female
chest. Normally, the smaller than the head newborns can
newborn's respiratory but appropriate for have breast
rate is 30 to 60 gestational age. enlargement. This
breaths per minute. Clavicles are bilateral is due to the
Swollen breasts are straight. Respirations female hormone
present during the are rapid but normal. estrogen passed
first week of life in No signs of distress. to the fetus from
many girl and boy the mother during
babies. pregnancy The
Abdomen - soft and
breast
slightly protuberant.
Abdomen - It should enlargement
No abdominal
be gently rounded almost always
masses and hernias
and symmetrical. The disappears during
noted. Cord is plump
abdomen of a the first few
and pale yellow in
full-term infant is weeks.
appearance.
generally 'plump'. In It's normal for a
other words, it should baby's abdomen
not be scaphoid (belly) to appear
(concave). somewhat full and
rounded. When
your baby cries or
strains, you may
also note that the
skin over the

83
 central area of the
abdomen may
protrude between
the strips of
muscle tissue
making up the
abdominal wall on
either side. This
almost always
disappears during
the next several
months as a baby
grows.

Anogenital Anus - Patent and Anus - present, According to

not ectopic. No patent and not Amerstorfer
fistulas present. covered by a (2022), the anus
membrane. lies in a normal
Genitalia - the labia position along the
majora are full, and perineum between
Genitalia - labia
the labia minora are the fourchette
majora cover clitoris
thickened. The (girls). It is of
and labia minora.
hymenal folds appear normal caliber and
thick and redundant. circumferentially
The vaginal mucosa surrounded by the
is pink and moist. sphincter muscle
complex.

In girls, the outer

lips of the vagina
(labia majora) may
appear puffy at
birth. The skin of
the labia may be

84
 either smooth or
somewhat
wrinkled.
Sometimes, a
small piece of pink
tissue may
protrude between
the labia — this is
a hymenal tag and
it's of no
significance; it will
eventually recede
into the labia as
the genitals grow
(Kids Health,
2022).

Back and Extremities - Feet Extremities - The According to

Extremities and legs are arms and legs Shimkaveg
symmetric in size, appears short. Hands (2020), babies
shape, and are plumped and make fists
movement. Warm and clenched into fists. because they
mobile, with adequate Fingernails are soft have a reflex
capillary refill. All and smooth. known as the
pulses should be Complete fingers and palmar grasp. You
strong and equal no sign of polydactyl can elicit it by
bilaterally. or syndactyl. Unusual gently pushing on
spacing of toes is not the palm of a
Back - Scapulae present. The sole of baby’s hand with
(shoulder blades) and the feet appears flat. your thumb, and
buttocks should be he or she will curl
symmetrical. The skin the fingers of that
Back - appears flat
should be intact along hand around it in
and symmetrical.
the length of the response. The

85
 spine. palmar grasp is a
primitive,
prehensile,
involuntary
response to a
mechanical
stimulus present
in a newborn. It
has to do with the
developing brain
and its system of
nerves and fibers
including the
spine.

D. Prophylaxis & Vaccines

Date Ordered Medications Purpose

January 07, ERYTHROMYCIN EYE Erythromycin belongs to the family of

2023 OINTMENT medicines called antibiotics.
9:00 a.m. OU Erythromycin ophthalmic
preparations are used to treat
infections of the eye. They also may
be used to prevent certain eye
infections of newborn babies, such
as neonatal conjunctivitis and
ophthalmia neonatorum. They may
be used with other medicines for
some eye infections (Mayo Clinic,
2022).

January 07, VITAMIN K Vitamin K is needed to form blood

2023 1 mg IM clots and to stop bleeding. Babies
9:00 a.m. are born with very small amounts of

86
 vitamin K stored in their bodies,
which can lead to a serious bleeding
problem known as vitamin K
deficiency bleeding (VKDB). VKDB
can lead to brain damage and death.
Bleeding from vitamin K deficiency is
a risk during the first 6 months of life.
VKDB is preventable with a one-time
intramuscular shot of vitamin K at
birth (Center for Disease Control and
Prevention, 2022).

January 07, HEPA B VACCINE ​Healthy newborns should receive

2023 0..5 ml IM their first dose of hepatitis B vaccine
9:00 a.m. within the first 24 hours of birth to
improve their protection against the
enduring and potentially fatal
disease, according to an updated
policy statement from the (American
Academy of Pediatrics, 2017).

January 07, BCG VACCINE The Bacillus Calmette–Guérin (BCG)

2023 0.5 ml ID vaccine is used to prevent
9:00 a.m. tuberculosis (TB). The BCG vaccine
is named after Dr Albert Calmette
and Dr Camille Guerin, who
developed the vaccine from a germ
called Mycobacterium bovis, which is
similar to TB. BCG is a live vaccine
that has been processed so that it is
not harmful to humans (Royal
Children's Hospital Melbourne,
2018).

87
 Essential Intrapartum and Newborn Care Checklist

Instruction: To be accomplished by the nurse in charge of the patient. Cross out the numbered blocks
of the items adequately carried out. Encircle the numbered blocks of the items not done.

1 Immediately dried

2 Skin-to-skin contact

3 Properly timed cord clamping

4 Non-separation from the mother and early latching on

5 Erythromycin eye ointment applied OU at 1/7/23

6 Vitamin K 1 mg given deep IM on left thigh at 1/7/23

7 Hepatitis B Vaccine o.5 ml given IM on right thigh at 1/7/23

8 BCG vaccine 0.05 ml given ID on right deltoid at 1/7/23

9 Initial bathing done after 6th hour of life at 1/7/23

10 Newborn Screening done after 24th hour of life at 1/8/23

Left Ear - Pass / Right Ear - Pass

11 Critical congenital heart disease screening at 1/8/23

Right Hand - Pass / Right Foot - Pass

12 Roomed in with mother at 1/7/23

13 Advised mother regarding proper breast attachment and importance of exclusive breastfeeding

14 Advised mother regarding daily newborn care

15 Vital signs monitored every 15-30 minutes until stable then decreased to hourly monitoring

16 Vital signs prior to rooming in/discharge:

Temperature: 36.8 °C Heart Rate: 145 bpm Respiratory Rate: 49 cpm Oxygen Saturation:
97%

88
E. Nursing Care Plan for Newborn

ASSESSME DIAGNOSI PLANNING INTERVENTION RATIONALE EVALUATI

NT S ON

Subjective Risk for Short term Independent: The newborn Goal met
data: hypothermi goals: Keep the may lose heat AEB
Mother a r/t newborn dry and quickly as a maintained
asked, inadequate Infant will tightly wrapped result of wet stable body
“Nag-aalala insulating remain free in a blanket: skin. The baby temperatur
po ako baka subcutaneo of should be e of 36.5°C
lamigin yung us fat and complication Demonstrated quickly dried and
baby ko, environmen s that to mother the and swaddled. respirations
medyo tal precipitate proper way of of 45 bpm
malamig po concerns hypothermia swaddling the Newborns by the end
kasi yung specifically and cold baby to keep her require barriers of the shift.
aircon. Okay cold room throughout warm when not to prevent heat No signs of
na po ba temperatur her stay in held by her or loss. Vigorous respiratory
yung blanket e the hospital the father. rewarming distress,
niya para AEB: while regularly infant’s
hindi siya Keep infant’ monitoring color is
lamigin?” Vital signs head, hands and temperature is pink and
within feet covered: needed. skin is
Objective normal Secured the Blankets, warm to
data: range cover of the isolettes, and touch.
Full term birth head and radiant
Skin color is T:36.4–37.3° extremities. warmers can
pink C be utilized.
Respirations PR: 120-140 Encouraged Encourage
are unlabored bpm mother to hold skin-to-skin
Temperature RR: 30-60 baby for skin to contact of the
is within rpm skin contact: newborn with
normal: 36.2 the mother.
°C Long term Placed the baby
No sign of goal: on mother’s

89
distress abdomen for The newborn
Absence of skin to skin has not
respiratory contact for 1 to 2 acquired extra
distress hours. adipose tissue
to act as
Provided a warm insulation and
environment: is not able to
shiver to warm
Adjusted the the body
room naturally.
temperature. Therefore,
newborns
Observe for cannot regulate
signs of cold their
distress by temperature.
observing color,
temperature, According to
and Stanford
Respirations: Medicine
Children’s
Temperature are Health,
taken every newborns can
hour. lose heat
nearly 4 times
quicker than an
adult. If the
room
temperature is
too low, even
healthy,
full-term
newborns may
struggle to stay
warm.

90
ASSESSM DIAGNOSI PLANNING INTERVENTION RATIONALE EVALUATION
ENT S

Subjective Interrupted Short term: Independent Independent Short term:

Data: breastfeedi After 6 Monitor baby’s Serve as a GOAL WAS
“Tinatry ko ng r/t hours of vital signs baseline for MET, after 6
magpaded ineffective nursing determining hours of
e kay baby latching as intervention Provide a calm whether any nursing
kaso evidenced the baby will and quite changes can be intervention
nahihirapan by nipple latch to the environment used to the baby was
siya soreness. nipple while feeding. determine the able to latch
dumede e” properly condition of the on to the
and nipple Educate the infant. breast and
Objective soreness mother on how improve her
Data: would to catch a good To avoid any intake and
Sore decrease. latch and how to distraction that mother
nipples help the baby can interfere verbalized
Inability to Long term: unlatch. with feeding. reduced pain
latch on to After 2 days related to
breast of nursing Provide ice pack Encourage nipple
correctly intervention for breast (not proper feeding soreness.
Unsustaine the mother’s for the nipple) technique and
d suckling nipple for at least 15 - latching against Long term:
at the soreness 20 minutes for 4 aspiration and GOAL WAS
breast will no times a day. by helping the PARTIALLY
longer be baby to unlatch MET, after 2
present and Collaborative properly it can days of
baby can Refer to reduce the nursing
latch to the community engorgement interventions
nipple and resources and provide the baby was
improve (public health comfort for the able to
intake. nurse) mother improve her
intake and

91
 This helps was able to
reduce the achieve a
swelling. good latch on
the breast.
Collaborative The mother
verbalized that
Even after there is still
discharge minimal pain
mother can still related to
receive proper nipple
care and soreness
recommendatio
ns needed.

92
ASSESSME DIAGNOSI PLANNIN INTERVENTIO RATIONALE EVALUATIO
NT S G N N

Subjective Ineffective After 12 INDEPENDEN Serves as The baby's

Data: infant hours of T baseline improvement
“Binebreast feeding nursing Monitor baby’s information; any in intake after
feed ko siya pattern interventio vital signs. changes will help 12 hours of
every 3-4 related to n the baby indicate the nursing
hours, pero parent’s will Provide a calm baby’s conditions intervention
parang lack of improve in and quiet, is partially
nahihirapan knowledge her intake non-stimulating To obscure any met because
siya dumede” regarding and no environment distractions that she can
-verbalized the infant’s signs and while feeding. may interfere with suckle
by the feeding symptoms the feeding. properly and
infant’s pattern. of Record and enough;
mother dehydratio monitor the To find an easier there are also
n will be baby’s progress and more no outward
Objective noted. with her sufficient feeding signs or
Data: feedings. pattern suitable symptoms of
Inability of Additionall DEPENDENT for the infant. dehydration.
the infant to y, the Explain to the
suck parents parents the Promote correct Additionally,
effectively will be importance of feeding procedure parents are
(poor sucking more proper nutrition and prevent now more
reflex) knowledge among infants aspiration and aware of the
able on by following the regurgitation. typical eating
Inability to the infant’s prescribed habits of
coordinate feeding feeding pattern. To increase the infants and
suckling and pattern COLLABORAT parents are taking
swallowing. and follow IVE understanding on extra care to
an Teach the the nutritional adhere to the
appropriat parents the needs of their proper
e feeding correct infant and feeding

93
 pattern positioning promote strict schedule.
suitable during feeding compliance to the
for infant. and ensure that correct feeding
the baby is fully patterns.
awake.

94
ASSESSME DIAGNOSI PLANNING INTERVENTION RATIONALE EVALUATIO
NT S N

Subjective Risk for After 1 day of Monitor the risk Serves as After a day of
Data: infection nursing factors for the baseline nursing
Mother related intervention, occurrence of information interventions
asked, “Ano open the infection. to know the the goal was
po bang umbilical mother will risks of met. The
p’wede kong stump be able to Advised the infection. mother can
gawin sa give proper mother to assess give a proper
pusod niya? cord care for and document To document cleaning
Hindi ko po the baby by: skin condition findings method in the
kasi alam around the base related to remaining
linisan.” Giving the of the umbilical skin umbilical
proper and cord. conditions cord.
Objective hygienic around the
Data: method of Monitor signs umbilical The mother
Cord is stump cleaning the and symptoms of cord. has a better
and pale remaining fever understandin
yellow in umbilical Serves as g and has
appearance. cord. Teach the mother baseline data broad
of proper to monitor knowledge
Giving the application of other for infection
mother a betadine and symptoms. in the
broad alcohol on the tip umbilical
knowledge in of the cord. To avoid any cord.
cleaning the infections in
umbilical the umbilical
cord to avoid cord and for
any hygiene.
infectious
disease.

95
ASSESSME DIAGNOSI PLANNIN INTERVENTION RATIONALE EVALUATIO
NT S G N

Subjective Disturbed After 3 Monitor the area and To have a After 3 hours
Data: sensory hours of secure a quiet good sleep, of nursing
The mother perception nursing environment. and lots of interventions
verbalized related to interventio time to rest. It the goal was
of “Lagi po noxious ns will be Advised the mother will help the partially met,
siyang stimuli and able to to minimize the noise baby to stay as the baby
naalimpung noisy prevent at their house. calm while can sleep
atan at iiyak environme the noisy sleeping and comfortably
nalang po nt. environme Encourage the to avoid and show no
siya ng nt. mother to play or use crying due to signs of
sobra. calming sounds that discomfort. distress such
Siguro na will help to relax the as extremely
iirita siya sa baby while sleeping. To prevent crying, and
mga ingay the baby irritability.
sa paligid.” 4. Avoid crowded from distress,
areas. and to avoid
Objective disturbance
Data: in sleeping.
Crying

Signs of
distress

96
 CHAPTER VII
DISCHARGE PLAN

A. Medications
● Advised the patient to continue the prescribed home medication such as Acetaminophen
325/650 mf PO q4hr and Naproxen 500 mg 2x a day, in the morning and evening.
● Advised the relative and the patient to monitor blood pressure and pulse, and report early
signs of overdosage such as salivation, sweating, flushing, abdominal cramps,

B. Environment
● Ensure the cleanliness in home to maintain the low risk of infection .
● Keep the room well ventilated for comfort, and rest to have enough sleep for better
recovery.
● To avoid incidents like slipping and falling in the dark or falling in bed, make sure your
home has enough illumination, especially at night.
● Keep the surrounding quiet for relaxation as part of recovery and healing.

C. Treatment
● Explained to the patient of continuing home medications as prescribed by the doctors.
● Advised to wear a well-fitting bra, nurse the baby as frequently as possible, and make
sure that the baby is latched properly to avoid sore and cracked nipples.

D. Health Teaching
● Advised the relative and the patient to monitor blood pressure, pulse and temperature.
● Advised the relative to monitor input and output.
● Advised the patient to use sanitary pads to absorb vaginal bleeding or discharge. Do not
douche or use tampons.
● Encourage the patient and relative to practice proper hygiene to avoid infection.
● Advised the relatives of the patient to assist the patient in doing some activities as
needed to prevent further injury.
● Encourage the patient to have adequate sleep to have enough rest.

97
E. Observable S/Sx
● Monitor if the patient is having an infection.
● Observe hypogastric pain and Vaginal discharge.

F. Diet
● Advised the patient to eat healthy foods such as vegetables, fruits, and whole-grain
foods. Foods rich in calcium, vitamins and minerals are also suitable for a healthy diet.
● Informed the patient that it is necessary to take more fluids for breastfeeding. Drink more
water and eat more soup to maintain the milk supply.
● Maintain breastfeeding for the baby's first six months to ensure the best possible growth,
development, and health and lower the baby's risk for infections, disease, and respiratory
allergies.

G. Spirituality
● Maintains effective communication between family members or other relations in order to
feel comforted and inspired.
● For a sense of connection, allow self to be open in any kind of conversation for emotional
support and an optimistic attitude.

98
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https://my.clevelandclinic.org/health/symptoms/23114-blurry-vision-pregnancy#:~:text=Having%20

blurry%20vision%20can%20be

Casadei, K., & Kiel, J. (2019, March 24). Anthropometric Measurement. Retrieved from Nih.gov website:

https://www.ncbi.nlm.nih.gov/books/NBK537315/

centralle medical. (2018, October 8). Clinical Microscopy. Retrieved from Centralle Medical | Accessible

Laboratory and Diagnostics Services website:

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ms%20scientific

Cleveland Clinic. (2022, January 19). High White Blood Cell Count: Test Details & Results. Retrieved from

Cleveland Clinic website:

https://my.clevelandclinic.org/health/diagnostics/17704-high-white-blood-cell-count

Eren, C. (2019). An analysis on HBsAg, Anti-HCV, Anti-HIV½ and VDRL test results in blood donors

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https://doi.org/10.1371/journal.pone.0219709

Fasting Blood Sugar: Screening Test for Diabetes. (n.d.). Retrieved from Cleveland Clinic website:

https://my.clevelandclinic.org/health/diagnostics/21952-fasting-blood-sugar

Madormo, RN, MPH, C. (2022, July 19). An Overview of Neutrophils and a High White Blood Cell Count

During Pregnancy. Retrieved from Verywell Health website:

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