NORMAL SPONTANEOUS DELIVERY; G2P2; PREGNANCY UTERINE DELIVERED

LIVE TERM BABY GIRL; CEPHALIC IN PRESENTATION

Maternal and Child Nursing Assessment

Presented to the Faculty of School of Nursing

St. Jude College Dasmariñas Inc., Cavite

Presented by:

Bornel, Lolita Shaira S.

Bueno, Janelle M.

Contreras, Kyle Kenneth G.

Faa, Darren Lloyd N.

Rai, Vijay Rishann G.

Tutol, Ivan C.

Level 2- BS Nursing (2P RLE)

Presented to:

Ms. Brigene B. Tabago, RN, MAN

Mr. Anthony Ryan C. Quintos, RN

Ms. Bernadette J. Mata, RN, RM, MANc

Faculty

Batch 2025
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TABLE OF CONTENTS

I. INTRODUCTION………………………………………………………………….... 4-8

A. Background of the study ………………………………………………………………….. 4

B. Biographical Data………………………………………………………………………….. 6

C. Genogram………………………………………………………………………………….. 7

D. History of Past Illness……………………………………………………………………... 8

E. History of Present Illness………………………………………………………………….. 8

II. GENERAL ASSESSMENT………………………………………………………… 9-25

A. Vital Signs………………………………………………………………………………… 9

B. Review of System - Physical Examination……………………………………………….. 9

C. Gordon’s Functional Assessment (Before, During and After Pregnancy)……………….. 17

D. Diagnostic and Laboratory Findings……………………………………………………... 23

III. ANATOMY AND PHYSIOLOGY……………………………………………… 26-32

IV. DRUG STUDY……………………………………………………………………. 33-37

V. NURSING CARE PLAN………………………………………………………….. 38-61

A. Prioritization……………………………………………………………………………… 38

B. Actual Problems…………………………………………………………………………... 44

C. Risk/Potential Problems……………………………………………………………….….. 51

D. Forseeable Problem…………………….....................………………………………..…... 56

VI. NEONATAL ASSESSMENT……………………………………………………. 62-71

A. Anthropometric Data………………………………………………………………….….. 62

B. APGAR Scoring………………………………………………………………………....... 62

C. Review of System Physical Examination………………………………………………..... 63

D. Other: Medication, Diagnostic Tests (Include only if present)…………………………....

E. Nursing Care Plan………………………………………………………………………..... 66

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VII. DISCHARGE PLAN…………………………………………………………….. 72-74

A. Health Teachings………………………………………………………………………....... 72

B. Anticipatory Guidance and Teachings………………………………………………........... 73

C. Spirituality………………………………………………………………………………...... 73

D. Medication………………………………………………………………………………...... 74

E. Incision Care………………………………………………………………………………... 74

F. Nutrition and Diet………………………………………………………………………....... 75

G. Exercise…………………………………………………………………………………...... 75

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 I. INTRODUCTION

A. Background of the study

Intrauterine pregnancy is a complex medical condition in which a fertilized egg is implanted in the

uterus and starts to develop within it. The only way pregnancy is sustainable is when it takes place inside

the uterus.

A pregnancy that develops anywhere else within a female reproductive tract such as the cervix,

fallopian tubes, or ovary is termed as Ectopic Pregnancy. They are often short-lived and tend to end with

abortion or a miscarriage. It is possible to confirm an intrauterine pregnancy with the help of certain tests.

Ultrasound is one of the most common and widely used tests for confirming an intrauterine pregnancy.

During an intrauterine pregnancy, a yolk sac develops in the uterus. This visibility of a yolk sac is most

prominent during 5.5 weeks of pregnancy. It is possible to verify an intrauterine pregnancy after the

development of an embryo with the help of an ultrasound. Another way of confirming an intrauterine

pregnancy is by examining fetal heart activity. The fetal heart activity is visible after 6 weeks of

pregnancy. Fetus’ heart rate tends to increase after every week and the average heart rate fluctuates

between 100 to 120 per minute.

According to Sharma S, Sidhu H and Kaur S. (2016) The present study consisted of 250 cases of

intrauterine fetal death or stillbirths which occurred during the study period. A total of 6942 deliveries

were conducted during this study period. The stillbirth rate was 36 per 1000 births. Of 250, 118 (47.2%)

were premature and 132 (52.8%) were mature. One hundred and eight-seven were fresh stillbirths and 63

were macerated. Two hundred and twenty mothers (88%) were immunized with tetanus toxoid and 30

(12%) were unimmunized. Only 28 (11.2%) were booked and supervised deliveries whereas 222 (88.8%)

were unbooked. Fifty-eight percent patients were from rural areas and 42% were from urban areas. About

71.2% were from low-income group, 17.2% were from middle-income group and 11.2% from high-

income group.

Patient M.P, a patient handled by student nurses last January 17, 2023, was interviewed to gain

information for the study. Patient M.P, a 28-year-old female, was admitted to Pagamutan ng Dasmariñas

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last January 16, 2023, at 4:47 PM with a chief complain of labor pain. Upon assessment, the patient had

normal blood pressure (110/80mmHg) with pulse rate 78 bpm and respiratory rate of 19 bpm. The patient

had admitting diagnosis G2 P1 (2001) PU 38 4/7 days AOG CIL.

Intrauterine pregnancy is usually diagnosed by a positive pregnancy test and demonstration of a

gestational sac in the uterus. The earliest an intrauterine gestational sac can be seen by a transvaginal scan

is 4-5 weeks' gestation (2-3 weeks embryo). Sometimes, early pregnancy problems create confusions

because of uncertainty about the site of the pregnancy, leading to further investigations and interventions.

These often increase patient’s anxiety and the cost. With the advent of expectant and medical treatment

of ectopic pregnancy, an early confirmation of the site of pregnancy has become more relevant. Color

Doppler has been used to investigate uteroplacental circulation in early pregnancy and early pregnancy

problems. It might be worthwhile to investigate the potential of color Doppler to locate very early

changes that are associated with intrauterine pregnancies. If it were successful, it may be very useful in

managing early pregnancy problems. (Paul S. 2016).

The patient underwent to NSD or Normal Spontaneous Delivery. According to Debra Rose

Wilson (2017) Vaginal delivery is the method of childbirth most health experts recommend for women

whose babies have reached full term. Compared to other methods of childbirth, such as a cesarean

delivery and induced labor, it’s the simplest kind of delivery process. A spontaneous vaginal delivery is a

vaginal delivery that happens on its own, without requiring doctors to use tools to help pull the baby out.

This occurs after a pregnant woman goes through labor. Labor opens, or dilates, her cervix to at least 10

centimeters.

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 B. Biographical Data

PATIENT’S DATA:

Name: M.P

Age: 28

Address: Brgy. San Jose Dasmariñas Cavite

Date of birth: 06/03/1994

Religion: Roman Catholic

Civil Status: Married

LMP: 04/21/2022

Date and Time admitted: January 16, 2023, at 4:47 PM

EDD: 01/26/2023

Chief of Complaint: Lower back pain, Radiating to lower portion of abdomen.

Admitting Diagnosis: G2 P1 PU 38 WEEKS AOG CIL

Final Diagnosis: Normal Spontaneous Delivery; G2P2; Pregnancy uterine delivered live term baby girl;

Cephalic in presentation; APGAR score 9: BW: 3.46 kg

Source of Information:

a.) Primary information: Patient (M.P)

b.) Secondary information: NONE

c.) Tertiary information: NONE

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 C. GENOGRAM

Analysis:

Patient M.P is 28 years old, female, married to F.P 30 years old they have a son named A.P 4-year-old

children, and they have a newborn born baby, baby P.P. M.P only have one sibling, which is A.B 25 years

old, M.P is the oldest. Their Mother and Father are both deceased. The mother and father of patient M.P’s

husband is also deceased. Genetic diseases are diseases in which inherited genes predispose to increased risk.

The genetic disorders associated with cancer often result from an alteration or mutation in a single gene. The

diseases range from rare dominant cancer family syndrome to familial tendencies in which low-penetrance

genes may interact with other genes or environmental factors to induce cancer. Research may involve

clinical, epidemiologic, and laboratory studies of persons, families, and populations at high risk of these

disorders (Ormond, KE 2015). The diagram shows that there are no present illnesses to their family, and they

don’t have any hereditary diseases.

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 D. HISTORY OF PAST ILLNESS

  Patient M.P has had no major illnesses in the past. In the past years, she only

experienced mild fever, cough, and colds but was never hospitalized. She was diagnosed with

tonsillitis last October 2018 and was treated with antibiotics prescribed by her doctor. She stated

that she has completed her childhood vaccines. She only has one previous surgery which is from

her first pregnancy. Her first pregnancy was at 39 weeks 2/7 days AOG and she had normal

spontaneous delivery.

E. HISTORY OF PRESENT ILLNESS

Patient M.P. is a 28-year-old female with G2 P2 and has no present illness. After

delivery, the patient's blood pressure had elevated and was measured to be 150/100. This is

her  2nd pregnancy. Both of her children were delivered at the Pagamutan ng Dasma. Patient

M.P. stated that her family has no present illness including her parents. Patient M.P. 1st

pregnancy which was at 39 weeks 2/7 days did not have any difficulties, however, she stated

that this 2nd pregnancy was quite painful. But, no complications were found on both Patient

M.P and her baby during her delivery.

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 II. GENERAL ASSESSMENT

A. VITAL SIGNS

VITAL SIGNS DURING ASSESSMENT

TEMPERATURE 36.4 °C NORMAL

PULSE RATE 81 BEATS/MIN NORMAL

RESPIRATORY RATE 19 BREATHS/MIN NORMAL

O2 SATURATION 99% NORMAL

BLOOD PRESSURE 110/80 NORMAL

PAIN LEG (7/10) MODERATE PAIN

EPISIOTOMY (6/10)

B.
B. Review of System
POST OPERATIVE ASSESSMENT

SYSTEM FINDINGS NORMAL FINDINGS ANALYSIS

SKIN Patient’s skin has stretch Pregnancy brings about a According to Dan

marks, scar, Linea nigra, lot of changes, but you Brennan, MD, when

and the skins are dry. may be surprised to learn you’re pregnant, your

that many of the changes body goes through many

involve your skin. For changes. This is especially

example, you may true of the skin on your

develop dark patches or belly as it stretches to

blotchy spots, as well as accommodate your

acne, rashes, and stretch growing baby. Linea nigra

marks. But pregnancy is one of those common

isn't the only time you pregnancy skin conditions.

may notice shifts in your Many women who are

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 skin health. Many skin pregnant experience a dark

changes continue or line that appears vertically

spring up after delivery down the front of their

as well. Like many belly. It is normal to all

postpartum issues, pregnant woman to have a

though, most of these can stretch mark and Linea

fade and resolve with nigra because their

time. abdomen started to stretch

(Elizabeth Millard 2022) because of the

development of the fetus

inside the uterus.

HEAD Hair is long in length, thin, The hair should equally The hair indicates that the

shiny, equal in distribution distributed, shiny, thick, patient practices proper

and free from lice. and free from infections hygiene as evidence by (-)

and infestations. infections, (-) infestations,

shiny and equally

distributed.

EYES The sclera of the pupil is According to Giddens, The patient doesn’t have

white color, and it has a (2007) The sclera should any vices like smoking,

good vision reflex of 20/20 be white, and the drinking and drug abuse. It

vision. conjunctiva should be is strongly evident by the

pink. There should not be color of her sclera which

any drainage from the is color white and not

eyes. The patient should yellowish or reddish. The

demonstrate behavioral normal sclera is white and

cues indicating effective surrounds the iris and

vision during the pupil. In the setting of

assessment. liver or blood disorders

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 that cause

hyperbilirubinemia, the

sclera may appear yellow,

referred to as icterus

according to Meded

(2010).

NOSE No blockage of nasal External nose is Upon pinching on the nose

cavities, no discharge, pain, symmetrical with no from left to right, the

swelling. discoloration, swelling or patient didn’t manifest any

malformations. Nasal pain or facial grimace, no

mucosa is pinkish red blockage in both nasal

with no cavities and swelling are

discharge/bleeding, not present.

swelling, malformations

or foreign bodies.”

Abnormal findings might

be documented as:

“Bright red nasal mucosa

with purulent discharge.

(Pressbooks library)

MOUTH AND TEETH Lips are slightly dry and In a healthy mouth, the The patient lips are

pale in color. tissues are pink, firm, and slightly dry and pale in

moist. If you have a color and according to

Tongue is slightly pale and healthy mouth, your Bethany Cadman (2018),

free from lesions. breath will smell pleasant This is a normal process,

or neutral. and it can cause both

The teeth are yellowish and peeling skin and dry lips.
Healthy gums are firm
have some cavities in the Her teeth have cavities

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 back and yellowish in color and
and pink, not red, or
it is normal to a pregnant
white. They are not
woman because of
swollen or sore. Teeth
hormonal changes the
should be firmly planted
acidity of the mouth
in the gums, not wiggly.
increases and it can cause
It should not hurt to chew
cavities to your teeth.
or brush your teeth.
According to the patient,

A healthy mouth will not during her pregnancy she

have any bumps, flaps, brush her teeth three times

gaps or rough patches. a day.

(Cleveland clinic 2021)

CHEST AND LUNGS Chest arouses normally as  Normal respiratory exam Upon assessing her

its breaths and the should look something respiratory, it turns out to

respiratory rate is normal along the lines of the be normal as evidence by

(20 Breaths / Min.) following: The chest wall the result of 20 Breaths

is symmetric, without per minutes.

No unnecessarily crackles deformity, and is For the patients that is not

and sound and shortness of atraumatic in appearance. pregnant, DOB or SOB is

breath is not manifesting. No tenderness is abnormal, however

appreciated upon according to Stacy A.

palpation of the chest Henigsam (2022)

wall. The patient does Shortness of breath is a

not exhibit signs of common symptom

respiratory distress. affecting people during

(Thrive AP 2016) pregnancy. It can begin in

the first trimester and may

get worse over time due to

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 increased pressure from

the fetus on the diaphragm

and hormonal changes.

Shortness of breath in

pregnancy is usually

harmless.

BREAST Areola and nipples are Changes to the breasts According to Debra

slightly brownish in color and nipples can begin in Sullivan Ph.D. (2019) A

and the breast are sag. very early pregnancy and woman may find that the

continue throughout it. shape of her breasts

The breast milk ducts are Hormones and increases changes permanently

clogged. in blood flow account for following pregnancy.

these changes. Many women find that

their breasts never look

the same as they did

before pregnancy. They

may be smaller or larger,

sag or droop more and

develop stretch marks.

The nipples may also look

different.

ABDOMEN Linea nigra and stretch During abdominal Upon assessing the

marks are present, and examination palpate the abdomen, Linea nigra and

abdomen is deflated. abdomen for tenderness. stretchmarks are present.

Note any guarding or Abdomen is deflated.

rigidity, shown by According to

contraction of the skinsight.com (2012), A

abdominal muscles. Note dark line extending

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 also rebound tenderness- vertically down the

pain when the palpating abdomen (Linea nigra) is

hand is suddenly one example. Another

removed- that may common example is striae,

indicate a sign of also known as stretch

peritonitis. marks. There are different

Listen for bowel sounds. types of striae, and they

(Gymdymas Kaunas are all most likely caused

2010) by a combination of

factors – including

mechanical stress on the

skin, hormones, and

genetics.

EXTREMITIES Varicose veins are not To assess for deep vein Upon assessing the

present, nails are trimmed thrombosis (DVT), the extremities of the patient,

and pale in color. lower extremities are nails are trimmed but pale

examined for the in color and varicose vein

presence of hot, red, are not present. According

painful, and/or to Veinreliever.com

edematous areas. An (2022), Varicose veins

elevated temperature may usually start in the second

also be present. The legs trimester and get worse as

for assessed for adequate you near delivery. This is

circulation by checking because the increased

the pedal pulses and pressure of the uterus on

noting temperature and the pelvic veins disrupts

color. In addition, the blood flow to the leg veins

lower extremities are in pregnant women. Upon

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 assessed for edema. pain scale, the patient

(Heidi Crean RN 2012) stated that her both legs

are in pain as evidence by

pain scale 7/10.

GENITAL Lochia rubra is present as After delivery, you'll Upon assessing patient has

evident by dark reddish begin to shed the lochia rubra as evidence of

vaginal discharge. superficial mucous (+) dark reddish vaginal

membrane that lined your discharge. According to

The external genitalia are uterus during pregnancy. Valinda Riggins Nwadike

dark free from pus. You'll have vaginal (2022), Lochia rubra

discharge made up of this refers to vaginal bleeding

Medio lateral episiotomy is membrane and blood for and discharge that occurs
present weeks. The discharge after childbirth.

will be red and heavy for Specifically, it consists of

the first few days. Then it blood, mucus, and tissue

will taper, become from the placenta and the

increasingly watery and uterus lining. This type of

change from pinkish discharge is a typical part

brown to yellowish of the postpartum process.

white. (Mayo Clinic Pain in episiotomy is also

2022) noted as evidence by pain

scale 6/10.

RECTAL Lesions, pain, and swelling A hemorrhoid is a painful According to Alana

are not presented. swelling of a vein in the Biggers (2018)

rectum. After having a Hemorrhoids are swollen

baby - especially after a veins inside your rectum

vaginal delivery - many or in the skin surrounding

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women develop your anus. They’re usually

hemorrhoids. Symptoms caused by increased

include pain, rectal pressure on your lower

itching, bleeding after rectum. When you’re

having a bowel pregnant, the baby puts

movement, or a swollen extra pressure on this area.

area around the anus. As a result, hemorrhoids

(University of Rochester can develop both during

2023) and after pregnancy.

They’re especially

common after vaginal

deliveries but upon

assessing the patient,

lesions, pain and swelling

are not present in rectum.

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 C. Gordon’s Functional Assessment (Before, During, and After pregnancy)

1) Health Perception Before Pregnancy:

Health Management “Okay naman ako bago ako ma-hospital.

Hilig ko ang kumain ng mga prutas at gulay. Hindi ako

umiinom o nagsisigarilyo, dahil dito napapanatili kong

malusog ang aking katawan” as verbalized by the patient.

During Pregnancy:

“Masasabi ko na nasa magandang estado an aking kalusugan

habang buntis ako dahil nagagawa ko naman ng maayos ang

gawain sa araw-araw at kumakain ng sapat at tama ayon sa

aking pangangailangan. Nagkakaroon ako madalas ng check-

up at madalas na normal naman lahat ng resulta” As verbalized

by the patient.

Analysis:

Good nutrition during pregnancy can help to keep you and

your developing baby healthy. Your need for certain nutrients

increases when you are pregnant.

Department of Health & Human Services.

(2000, August 14). Pregnancy and Diet.

2) Nutritional Metabolic Before Pregnancy:

Patter “Wala akong kahit anong allergy sa pagkain o kahit sag gamot.

Kumakain naman ako ng tatlong beses sa isang araw at

umiinom ng 7-8 na basong tubig. Umiinom pero kapag meron

lamang ganap sa pamilya." As verbalized by the patient.

During Pregnancy:

The patient is under DAT (Diet as tolerated). She eats the food

that was served in the hospital. Drinks a lot of water and

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 vitamins, and coffee sometimes.

Analysis:

Pregnancy creates extra demands for certain nutrients,

including iron, calcium, iodine and many vitamins.

The Royal Women's Hospital. (n.d.). Food and Nutrition in

pregnancy.

3) Elimination Process Before Pregnancy:

The patient usually void 3-4 times a day and defecates once a

day. “Wala naman akong nararanasang hirap sa pag-ihi or

pagdumi.” As verbalized by the patient.

During Pregnancy:

The patient usually void 5-6 times a day than the usual pattern.

She defecates once a day. There's still no concern with regards

on voiding or defecating.

Analysis:

Frequent urination is when you need to urinate (wee) more

often than usual when pregnant. Needing to go to the toilet

more often during your pregnancy is normal and is caused by

the hormonal and physical changes occurring in your body.

Frequent urination during pregnancy. Pregnancy Birth and

Baby.

4) Activity Exercise Pattern Before Pregnancy:

The patient states that she exercises while doing household

chores in the morning and evening.

During Pregnancy:

The patient stated that she gets tired during prolonged

activities. He can only perform limited activities such as

walking around the hospital. The doctor also advised to only

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 have moderate intensity activity.

Analysis:

Moderate intensity means you’re active enough to sweat and

increase your heart rate. Taking a brisk walk is an example of

moderate-intensity exercise during pregnancy. March of

Dimes.

5) Sleep Rest Pattern Before Pregnancy:

"Nakakatulog naman ako ng mahimbing, madalas ay 7-8

hour’s akong natutulog kaya nakakabawi talaga ng lakas

pagkagising. Nakakatulog ako ng bandang mga 10 ng gabi at

nagigising ng mga 5 or 6 kinaumagahan. Hindi naman ako

nagkakaroon ng problema sa tulog ko." As stated by the

patient.

During Pregnancy:

The patient still continues to have 7-8 hours of sleep. She often

sleeps every afternoon for 1-2 hours. However, her sleep was

being disturbed most often due to visitor and other health care

team.

Analysis

“Whether you are in your first, second, or third trimester, or at

the beginnings of labor, pregnancy can have profound effects

on your ability to sleep. Hormone changes may alter the nature

of a pregnant woman’s sleep.”

Brandon Peters, M. D. (2020, February 3). How sleep changes

during pregnancy

6) Cognitive Preparation Before Pregnancy:

Pattern The patient is very cooperative during the interview. She

understands and answered every question we ask them with

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 precision. Furthermore, she understands what's going on with

her current status and told us that she's old enough to know her

present health condition.

During Pregnancy:

The patient was able to do what she's instructed to do to

maintain he good health. She felt and experienced back pain

but was able to manage herself by following instructions

thoroughly.

Analysis

It is interesting to note that many of the hormones that play a

key role in the establishment and maintenance of pregnancy

have been found to influence selective cognitive functions

Henry, J. F., & Sherwin, B. B. (2012, February).

Hormones and cognitive functioning.

7) Self-Perception/Self Before Pregnancy:

Concept Pattern The patient stated that she feels positivity towards everything

in her life. She knows that she can't control everything that but

she can control her response over everything.

During Pregnancy:

The patient shows positivity towards her present health

situation. She knows that being pregnant would make many

changes in her body appearance yet she's feeling good about it.

8) Role Relationship Before Pregnancy:

Pattern The patient stated that she lived with her husband. As a wife,

she did most of the household chores and budgeting. She and

her husband work together as a team to build a wonderful

family.

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 During Pregnancy:

Since she was pregnant and was admitted to the hospital, her

husband was the only one to do all her chores. She feels

grateful that she has a loving partner to care for her.

Analysis:

Pregnancy is usually a time of excitement. But sometimes,

pregnant women and their partners may feel like they're

expecting a bundle of anxiety along with the joy. They have a

long list of to-dos. They have to cope with the changes and

unknowns that come with pregnancy and birth.

Partner support during pregnancy. MyHealth.Alberta.ca

Government of Alberta Personal Health Portal.

9) Sexually reproductive Before Pregnancy:

The patient stated that they are sexually active but they do no

use any contraceptive.

During Pregnancy:

The patient stated that they are sexually inactive due to her

current condition.

Analysis:

During pregnancy, it’s common for sex drive to be different

from before.

Focus on strengthening your relationship through talking,

being intimate in other ways and spending time together.

Pregnancy, sex drive and your relationship: Pregnant women.

Raising Children Network. (2022, February 23).

10) Coping stress tolerance Before Pregnancy:

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 pattern The patient copes up with stress by watching television,

cleaning the house and gardening, when they have a problem

as a family they resolved it by means of taking to each other.

During Pregnancy:

The patients take a nap and rest when she's tired. She

verbalizes desires to recover. Able to accept situation by

cooperating with the medical advices.

Analysis:

Feeling stressed is common during pregnancy because

pregnancy is a time of many changes. Your family life, your

body and your emotions are changing. You may welcome

these changes, but they can add new stresses to your life.

Stress and pregnancy. March of Dimes. (n.d.).

11) Values and Belief Before Pregnancy:

Pattern The patient’s religious affiliation is roman catholic. They

seldom go to church due to his job, but she and her family

never forgot to pray. When he goes to church he brings his

husband and their child.

During Pregnancy:

The patient was grateful God for her pregnancy. The patient's

relationship with God got even more firmed and stronger.

Analysis:

Depending on your social, religious and cultural background,

you may have certain needs and expectations when you are

having a baby. Cultural practices and preferences when having

a baby mo. Pregnancy Birth and Baby.

D. DIAGNOSTIC AND LABORATORY FINDINGS

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 HEMATOLOGY COUNT

COMPLETE BLOOD COUNT

Result Normal Value

Hematology:

Hemoglobin: 120 M: 133 -179 G/L; F: 123 – 156 G/L

Hematocrit: 0.36 M: 0.40 -0.54; F:0.37 – 0.47
WBC: 8.9 5 – 10 X 10 9/L

Differential Count:

Segmenters: 0.67 0.50 – 0.70

Lymphocytes: 0.30 0.20 – 0.40
Monocytes: 0.03 0.03 – 0.07
Eosinophils: 0.00-0.05

Platelet counts: ADEQUATE 150 -450 X 10 9/L

BLOOD TYPING: “ RH POSITIVE”

URINALYSIS

Macroscopic Examination: Microscopic Examination:

Color: Yellow WBC: 2-4/hpf

Transparency: Hazy RBC: 0-1/hpf
Reaction: 5.0
Specific Gravity: 1.020 Epithelial Cells: Moderate
Amorphous Urates: Moderate
Mucus Threads:
Bacteria: Few
Calcium Oxalate:
HEPATITIS B SCREENING:

NON-REACTIVE
VDRL Screening:

               NON-REACTIVE

ANALYSIS:

In urinalysis, WBC appears to be more in count than RBC. In pregnancy, WBC is usually

higher and elevated. White blood cell count is increased in pregnancy with the lower limit of the

23
reference range being typically 6,000/cumm. Leukocytosis, occurring during pregnancy is due to the

physiologic stress induced by the pregnant state.

White blood cells (WBC) are commonly measured to investigate suspected infection and

inflammation in pregnant women, but the pregnancy-specific reference interval is variably reported,

increasing diagnostic uncertainty in this high-risk population. It is essential that clinicians can interpret

WBC results in the context of normal pregnant physiology, given the huge global burden of infection on

maternal mortality. (S. Dockree, 2021)

Your body uses iron to make hemoglobin. Hemoglobin is a protein in the red blood cells that

carries oxygen to your tissues. During pregnancy, the volume of blood in your body increases, and so

does the amount of iron you need. Your body uses iron to make more blood to supply oxygen to your

baby. If you don't have enough iron stores or get enough iron during pregnancy, you could develop iron

deficiency anemia. (Mayo, Clinic)

The red blood cells (RBCs) contain an important protein called hemoglobin. This protein holds

oxygen and helps your red blood cells carry oxygen from your lungs to your body. It also helps carry

carbon dioxide from your body to your lungs so you can breathe it out.

Anemia is when you don’t have enough red blood cells to carry oxygen throughout your body. When

your body doesn’t get enough oxygen from your blood, it can’t function properly. A person who has

anemia during pregnancy is considered anemic. (Cleveland Clinic).

Lymphocyte count decreases during pregnancy through the first and second trimesters and

increases during the third trimester. There is an absolute monocytosis during pregnancy, especially in the

first trimester, but decreases as gestation advances. Monocytes help in preventing fetal allograft rejection

by infiltrating the decidual tissue (7th–20th week of gestation) possibly, through PGE2 mediated

immunosuppression. The monocyte to lymphocyte ratio is markedly increased in pregnancy. Eosinophil

and basophil counts, however, do not change significantly during pregnancy.

Monocytes are short-lived cells, arising from the bone marrow and maturing in the circulation.

They play an important role in immune responses and are thought to be important for healthy pregnancy.

In humans, 3 subpopulations of monocytes have been identified: classical, intermediate and non-classical

monocytes. These subpopulations have different functions and phenotypical characteristics. Healthy

24
pregnancy is characterized by a pro-inflammatory condition, with increased numbers of monocytes and

monocyte activation as well as with increased numbers of intermediate monocytes and decreased

numbers of classical monocytes. This may suggest monocyte maturation. Preeclampsia is an important

pregnancy complication characterized by hypertension and proteinuria developing in the second half of

pregnancy. The pathophysiology of preeclampsia is associated with further activation of the

inflammatory response, further activation of monocytes, and further monocyte maturation. In the present

review, we focus on the role of monocyte activation and maturation in healthy and preeclamptic

pregnancy.

BLOOD BANK
BLOOD TYPE: “A” RH POSITIVE

ANALYSIS:

Up until the mother's second or later pregnancies, Rh antibodies are safe. Her Rh antibodies will

identify any future Rh-positive children she carries. The baby's blood cells' surface Rh proteins are

recognized as foreign. her immune system will enter the infant's blood and assault those cells.

Apparently, Mayo Rh + blood is the most prevalent blood type as of 2020. One who is Rh negative Blood

type is not a disease, and it typically has no impact on your health. Although it can impact the pregnancy.

If you are Rh negative, you must take extra care throughout pregnancy if your child is Rh positive (Rh

incompatibility).

III. ANATOMY AND PHYSIOLOGY

The Female Reproductive System

25
 The reproductive system is one of the fundamental features of a living organisms

because it helps us to procreate for the survival of our species. They are the one responsible to

produce egg cells and sperm cells. One of its primary functions is to transport and sustain

these cells, for it to fertilize, and nurturing the new life created. Reproductive system provides

foundation knowledge for learning about puberty, menstruation, conception, and pregnancy.

The female reproductive system has internal and external part. Internal reproductive

system consists of Ovary, Fallopian tube, Uterus, Cervix, and Vagina. The reproductive

system also has external genitalia or vulva that consists of mons pubis, labia majora, labia

minora, clitoris, urethral opening, vaginal opening, and perineum. Also, part of the female

reproductive organ is the mammary gland.

Internal Reproductive System

 Ovary

26
 The female gonads or ovaries are oval-shaped, solid structures about 3.5 cm long, 2

cm wide, and 1-cm thick. Ovarian tissues consist of an inner medulla and an outer cortex. The

medulla is made up of loose connective tissue with many blood and lymphatic vessels as well

as nerve fibers. The cortex has more compact tissue with a granular appearance because of

masses of ovarian follicles. The ovary’s free surface is covered with cuboidal epithelium

above a layer of dense connective tissue. The almond-shaped ovaries perform three main

functions: production of immature female gametes called oocytes; secretion of female sex

hormones, including estrogens and progestins; and secretion of inhibin, which is involved in

the feed-back control of pituitary FSH production. The most common form of estrogen is

estradiol, followed by estrone and estriol.

In women of childbearing age, one ripening follicle ejects its oocyte from an ovary

every month in a process called ovulation. When sperm enters an ovum, it fertilizes an egg, this

fertilized egg is called a zygote. The zygote goes through a process of becoming an embryo

called mitosis where it will undergo cell division. After seven weeks of cell division, the

fertilized egg will now implant its self to the uterus where it will continue to grow for nine

months and become a fetus.

 Ovarian Cycle

Ovarian cycles occur regularly in women with matured ovary and non- pregnant

women during menstrual cycle. The cycle is divided into three phases which is the pre-

ovulatory phase that occurs before ovulation, ovarian phase that occurs when the ovum inside
27
the follicle is developing and it is ready to release for ovulation, and the luteal phase that

occurs after ovulation.

Each of your ovaries has thousands of ovarian follicles. Ovarian follicles are small sacs in

the ovaries that hold immature eggs. Each month, between days six and 14 of your menstrual

cycle, follicle-stimulating hormone (FSH) causes follicles in one of your ovaries to mature. At

about day 14 in the menstrual cycle, a sudden surge in luteinizing hormone (LH) causes the

ovary to release an egg (ovulation).

The egg begins its travel through a narrow, hollow structure called the fallopian tube

to the uterus. As the egg travels through the fallopian tube, the level of progesterone rises,

which helps prepare the uterine lining for pregnancy. If you don't become pregnant in that

cycle, the egg disintegrates and gets reabsorbed by your body so menstruation can begin.

As the levels of FSH and LH in the blood increase with puberty, the eggs begin to

mature and a collection of fluid, the follicle, begins to develop around each one. The first day

of menses is identified as cycle day one. Estrogen is at a low point. Therefore, the pituitary

secretes FSH and LH, a process which begins before the onset of your menses. These

hormones in turn stimulate the growth of several ovarian follicles, each containing one egg.

The number of follicles in the monthly "cohort" of developing follicles is unique to everyone.

One follicle will soon begin to grow faster than others. This is called the dominant follicle. As

the follicle grows, blood levels of estrogen rise significantly by cycle day seven. This increase

in estrogen begins to inhibit the secretion of FSH. The fall in FSH allows smaller follicles to

die off. They are, in effect, "starved" of FSH.

When the level of estrogen is sufficiently high, it produces a sudden release of LH,

usually around day thirteen of the cycle. This LH peak triggers a complex set of events within

the follicles that result in the final maturation of the egg and follicular collapse with egg

extrusion. Ovulation takes place 28 to 36 hours after the onset of the LH surge and 10 to 12

hours after LH reaches its peak. The cells in the ovarian follicle that are left behind after

ovulation undergo a transformation and become the corpus luteum. In addition to estrogen,
28
they now produce high amounts of progesterone to prepare the lining of the uterus for

implantation.

 Fallopian Tubes

The uterine tubes, also called the fallopian tubes or oviducts, receive the ovulated

oocytes from the ovaries and are each about 10 cm (4 inches) long. The uterine tubes are the

sites where fertilization usually occurs. Each uterine tube empties into the superolateral area of

the uterus via a constricted isthmus. As it curves around the ovary, each uterine tube’s distal

end expands to form an ampulla. Near the ovaries, each tube expands into a funnel shaped

infundibulum, that partially encircles the ovary. Finger-like fimbriae surround its margin with

one of the larger extensions connecting with the ovary.

The transport of oocytes involves a combination of ciliary movement and peristaltic

contractions in the uterine tube walls. Non-ciliated mucosal cells have dense microvilli and

produce secretions that keep oocytes as well as any present sperm nourished and moist.

 Uterus

If the secondary oocyte is fertilized to become a zygote, the uterus receives the

developing embryo, sustaining its development. The uterus is hollow and muscular, shaped

slightly like an inverted pear. Its size changes during pregnancy, from about 7.5 cm by 5 cm

by 2.5 cm to much larger, able to hold the developing baby up until birth. At this point, it

weighs 30–40 g. The uterus is in the anterior pelvic cavity, superior to the vagina, usually

bending over the urinary bladder. The uterine body is also called the corpus, the largest

portion of the uterus. The fundus is the rounded portion of the corpus and is superior to the
29
attachment of the uterine tubes. It ends at the constriction known as the isthmus. The cervix is

the inferior portion of the uterus, extending from the isthmus to the vagina. The cervix

surrounds the cervical orifice, where the uterus opens to the vagina. The uterine wall is thick,

with three layers.

The uterine wall has three layers: the endometrium, which is the innermost layer of

the uterus, and this is the layer where the placenta normally sticks, the second layer is

myometrium, a muscular muscle since it is composed of thick layer of smooth muscle. And

the last layer which is located at the outermost layer of the uterus, it is also called a serous

membrane layer.

 Vagina

The vagina is a thin-walled fibromuscular tube, about 8–10 cm (3–4 inches) in length,

extending from the cervix to the outside of the body. It conveys uterine secretions, receives

the erect penis during intercourse, and provides the open channel for offspring.

The vaginal wall has three layers: (a) Inner mucosal layer (mucosa): Stratified

squamous epithelium with no mucous glands. (b) Middle muscular layer (muscularis): Mostly

smooth muscle fibers; helps to close the vaginal opening. (c) Outer fibrous layer (adventitia):

Dense connective tissue and elastic fibers.

External Female Genitalia

The external female genitalia which is called vulva consists of various structures.

These structures are mons pubis, clitoris, labia majora, labia minora, and urethra.

30
 The mons pubis is a rounded area made of fatty tissue that overlies the pubic

symphysis. This area becomes covered with pubic hair after puberty; it acts as a cushion

during intercourse.

The clitoris projects from the anterior end of the vulva between the labia minora. It is

usually about 2 cm in length and 0.5 cm in diameter. It corresponds to the penis in males, with

a similar structure. The clitoris has a rich innervation of sensory nerve endings and swells with

blood, becoming erect during tactile stimulation and sexual arousal.

The labia majora (major lip) enclose and protect the other external reproductive

organs. They are made up of rounded folds of adipose tissue and thin smooth muscle covered

by skin and hair. They lie close together, with a cleft that includes the urethral and vaginal

openings separating the labia longitudinally.

The labia minora (minor lip) are flattened, hairless longitudinal folds composed of

connective tissue. They contain the external openings of the urethra and vagina. They have a

rich blood supply, and therefore a pinkish appearance.

The urethra opens into the vestibule in the midline, about 2.5 cm posterior to the

glans of the clitoris. One pea-sized vestibular gland lies on each side of the vaginal opening.

They release mucus into the vestibule, moistening and lubricating it for intercourse.

Perineum is the region between the genitals and anus, from the vagina to anus. This

region is prone to laceration during childbirth, an incision at the fourchette called episiotomy

prevents laceration by widening the vaginal opening that facilitates delivery of the baby.

Mammary Glands

31
 The mammary glands are specialized to secrete milk after pregnancy. They are in

the subcutaneous tissue of the anterior thorax within the breasts.  Mammary glands are

consisting of various structures such as nipple and areola on the external breast while in the

internal breast there are lobules, lobes, and lactiferous ducts.

Just below the center of each breast is an areola, which is a ring of pigmented skin.

The areola is slightly bumpy because of large sebaceous glands and produces sebum to reduce

cracking and chapping of the nipple, which is located near the tip of each breast within the

areola surrounding it. Smooth muscle fibers in the areola and nipple are controlled by the

autonomic nervous system. This can cause the nipple to become erect when it is stimulated by

touch or cold temperatures.

Each mammary gland is a modified sweat gland made up of 15–25 lobes that contain

alveolar glands and an alveolar duct, which leads to a lactiferous duct. This leads to the

nipple. Lobules are smaller units inside the lobes. They contain glandular alveoli, which

produce milk during lactation. Milk is passed from these compound alveolar glands

into lactiferous ducts, which open to the outside of the nipple.

32
 IV. DRUG STUDY

DRUG NAME MECHANISM OF INDICATION CONTRAINDICATION SIDE EFFECTS ADVERSE NURSING

ACTION EFFECT RESPONSIBILITY

Generic name: This drugs is a Several upper Cefuroxime is contraindicated • Stomach pain • Oral thrust • Monitor sign of
Cefuroxime bactericidal agent respiratory tract in patients with cephalosporin infections and
that acts infections, hypersensitivity or cephamycin • Dizziness • Vaginal yeast anaphylaxis
by inhibition of gonorrhea, early hypersensitivity. Cefuroxime infection • Educate patient about
Brand name: bacterial cell wall Lyme disease, should be used cautiously in • Swelling/ side effect such as pain
Ceftin synthesis. impetigo, and acute patients with hypersensitivity itching • Vomiting in stomach area and
Cefuroxime has bacterial otitis to penicillin. The structural diarrhea
Classification: activity in the media are among the similarity between cefuroxime •Restlessness • Chills • Keep all side ails up
Cephalosporin presence of some infections that can and penicillin means that •Advised to have
Antibiotics • SOB (Shortness •Confusion
beta-lactamases, be treated with cross-reactivity can occur. adequate rest
of breath)
both penicillinases cefuroxime, a type • Reduce focus on pain
Frequency: TID • Hives
and of antibiotic known by doing diversional
• Headache
cephalosporinases, as a cephalosporin. activities
Route: IV •Candidiasis
of Gram-negative • Advised to do deep
•Hypersensitivity
and Gram-positive breathing exercises
•Convulsion
bacteria.

33
 DRUG NAME MECHANISM OF INDICATION CONTRAINDICATION SIDE EFFECTS ADVERSE NURSING

ACTION EFFECT RESPONSIBILITY

Generic name: Oxytocin increases Oxytocin is Oxytocin is contraindicated •Confusion •Difficult of •nurses are responsible
Oxytocin the sodium indicated during in patients with a known breathing for safely administering
permeability of pregnancy to induce hypersensitivity to the drug •Headache oxytocin during labor,
Brand name: uterine myofibrils, labor; it precipitates or any of the specific •convulsion avoiding excessive
Pitocin indirectly uterine contractions and product ingredients. •Weakness stimulation to the uterus
stimulating used to help start or Oxytocin is indicated during • Severe or harm to the fetus. So,
Classification: contraction of the continue labor and to pregnancy to induce labor; it • Weight Gain abdominal pain before starting the
Oxytocic uterine smooth control bleeding after precipitates uterine (rapid) and pelvic pain. infusion, be sure to
Hormones muscle. The uterus delivery. It is also contractions. review the client's
•Abdominal pain •Fast or irregular
responds to oxytocin sometimes used to help medical record to be sure
Frequency: or cramping heartbeat.
more readily in the milk secretion in there are no
presence of high breast-feeding. contraindications to
• Dizziness
estrogen Oxytocin may also be administration.
Route: IV or IM
concentrations and used for other
with the increased conditions as
duration of determined by your
pregnancy. doctor.

34
 DRUG NAME MECHANISM OF INDICATION CONTRAINDICATION SIDE EFFECTS ADVERSE NURSING

ACTION EFFECT RESPONSIBILITY

Generic name: Ampicillin works Ampicillin is used to Penicillin is contraindicated to • Fever • diarrhea Watch for seizures;
Ampicillin by binding to treat certain patients with: notify physician
penicillin-binding infections that are : Dialysis, renal disease, renal •Seizures •inflammation of immediately if patient
Brand name: proteins (PBPs) to caused by bacteria failure, renal impairment. some organs. develops or increases
Principe n inhibit bacterial cell and infections of the : Asthma, carbapenem • Rash seizure activity. Monitor
wall synthesis. This throat, sinuses, hypersensitivity, cephalosporin • anemia signs of
Classification: causes disruption of lungs, reproductive hypersensitivity, eczema, •Vomiting pseudomembranous
Penicillin the bacterial cell organs, urinary tract, penicillin hypersensitivity, •Headache • allergic reaction colitis, including
wall and leads to and gastrointestinal serious rash, urticaria. diarrhea, abdominal
Frequency: • nausea • yeast infection in
bacterial cell death. tract. pain, fever, pus or mucus
Q6 the mouth
in stool, and other severe
• dark urine
or prolonged GI
Route: PO, IV •inflammation in
problems (nausea,
and IM kidney
vomiting, heartburn).

35
 DRUG NAME MECHANISM OF INDICATION CONTRAINDICATION SIDE EFFECTS ADVERSE NURSING

ACTION EFFECT RESPONSIBILITY

Generic name: Mefenamic acid binds This drug used to Mefenamic acid is • Stomach pain • Chest pain • Check for allergic
Mefenamic Acid the prostaglandin relieve mild to contraindicated in patients reactions
synthetase receptors moderate pain. It is with salicylate • Nausea • SOB
Brand name: COX-1 and COX-2, in a class of hypersensitivity or NSAID • Advised patient to
Ponstel inhibiting the action of medications called hypersensitivity who have • Vomiting • Weakness on one observe feces and
prostaglandin NSAIDs. It works experienced asthma, side of your body urine check for
Classification: synthetase. As these by stopping the urticaria, or other allergic • Heartburn presence of blood
NSAID receptors have a role as body's production reactions after taking aspirin • Slurred speech
• Constipation • Advised the patient
a major mediator of of a substance that or other NSAIDs.
Frequency: OD • Stomach pain or to take mefenamic acid
inflammation and/or a causes pain, fever,
• Diarrhea upset stomach After meal to avoid
role for prostanoid and inflammation.
Route: PO stomach pain
signaling in activity
• Rash • Vomiting of
dependent plasticity,
blood • Monitor Vital Signs
the symptoms of pain
• Dizziness
are temporarily
• Swelling lips, • Increased fluid intake
reduced
• Black, sticky stools face and throat

36
 DRUG NAME MECHANISM OF INDICATION CONTRAINDICATION SIDE EFFECTS ADVERSE NURSING

ACTION EFFECT RESPONSIBILITY

Generic name: Iron combines Used to treat and Patient with allergic reaction  feeling or Upset stomach, Monitoring, education,
Ferrous sulfate with porphyrin prevent iron to iron supplements, or if you being sick constipation, and administering
and globin chains deficiency have a condition called (nausea or nausea, medications
Brand name: to form anemia. Iron hemochromatosis (iron vomiting), abdominal pain,
Slow FE, Fer-In-Sol, hemoglobin, helps the body to overload disease) or stomach pain vomiting, and Monitor patient for

Feratab, Iron, Mol- which is critical make healthy red hemosiderosis (iron in the or heartburn. diarrhea. bleeding and hemoglobin

Iron, Feosol, and for oxygen blood cells, which lungs), or any type of anemia  loss of levels and other major

MyKidz Iron 10. delivery from the carry oxygen that is not caused by iron appetite. signs and symptoms…

lungs to other around the body. deficiency.  constipation. assessing diet, menstrual
Classification: tissues. Iron Some things such  diarrhea. cycles etc.
 oral iron bivalent deficiency causes as blood loss,  dark or black
preparations a microcytic pregnancy or too poo.
anemia due to the little iron in your  black stained
Route: formation of diet can make teeth (from the
Oral, IM,IV small erythrocytes your iron supply drops)
with insufficient drop too low,
hemoglobin. leading to anemia.

37
 V. NURSING CARE PLAN

A. PRIORITIZATION

ACTUAL PROBLEM

NURSING DIAGNOSIS RANK JUSTIFICATION

An episiotomy is a procedure developed to augment

ACUTE PAIN RELATED TO TISSUE 1st
difficult vaginal deliveries while controlling for and
TRAUMA AS EVIDENCED BY avoiding potentially dangerous perineal lacerations
during the delivery process. This activity outlines the
EPISIOTOMY
clinical indications for episiotomy and reviews the role
of the interprofessional team in ensuring proper use,
understanding current recommendations, and caring for
patients who undergo episiotomy. This includes, but is
not limited to, history, different techniques, personnel,
and post episiotomy care as
it relates to all members of the healthcare team.
( K. Barjon, 2022). Pain related to episiotomy is one of
our top priority consideration to see and to assess the
growing infection inside.

38

ELEVATED BLOOD PRESSURE
RELATED TO ACUTE BACK PAIN
IMPAIRED PHYSICAL MOBILITY
RELATED TO PAIN ON SURGICAL
WOUND
KNOWLEDGE DEFICIT AS RELATED TO
MISINTERPRETATION OF INFORMATION
ABOUT BREASTFEEDING EVIDENCED BY
VERBALIZATIONS OF CONCERNS AND
QUESTIONS
RISK FOR INEFFECTIVE COPING
RELATED TO FATIGUE AND BODY
39
The vagous nerve connects to the sympathetic system,
2nd
which considers the flow of blood pressure in the body
of the pregnant woman. Considered as second priority
to assess the growing eclampsia which may cause
complications during birth. (WHO, 2011)
To lessen and to stop the pain local anesthetics are
3rd
applied on the locality of the area being given a
surgery. The anesthesia will no longer be effective after
some few hours and the pain on the post-operation will
occur. Hence the fact, the anesthesia will be staying
inside the body and relaxes all the muscle as a result of
impaired mobility. ( B.A. Saddiqui, 2022)
Pain related to swelling of right breast indicates that the
4th
maneuver on how the baby breastfeeds has indicated
that the mother has a lesser thoughts about the way she
feeds her newborn. (P. Douglas, 2022)
The coping mechanism of a mother has been identified
5th
to be lesser when they deliver the baby. The
postpartum changes are happening despite the fact that

TRANSITION
POTENTIAL PROBLEM
NURSING DIAGNOSIS
RISK OF INEFFECTIVE
BREASTFEEDING RELATED TO
UNSATISFACTORY FEEDING PROCESS
RISK FOR FATIGABILITY RELATED TO
IRON DEFICIENCY
RISK FOR INJURIES, AND PROBLEMS
WITH INTER PERSONAL
40
the newborn is now existing. The efforts and the
energy being conserved has been exhausted after the
delivery of the baby.(J. Henderson, 2019)
RANK JUSTIFICATION
1st Ineffective breastfeeding is one of our top priority
when it comes to potential problems. After the
delivery, the mother has shown any signs of a clogged
breast and ineffective maneuver on how she feeds her
child. (P. Douglas, 2022)
2nd Postpartum fatigue is normal when it comes after
delivery. But some show any idleness that may affect
the newborn’s care. Fatigue to be exact is one of the
most considerate and understandable situations.
Helping them on how to overcome it will be effective
and will work efficiently. (J. Henderson, 2019)
3rd Relationship to newborn and parental care must be
advised and must be done efficiently. Within the hour
of post-delivery, the mother has shown “Postpartum
 RELATIONSHIP blues”. Psychologically, this phenomenon is very
obvious and can be seen easily but somehow,
postpartum blues has been leading to some prior
complication with the relation of a mother to her
newborn. (K. Balaram, 2022)
RISK FOR SEPARATION ANXIETY RELATED TO FEAR
4th Completely normal that after the postpartum blues the
OF SEPARATION WITH THE GROWING NEWBORN fear of the mother with the linkage of her newborn
has somewhat seen by the acceptance of her with her
newborn. The mother will now show signs of anxiety
just by thinking about the situation. Assessment will
help the mother to conjure and to organize her
thoughts in the near future. ( Rubin, 2018)
RISK FOR BACTERIAL INFECTION RELATED TO
5th After the day of taking care of her newborn, she must
POOR HYGIENE have been stressed to relate the situation that her
newborn needs. She has somehow forgetting about
herself and all she thinks is about her newborn. (F.
Ghiasvand, 2017)

FORSEEABLE PROBLEM

41
 NURSING DIAGNOSIS
RISK TO DISTURB SLEEPING PATTERN
RELATED TO CAREGIVING
RESPONSIBILITIES AS EVIDENCED BY
PATIENT VERBALIZATION OF BEING
THE ONLY ONE DOING CHILD CARE
AND HOUSEHOLD CHORES.
RISK FOR ANXIETY RELATED TO
THREAT OF DEATH OF HER CHILDREN
42
RANK JUSTIFICATION
One hundred eighty-nine women completed both baseline
1st
and follow-up sleep surveys. The mean gestational age was
13.8 weeks at the first and second surveys, respectively.
Compared with the baseline assessment, mean sleep duration
was significantly shorter hours compared with hours, and the
proportion of patients who reported frequent snoring (at least
three nights per week) was significantly greater (11%
compared with 16.4%, P=.03) in the third trimester.
Conclusion: Sleep disturbances are prevalent among healthy
nulliparous women and increase significantly during
pregnancy. (Facco, 2010)
As a parent, regardless of who the family member is; the
2nd
burden of something will take hold of the grudge and may
lead to somewhat incidents of anxiety. The postpartum
psychologic change will lead to benign thinking but lesser to
sum up the created scenario inside their head. (K. Hofberg,

RISK FOR BODY CONSCIOUSNESS RELATED TO
DISTURBED BODY IMAGE
RISK FOR STRESS RELATED TO
CHANGE IN SOCIOECONOMIC STATUS
SECONDARY TO UNEMPLOYMENT
RISK FOR BREAST INFLAMMATION RELATED TO
CLOGGED MILK DUCTS
43
2003)
Postpartum physiologic changes will be seen and can be
3rd
obvious related to pregnancy. Some of the others are being
depressed and being anxious by their looks, but helping them
to understand that it’s all normal and to say that it will
eventually gone will help the mood of the mother. (E.L
Hodgkinson, 2015)
Nowadays the sufficient amount of needs of the family is
4th
adjusting by size. To build a family is a big role to support
the children from their growing. Stress related to thinking
about the socioeconomic of the family will link to too much
convention and too much burden to hold as a growing family.
( D. Conger, 2010 )
A clogged milk duct (also called plugged ducts or blocked
5th
ducts) occurs during lactation when a milk duct becomes
blocked or obstructed, preventing breast milk from flowing to
your nipple. Your breast contain a network of milk ducts
(mammary ducts). These tube-like ducts carry milk from
your breast tissue to your nipples. Milk can back up in the
duct if there’s anything compressing the ducts such as
inflammation in the soft tissues and surrounding blood
vessels. (Cleveland Clinic, 2010)
B. ACTUAL PROBLEM

ACTUAL PROBLEM #1

ASSESSMENT DIAGNOSIS PLANNING IMPLEMENTATION RATIONALE EVALUATION

Subjective cues: Short term goal: Independent: Independent: Short term:
Acute pain related  Serves as a
 Monitor vital signs; maintain
to tissue trauma as After 2-3 hour After 2-3 hours
“Masakit po yung tahi ko, strict asepsis for every baseline data
evidenced by rendered nursing to monitor for rendered nursing
hindi padin po ako patient contact.
episiotomy intervention, the intervention, the
makalakad at makatayo ng  any deviation
matagal” as verbalized by patient will be able  Ensure that used articles in patient’s GOAL WAS MET,
the patient to gain knowledge are properly disinfected vital signs. the patient gained
and understanding and sterilized before use. the knowledge and
 Pain scale of 6/10 of situation,  Encourage the patient to  To know if the understanding of
individual treatment notify nurse on duty if aseptic situation, individual
Objective cues: regimen, and safety the pain becomes technique will treatment regimen,
(+) Limited mobility measures. intolerable decreases the and safety measures.
(+) Distorted facial chances of
expression Long term goals: Dependent: transmit ting Long term:
(+) Weakness  Administer the prescribed or spreading
After 3 days of medications for pain. pathogens to After 3 days of
rendered nursing or between rendered nursing
intervention, the Collaborative: patients. intervention, the
patient will Interrupting GOAL WAS
verbalized ease of Provide optimum the chain of PARTIALLY MET,
pain in the incision nutrition such as infection is an as verbalized by the
site from 6/10 to increased protein intake effective way patient ease of pain in
2/10 to prevent the the incision site from
spread of 6/10 to 2/10
infection.

44
  This approach
will provide
immediate
pain
management
by the nurse,
and prevent
the pain from
becoming
severe.

Dependent:
 These
medications are
given to reduce
the severity of
pain.

Collaborative:
 This will
provide a
positive
balanced
nutrition that
aids in
healing.

45
 ACTUAL PROBLEM #2

ASSESSMENT DIAGNOSIS PLANNING IMPLEMENTATION RATIONALE EVALUATION

Subjective data: Elevated blood -Identified the presence of other -Can exacerbate the
After 5 days of After 5 days of
pressure related to conditions such as physical or already elevated blood
nursing nursing
“Masakit po yung acute back pain as emotional stress. pressure.
intervention, the intervention the
likod ko” as verbalized evidenced by blood
patient will be GOAL WAS
by the patient pressure of 150/100.
able to verbalize MET as the patient
understanding was able to
-Referred and collaborated in -To restore
Objective data: of condition verbalize
management of underlying hemodynamic stability.
and  therapeutic understanding of
condition.
BP: 150/100 regimen. their condition and 
learn some
-Encouraged the patient to have
-Exercise programs and therapeutic
lifestyle modifications.
stress management regimen.
techniques can help
reduce blood pressure
and enhance general
well-being.
-Emphasize the importance of
having regular medical
appointments -To monitor blood
pressure and provide
early interventions to
reduce risk of
complications.

46
 ACTUAL PROBLEM #3

ASSESSMENT DIAGNOSIS PLANNING IMPLEMENTATION RATIONALE EVALUATION

Subjective: Short Term: Independent: Short Term:
Impaired -Until healing occurs, After 8 hours of nursing
“Hindi po ako makatayo, After 8 hours of nursing - Monitor the patient with
Physical activity is limited and intervention, GOAL WAS MET,
maka-lakad at kumilos intervention, the patient ample time to perform
Mobility advanced slowly the patient were able to:
mag-isa dahil kapag will be able to: mobility related task.
related to according to
gumagalaw po ako - Move within range of
pain on individual tolerance. - Move within range of motion.
sumasakit yung opera motion.
surgical
ko.” as verbalized by the - Increase strength and
wound - Increase strength and function of
patient. function of affected
body part. -To promote optimal affected body part.
Objective: - Advised the patient to do level of function.
(+) facial grimace when Long Term: activities of daily living when Long Term:
trying to move from side After 3 days of nursing possible. After 3 days of nursing
to side intervention, the patient -To immobile the intervention, GOAL WAS MET,
will be able to: greater the level of the patient were able to:
-Assist with each initial
(+) Inability to perform - perform activities debilitation that will
change: dangling,
action as instructed such as daily exercises occur. - perform activities such as daily
sitting in chair,
with the least amount of exercises with the least amount of
ambulation.
(+) Limited ROM assistance. assistance.
- Verbalized an
increased feeling of - Verbalize an increased feeling of
(+) slow strength by showing early
movement strength by showing
early ambulation. ambulation.

47
 -Verbalize that pain is -Verbalize that pain is controlled
controlled during during physical activities.
physical activities.

ACTUAL PROBLEM #4

ASSESSMENT DIAGNOSI PLANNING IMPLEMENTATION RATIONALE EVALUATION

S
Knowledge deficit Short Term: Provide correct and proper Provide education
Subjective as related to education on breastfeeding and support for After nursing
data: misinterpretation of After 4 hours of nursing intervention, like: patients and intervention, the
information about -Alternate breasts when encouragement to GOAL WAS
“Tama poba the patient:
breastfeeding feeding continue proper MET. The
yung way ng patient have
pag papa-dede evidenced by -will have proper knowledge on how -Adjust or alternate positions breastfeeding.
verbalizations of for feedings shown
ko? Parang to breastfeed.
concerns and improvement
hindi kasi and better
nakaka-dede ng questions -will report increased latching of the
Encourage hydration Drinking water helps understanding
maayos ang baby at the breast.
to promote milk about
baby ko.” As breastfeeding.
production and flow.
verbalized by Long Term: Also the patient
the patient have reported
After 2 days of nursing intervention, Examine patient Improper positioning good latching of
Objective data: the patient: breastfeeding; observe or bad latch can the baby that
(+) Concerned position and baby’s latch cause nipple pain and helps with the
look -will have better and right irritation and increased
understanding on how to breastfeed discourage the patient emptying of her
(+) Worrisome properly. from fully emptying breast.
voice the breast.
(+) Poor

48
 -will report good latching of the baby.
latching of the
baby at the -will report increased emptying of the
breast breast.

ACTUAL PROBLEM #5

ASSESSMENT DIAGNOSIS PLANNING IMPLEMENTATION RATIONALE EVALUATION

Subjective cues: “Madalas Short term: after 3 hours
akong naiirita kapag Risk for of nursing intervention the
naririnig kong naiyak yung ineffective patient will understand the
bata” as verbalized by the coping related health teaching and will
patient. express her feelings
to fatigue and
Objective Cues: body transition
(+) irritable after child birth Long term:
(+) extreme mood swings after 8 hours of
nursing
intervention the
patient will be
able to
demonstrate a
secure bond
with the baby,
perform
activities of
daily living,
Independent: Independent: Short term: after 3 hours
of rendered nursing
 Establish rapport by  To facilitate intervention, the GOAL
WAS MET, the patient
introducing yourself and cooperation as
understand the health
by explaining why is it well as to gain teaching and expressed her
necessary to cooperate patient’s trust. feelings
 Active-listening and  To assess client’s
identify client’s coping abilities Long term: after
perceptions of current and evaluate her 8 hours of
situation. ability to nursing
understand present intervention the,
situation GOAL WAS
MET, patient
 Encourage significant  One of the best demonstrate a
other (SO) to spend time strategies to help secure bond with
with the client mothers decrease the baby,
their well-being perform activities

49
  Emphasize the need for
and participate
continued communication
in desired
with the partner or a close
activities at
friend who is available to
level of ability
provide support when
and being open
loneliness or anxiety
about any
becomes a problem
feelings.
Dependent:
 Administer anti-
depressant/medications
as prescribed.
during the
postpartum period of daily living,
is conveying a and participate in
caring attitude. desired activities
at level of ability
and being open
 To determine if the about any
patient needs any feelings.
further counseling
and support groups
to avoid
postpartum
depression

Dependent:

 Taking prescribe
medication such
as anti-depressant
may lift the
patient’s mood
and support her
mental health.

50
C. POTENTIAL PROBLEM

POTENTIAL PROBLEM #1
ASSESSMENT DIAGNOSIS PLANNING IMPLEMENTATION RATIONALE EVALUATION
Subjective Data: Risk of ineffective Short Term: Independent:  To help the Short Term:
“Parang palaging gutom breastfeeding related to After 8 hours of nursing  Provide health mother achieve After 48 hours of
ang baby ko. Iyak siya unsatisfactory feeding intervention, the mother teaching in terms of proper nursing intervention,
ng iyak kahit kakatapos process will be able to: proper techniques in breastfeeding GOAL WAS MET.
niya lang mag-dede.” as  Learn techniques breastfeeding. techniques. The mother was able to
verbalized by the on proper learn new techniques
patient. breastfeeding  Promote comfort and  Discomfort on breastfeeding.
 Persistence of  The mother will relaxation during associated with Breastfeeding time has
sore nipples increase breastfeeding to breastfeeding increased, and mother
beyond the first breastfeeding reduce pain and can cause some was able to show
week of frequency and anxiety. women to decreased anxiety and
breastfeeding. duration while discontinue apprehension.
 Insufficient maintaining the  Provide and encourage breastfeeding
emptying of correct support by actively prematurely. Long Term:
each breast. breastfeeding helping the mother to Promoting After a week of
position. correctly position the comfort and nursing intervention,
Objective Data:  Show decreased baby to attain a good relaxation can GOAL WAS MET.
 Observable anxiety and latch on the nipple and lead to more Mother was able to
signs of apprehension encouraging her to successful verbalize physical and
inadequate Long Term: continue trying. breastfeeding psychological comfort
infant intake After a week of nursing in breastfeeding
-Inadequate weight gain intervention, the mother Dependent:  Many problems practice and
51
of the baby will be able to:  Refer the patient to that can lead to techniques. The infant
 Express physical lactation consultants. discontinuing was able to manifests
-Decrease in number of and psychological breastfeeding signs of adequate
wet diapers. comfort in can be intake of milk at the
breastfeeding prevented by breast and appear
-Baby arcs and cries practice and giving a high satisfied for atleast 2
when at the breast techniques. level of practical hours after feeding.
 Achieve effective and emotional
breastfeeding support to the
with adequate mother.
breast milk intake  To have a
for the infant. professional
And the infant will be advice and to
able to: address other
 Feed successfully possible
on both breasts breastfeeding
and appear issues.
satisfied for
atleast 2 hours
after feeding.

POTENTIAL PROBLEM #2
ASSESSMENT DIAGNOSIS PLANNING IMPLEMENTATION RATIONALE EVALUATION
Subjective: Short term Planning: Independent: -Proper nutrition promotes
“Madalas po akong Risk for •Follow a healthy diet. healthy pregnancy The GOAL WAS
nahihiloAt nang hihina Fatigability On the 1 week of the
st
Sometimes, fatigue can be outcomes, supports normal PARTIALLY MET
at mabilis mairita sa related to iron intervention the patient linked to iron deficiency, so growth, development and after rendering
mga bagay bagay, deficiency will be able to Have you'll want to eat plenty of ageing, helps to maintain a nursing intervention,
pero minsan ayos lng healthy lifestyle to foods that are rich in protein healthy body weight, and It only has short term
naman yung structured plan for and iron. reduces the risk of chronic process because this
pakiramdam ko” as regular physical disease leading to overall problem will only last
verbalized by the activity that consists of •Make time for yourself, health and wellbeing. for atleast 2 weeks
patient. stretching and aerobic make sure that you are not after delivery.the

52
 exercise, such as stressing too much due to -It gives you the
Objective: walking. Caffeine and your delivery. satisfaction that patient patient follows the
•Fatigue modafinil may be need and help her to be healthy life style and
•Lack of Energy And useful for episodic •Rest, Make sure you allow motivated. the relative of the
motivation situations requiring yourself to get extra bed patient cooperates
alertness. Short naps rest during the times you feel -It minimized sleep loss. with us to help her
are proven performance fatigued. This can be lessen the stress of the
enhancers. accomplished by going to bed -To help the patient lessen patient. She still didn’t
earlier or taking a nap during her burden. have good sleeping
the day, if possible. routine due to
-So that the patient responsibilities that
won’t experience she need to give to her
Dependent: emotional baby like breast
• Tell the relative to ask the problems. feeding.
patient what she needs.

• Encourage her to share her

thoughts and feelings to her
family.

POTENTIAL PROBLEM #3
ASSESSMENT DIAGNOSIS PLANNING IMPLEMENTATION RATIONALE EVALUATION
Subjective: Short term: Independent: To cultivate Short Term:
“may konting pag tatalo Risk for After 1 day of Practice meditation, mindfulness or discernment, awareness, GOAL MET, After rendering
kami ng asawa ko sa mga injuries, and intervention the patient yoga to help lower stress hormones self-regulation and Nursing intervention, the patient
bagay bagay na hindi problems will be aware on the in our bodies while simultaneously higher consciousness in realized the things that she need to
naman dapat pinapalaki” responsibities that she increasing beneficial brain the individual. prioritize especially to her baby.
with inter
need to have. chemicals.
personal Long term:
Objective: relationship. Long term: Get plenty of sleep it helps the It improves GOAL MET, after rendering
•Distress After 3 days of person to keep emotion in check concentration, regulates nursing intervention, the relatives
53
•(+) Body weakness intervention the patient and helps the brain to function mood, and sharpens of the patient helped her to cope
will realize that being well. judgment and decision- up distress by having health
a mother is not about making. teaching and proper treatment.
focusing on herself but
instead focusing on her
baby. Dependent: To  determine
how we handle
• Joining in some stress, relate to
program that can help others, and
your mental improve. make healthy
choices.

POTENTIAL PROBLEM #4
ASSESSMENT DIAGNOSIS PLANNING IMPLEMENTATION RATIONALE EVALUATION
Subjective: Short-term Independent: Long Term:
Risk for planning: -The patient needs
“ Ayaw kong iwan mga separation -One on one talk about her someone to talk about
anak ko dahil bata pa anxiety related After a three hour of problems and listens to it it, knowing that she After nursing
sila pero kailangan ko to fear of nursing intervention, carefully. has somebody to talk intervention the GOAL
kumayod kasi sapat lng separation with the patient will be about it. WAS MET, it shows
kinikita ng asawa ko.” the growing able to understand: that the patient have
as verbalized the newborn -Use presence, touch (with -Being supportive and ought to understand but
patient. -Separation anxiety permission), verbalization, and approachable promotes verbalizing words like
works for both of her demeanor to remind patients that communication. Also she may not be able to
Objective: kids and as a mother they are not alone and to patient will feel secure address it directly with
encourage expression or and will open up more. herself but she has now
-Discourage facial herself, but they will
expression and voice thrive on it. clarification of needs, concerns, patterns and planning
tone unknowns, and questions. on how to do with her
-Needs moral current situation.
support from her
peers and her closest
ones.
54
 POTENTIAL PROBLEM #5
ASSESSMENT DIAGNOSIS PLANNING IMPLEMENTATION RATIONALE EVALUATION
Subjective:  The student nurses  To establish
“Diko pa magawang Risk for bacterial The GOAL WAS
After a couple must assess the the patient’s
maligo kahit na init na infection related to poor PARTIALLY MET,
init nako dahil sabi ng hygiene of days of patient’s capacity, capacity, after rendering nursing
tiyahin ko isang lingo nursing readiness, and readiness and intervention, the patient
daw pag tapos manganak
intervention, barriers to receiving learning has different beliefs that’s
tsaka lang maligo” as health teaching. obstacle. why some self-care needs
verbalized by the patient. the patient will didn’t accomplished, but
be able to students nurses still
identify what  The student nurses respect her decisions.
kind of self- must identify  Cultural
Objective: care she needs
Lack of health teaching cultural norms and beliefs may
when it comes to proper to do and beliefs to filter the affect t5he
hygiene. suited for her. information and patient’s
identify facts over understandin
myths. The nurse g during and
must remain after
judgmental while pregnancy.
also prioritizing
accurate
information.

55
 .

D. FORSEEABLE PROBLEM

FORSEEABLE PROBLEM #1

ASSESSMENT DIAGNOSIS PLANNING IMPLEMENTATION RATIONALE EVALUATION

Subjective data:  Determined the  Sleep problems After 3 days of
Risk to disturb After 3 days of
presence of factors may arise from nursing
sleeping nursing
“Wala po kaming that can interfere with internal and intervention, the
pattern related intervention,
katulong at ibang the patient’s sleep external factors GOAL WAS
to caregiving the patient will
kasama sa bahay kaya patterns such as and may require MET as patient
responsibilities be able to
ako lang mag-aalaga sa having a newborn. assessment over reported an
as evidenced report an
mga anak ko at time. improved quality
by patient improved
gumagawa sa mga of sleep pattern.
verbalization quality of sleep
gawaing bahay” as
of being the pattern.
verbalized by the
only one doing
patient.  To determine
child care and
 Assessed patient’s intensity and
household
usual sleep patterns duration of
chores.
and compare with problems.
Objective data: current sleep
disturbance, relying
on patient’s report of  Helps to clarify
 Fatigue
problem beliefs and
 Lack of energy
expectations and
 Restlessness their perception
 Determined the of quality sleep
patient’s sleep and inadequate
expectations and
reports of sleep
56
 .

quality. sleep.

 Assured the client

that occasional  Helps promote
sleeplessness should relaxation and
not threaten health relief from
and that resolving worry by
time-limited addressing that
situations can restore occasional
healthful sleep. insomnia is
common and
usually is not
 Problem-solve harmful.
immediate needs.

 Short-term
solutions such as
hiring a nanny
or having a
relative help
may be needed
until the patient
is able to adjust
to the current
situation and
return to the
usual sleep

57
 .

pattern.

58
 .

FORSEEABLE PROBLEM #2

ASSESSMENT DIAGNOSIS PLANNING IMPLEMENTATION RATIONALE EVALUATION

Subjective: Risk for anxiety Short Term:  Assess the client’s  To provide Short Term:
"Natatakot akong hindi related to threat of After 1hr. the client level of fear reassurance and
ko magawang alagaan death of her children will identify the comfort After the nursing
ng mabuti yung baby different strategies intervention, GOAL
ko at mawala siya" as to reduce the fear WAS MET, client
 Provide calm,  Promotes learned the different
verbalized by the and combat anxiety
peaceful relaxation strategies on how to
patient.
setting and and ability to lessen the anxiety.
Long Term: After
Objective Data: privacy as deal with the
a week of nursing
appropriate. situation. Long Term:
intervention, the
Client was
client will able to
observed rattled After a week of nursing
hush her fear and
while speaking intervention, GOAL
will be able to face
the challenges that WAS MET, the client
lay ahead and able was able to hush her
to provide a safe fear and able to face
place conducive for the challenges that lays
a newly born baby. ahead of her and
provide a place safe for
her newly born baby.

59
 .

FORSEEABLE PROBLEM #3

ASSESSMENT DIAGNOSIS PLANNING IMPLEMENTATION RATIONALE EVALUATION

Subjective: Short term Independent:  To promote Short term
Risk for body
“babalik pa po ba sa Planning: • Explained all procedure and coping skill of
consciousness After 1 hour of
dati yung tiyan ko? skin care with the use of calm the patients.
related to After 1 hour of nursing
Pangalawang anak ko and slow speech and validates
nursing intervention, the
na po kase” as disturbed body patient understanding.  Replacing
intervention, GOAL WAS
verbalized by the image inaccurate
patient gain MET, patient
patient •provided accurate information to
self-esteem to gain her self-
information if incorrect accurate
her body esteem and free
information is present. information to
image. from doubt and
prevent doubt.
shame about her
Objective:
body
(+) Frequent question
about body image.
(+) expression of

60
 .

FORSEEABLE PROBLEM #4
ASSESSMENT DIAGNOSIS PLANNING IMPLEMENTATION RATIONALE EVALUATION
SUBJECTIVE SHORT TERM: SHORT TERM:
Risk for stress Help the client to identify -Financial stability and
DATA: After 4 hours of After nursing
related to resources that are in tune with economic support
“Hindi namin na alam nursing intervention intervention, GOAL
change in national and local during healthcare
sa ngayon paano namin the client will be able WAS MET, the client
socioeconomic organizations offering treatment can have
maipoprovide yung to identify their need were able to identify
status secondary support. positive impacts on
pangangailangan ko at and will feel at ease their needs and the
to quality of life and a
ng anak namin dahil knowing that they can resources they can go to
unemployment Demonstrate comfort in patient’s likelihood of
pareho kaming walang make and create a way help them meet their
trabaho ngayon dahil to meet their financial assessing and providing adhering to a treatment current financial
ganito kalagayan ko needs. referrals for support plan. demands.
ngayon at binabantayan
naman ako ng asawa LONG TERM: LONG TERM:
ko.” After a month of After the nursing
nursing intervention, intervention, GOAL
OBJECTIVE DATA: the client will be able WAS MET, the client
Feeling anxious and to find various were able to understand
worried how to provide solutions with regards the different ways of
the things they need in the financial problem dealing stress in terms
the near future of financial problem
and to create a way to
their needs, both here
and hereafter.

61
 .

FORSEEABLE PROBLEM #5

ASSESSMENT DIAGNOSIS PLANNING IMPLEMENTATION RATIONALE EVALUATION

Subjective: Short term Planning: Independent: GOAL WAS MET.

“Ang sakit po ng dibdib Risk for breast After 4 hours nursing  Apply warm,  To melt the After 4 hours of nursing

ko feel ko puno na sya inflammation related to intervention the patient moist compress clogged milk in intervention the patient
clogged milk ducts
ng gatas.” as verblized will manifest (-) wedge- to the affected the ducts to verbalized her breast

by the patient shaped area of breast every few flow the milk pain decrease from 7/10

engorgement of the hours. well. to 4/10, and the patient

Objective: breast, (-) hard lump, manifest (-) wedge-

(+) wedge-shaped area and the breast pain  Breastfeed every  To avoid shaped area of

of engorgement of the scale will decrease from 2 hours. clogged curdled engorgement of the

breast 7/10 to 4/10 milk to the milk breast, and (-) hard

ducts. lump.
(+) Hard lump

Breast pain scale 7/10

62
 .

VI. NEONATAL ASSESSMENT

A. ANTHROPOMETRIC DATA
Body Weight 3460 g

Body Length 49 cm

Head Circumference 34 cm

Chest Circumference 33 cm

Abdominal Circumference 32 cm

BS 38 weeks

AS 9

AF Clear

Temperature 36.8 celsius

B. APGAR SCORING

APGAR sign 0 point 1 point 2 points Points

totaled
Appearance Absent Arms and Active 1
(Skin color)
legs  flexed Movement
Pulse Absent Below Over 100  bpm 2

(Heart rate) 100 bpm

Some Active motion 2
Grimace (Sneeze,
(Reflex Flaccid flexion of extremities Cough, pull
irritability) away)
Blue, Pale Body pink, Completely 2
Activity Extremities   Blue Pink

(Muscle tone)
Respiration Absent Slow, Irregular Vigorous cry 2

(Breathing rate
and effort)
Total 9
63

63
 .

C. REVIEW OF SYSTEM PHYSICAL EXAMINATION

SYSTEM FINDINGS ANALYSIS

Misshapen skull occurred

HEAD
 Head slightly misshapen due to pressure from
 Normal ear symmetry and uterine contraction as the
position baby passed through the
 Open anterior and posterior birth canals. Birth canal is
fontanelles narrow, and the
fontanelles and sutures
overlap to accommodate
size. Ear symmetry and
position indicates absence
of genetic disorders. Open
anterior and posterior
fontanelles are normal to
allow brain growth and
development.

Face is smaller than the

FACE cranium with a ratio of
 Normal Configuration 1:8, the forehead is high
and slightly bulged due to
the size of the frontal
lobe.

Pupils are large enough to

EYES  Symmetrical allow light to pass
 Open through and optical media
 Red Reflex is transparent. Eyes are
both open and appear
symmetrical in size and
movement.

Nasal passages are patent

NOSE  Symmetrical and are located midline in
the face with a straight
septum.
64
Ear canals are patent. The

64
 .

EARS baby’s ears  have an external

 Formed and firm ear meatus (opening). and have
 Response to sound a small skin tags and usually is
not concern

Tissues are fused

MOUTH together, and palate is
 Normal configuration intact, indicating absence
of cleft lip and cleft
palate. Tissues normally
fuse together during the
sixth and ninth weeks of
pregnancy. Tongue
extends beyond the lower
gum.

Neck is symmetrical in shape

and no masses were palpated
NECK  Normal mobility which indicates absence of
 No masses congenital torticollis and
masses. Head is not tilted
which means there was no
trauma resulting from delivery.

Normal respiratory rate

 Two aligned nipples
 Normal respiration
CHEST
(40-60 breaths/minute)
o RR: 40 bpm
 Normal Heart rate
(110-160 beats/minute)
o HR: 142 bpm
for neonates is 40-60
breaths per minute and
normal heart rate is 110-
160 beats per minute. The
infant’s respiratory rate is
40 bpm and heart rate is
142 beats per minute,
both of which indicate
normal respiration and
heart rate.  Chest is
symmetrical.

 Round and symmetric

There is no hernia nor
ABDOMEN  Umbilical cord intact and distention. Upon
auscultation, bowel
clamped
sounds are present which
 Bowel sounds present means there is normal
 Abdominal circumference: functioning of the
32cm gastrointestinal tract.
Umbilical cord was
clamped during delivery. 65

65
 .

An infant is delivered
 Smooth pink visible veins with skin ranging from
SKIN dark red to purple and
turns red when the baby
begins to breathe air. Skin
has no lesions and is
smooth.

Full term female infants

GENITALIA have prominent labia,
 Labia Majora and Labia with the labia majora
Minora equally prominent being more prominent and
Female covering the clitoris and
labia minor, due to
 Patent exposure to their mother’s
hormones. Anus is patent
Anus
indicating absence of
imperforate anus.

Extremities Gluteal folds are equal

and full hip abductions
(Arms, Legs, Hands, are normal. This indicate
Feet) that the child can move
 Normal their leg away from the
midline of the body.
   Hips Ortolani’s sign and
Barlow’s sign are
negative showing absence
Spinal Column of posterior hip
 Normal dislocation and stable hip
joints.

A newborn’s spine is normally

flexible accompanied by
convex dorsal and sacral
nerves. Flaccidity and rigidity
are both considered abnormal
in newborns.

 Normal activity
Extremities  Primitive reflexes present
Neurological exam  Head lag
Appropriate responses to
stimuli indicate a well-
functioning central nervous
system. Head lag, wearing
the head flops around
posteriorly to the trunk, is a
normal finding and is 66
expected to be corrected by

66
 .

20 weeks. Presence of
primitive reflexes indicate a
normal functioning of the
CNS as they are necessary
for survival of newborns.

67

67
 .

D. NURSING CARE PLAN

NUMBER 1

ASSESSME DIAGNOS PLANNIN IMPLEMENTATION RATIONA EVALUATI

NT IS G LE ON
Short-Term: Independent: Short-Term:
Objective: Risk of To avoid the
Reduce or eliminate the sources of heat
Hypothermi After 2 hours hour abnormal fluctuation The GOAL WAS
loss in infants
Temp: 36.6 a related to of nursing of temperature in MET after 2 hours of
HR: 146 BPM ineffective intervention, the Evaporation newborn, we tend to intervention, the
thermal patient will now be When a shower, prepare a warm assess the following mother understood the
Crying moderately regulation. able to understand environment. factors that trigger assignment being
and achieve: Wash and dry each section to reduce the abnormal given to her as they
Can breastfeed
evaporation findings in newborn. reach home. The
easily
Babies will: mother will now
Having a Limit the time of contact with clothing Monitoring and perform health
temperature or a wet blanket assessing the vital teaching as she told
between 36.4 to Convection signs will also help her to do.
37.5 º C. Avoid the flow of air (air conditioning, the newborn to
ceiling fan, open vent) assess where to be
Parents will: given something to .
Explain the Conduction
sort especially the
techniques to Warm all the goods for care temperature.
avoid heat loss at (stethoscope, scales, hand care givers,
home. clothes, bed linen)
Radiation
Reduce the objects that absorb heat
(metal)
Place the baby swing bed away from

68
 .

the wall (outside) or window if

possible.
Monitor the baby's body temperature
If the temperature is below normal
Use with two blankets
Assess the environmental sources for
heat loss
If hypothermia settled more than 1
hour, refer to the more expert.
Review of the complications of cold
stress, hypoxia, respiratory acidosis,
hypoglycemia, fluid and electrolyte
imbalance, weight loss.
If the temperature is above normal
Remove the blanket
Remove the headgear, when worn
Assess the environmental temperature
again
If the temperature hyperthermia settled
more than 1 hour, report the physician.
Teach caregivers why babies are
vulnerable to temperature (hot and
cold)
Demonstrate how to save heat during
the bath.
Instruct that do not need to routinely
measure the temperature at home.
Teach to measure the temperature if
the baby is hot, sore, or sensitive
69
 .

excitatory.
Teach the elderly why they are
vulnerable to heat and cold weather.
Refer to the hypothermia and
hyperthermia for prevention.

NUMBER 2

ASSESSMENT DIAGNOSIS PLANNING IMPLEMENTATION RATIONALE EVALUATION

Objective: Impaired skin integrity Short-Term: Independent: Short-Term:
secondary to contact with
the allergens Assess the patient’s Assess skin, noting color, Specific types of After an hour of
The newborn’s skin was status within the hour of moisture, texture, dermatitis may have intervention, the goal was
dry and very rough. intervention and after temperature; note characteristic patterns of met, and when they got
2hrs of intervention the erythema, edema, skin changes and home, the mother
The skin appears to be patient understood that: tenderness. lesions. understood the task she was
peeling and seemed to be assigned. As instructed, the
shedding. treatment for atopic Promote proper skin care Proper skin care and mother will now provide
lesions consisting of with the newborn and adequate to a little health education.
eliminating all allergens never put highly formed lotion will help the baby
and avoiding irritants, lotion with a strong avoid dryness and
extreme temperatures, chemical substance, to itchiness of the skin.
and humidity changes, avoid irritation and might
and other factors. cause bleeding.
Therapy also involves
teaching the client on the
Analysis of the newborn Proper bath with warm
proper application of
within the hour of water to use with the
topical medications.
intervention to see any newborn, will help the
Should not be cut or changes and avoid mother to properly
forcefully peel the skin unfortunate outcomes. shower the baby to
as it will result in avoid infection.

70
 .

bleeding and total

irritation to the newborn.

Should apply baby lotion

as the doctor’s
prescribed to avoid
irritation.
NUMBER 3

ASSESSMENT DIAGNOSIS PLANNING IMPLEMENTATION RATIONALE EVALUATION

Objective: Head deformity secondary Short-Term:
to vaginal pressure of
The head is seemingly delivery Assess the patient’s
higher within the status within the hour of
designated suture line. intervention and after
1hr(s) of intervention
Caput the patient understood
that:
The newborn’s head is
normal because
eventually, the
newborn’s head will get
back to normal as it
should.
Independent: Long term:
Help the mother to The behavior of mother After an hour of
understand that the cause was very worried which intervention, the GOAL
of the unsolicited result can be seen throughout WAS NOT YET MET,
of the baby’s cone head her responses and but the mother
was just a result of the actions with the understood the situation
pressure. questions being asked. and after a week or so
We tend to lessen and her baby’s cone-head
Interviews and calm the mother that will get back to normal.
intervention to lessen the everything that
mother’s worried happened with her
response to her newborn. newborn is all normal.

Cone-headed babies are

a result of pressured
delivery of the mother.

It has no pathological
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significance with the
newborn.
NUMBER 4
ASSESSMENT DIAGNOSIS PLANNING
Risk to aspiration as a Short-Term:
Objective: result of ineffective
breastfeeding Assess the patient’s
The anterior fontanelle status within the hour of
of the newborn is intervention and after
seemingly sunken. 1hrof intervention the
patient understood that:
Crying non-stop but
moderately. The timeframe of the
newborn’s feeding time
should not be exceeded
an hour from the time
she fed her newborn.
Should assess how the
mother is feeding her
newborn. The
techniques and the
maneuver.
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IMPLEMENTATION RATIONALE EVALUATION
Independent: Short-Term:
Provided enough health Providing health After a short hour of
teaching to support the teaching to the mother intervention, the short-
mother and the technique will identify the term planning and
she does whenever she’s supportive details from implementation were
feeding her newborn. the time the newborn met. The goal was
got fed, and she will be focused on the mother
able to understand the on what she will do to
importance of support her newborn.
timeframe. The mother is now able
Assessing the mother’s to understand and can
technique as she feeds follow some techniques
her newborn. Nurses to do with her newborn.
would be able to stance
and prevalence to
support the mother’s
maneuver/
 .

NUMBER 5

ASSESSMENT DIAGNOSIS PLANNING IMPLEMENTATION RATIONALE EVALUATION

Subjective Cue: Short term:
“Sa ngayon di ko Risk for
pa po hyperbilirubinemia After 30 minutes of
napapaarawan si related to no exposure nursing intervention,
baby sa labas kasi to sun as evidenced by the mother will
nasa ospital pa yellow skin color increase her
kami” as knowledge about the
verbalized by the importance of
patient. breastfeeding and the
importance of baby's
Objective Cues: exposure to sunlight
(+) yellowish skin
Color Long term:
After 1 week of nursing
intervention, the baby
was seen at normal
color and there is no
yellowish of skin at all.
The mother also
verbalized that walking
in the morning are part
of their everyday
routine
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-Encourage mother to -Breastmilk can help to Short term:
breastfeed the baby at alleviate bilirubin that After 30 minutes of
least three times in the may cause yellowish nursing intervention,
morning and two times of the skin of the baby the GOAL was
in the evening MET, the mother
increased her
-Suggest schedule of -Sunlight obviously can knowledge of how
morning walk to the treat she can manage her
mother at least 30 hyperbilirubinemia, as baby to avoid
minutes everyday this is how the increasing bilirubin
treatment of and verbalized the
phototherapy was importance of
discovered, and the sun breastfeeding and
emits blue–green light exposing baby to
in the spectrum needed sunlight
to most effectively
convert bilirubin to its
water‐soluble isomers Long term:
for excretion After one week of
nursing intervention,
-Observe the baby after -To monitor if the skin the GOAL was
blanching by pressing will become yellow MET, the baby was
one finger on baby's after pressing it seen at normal skin
forehead color and no presence
of yellow skin at all
 .

VII. DISCHARGE PLAN

HEALTH TEACHING

You must follow the instructions for home care as seen in the following:

• If you are in distress after a surgical incision, tell your loved ones.

• Permit the family members or partners to accept any type of assistance

quickly recovery.

• Avoid applying alcohol, powders, oils, and lotions directly to the affected
area.

• With gentle soap and water, clean the surgical wound, then pat it dry

• Give the body plenty of time to rest and sleep so it can heal more quickly.

• Continue doing the recommended leg exercises, deep breathing, and

coughing.

• If you are experiencing constipation, use any sort of laxative or a moderate

stool softener as prescribed by a doctor.

• Aim for 6 to 8 glasses of water per day.

• Continue consuming nutritious foods including fruits, vegetables, and the

whole grains rapid healing and recovery.

• Take a bath regularly, but pay close attention to the surgery incision.

Outpatient follow-up

• Follow-up blood tests are required to ensure that the ectopic pregnancy has
not returned once pregnancy has been totally removed.

• Keep scheduling follow-up appointments as instructed by your doctor.

Call the emergency department if experiencing any kind of this following:

• Pain intolerance or the ineffectiveness of painkillers

• Edema and redness at the site of the incision 74

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• Constant or sudden stomach pain that gets worse

• An unexpectedly high fever of at least 100.4° F (38.0°C)

• Periods of nausea and vomiting brought on by stomach discomfort

• Fainting or dizziness experience

Environment

• To keep a minimal risk of infection, make sure your home is clean.

• Maintain a well-ventilated space for your comfort, so you may rest and get
enough sleep to improved recovery

• Ensure that your home has sufficient lighting, especially at night,

• Keep the area calm so you can unwind as you mend and recover.

Spirituality

• Maintains open lines of communication among family members or relatives

for comfort and inspiration.

• Maintain a close bond with your partner to keep your marriage happy.

• Allowing oneself to be open in any type of communication will foster a sense

of connection and an upbeat outlook.

Medications

You may need the following medications if the signs and symptoms persist:

• PARACETAMOL cures aches and pains and lowers fever-related high

temperatures.

• CEFUROXIME cures bacterial infections in numerous bodily areas.

• MEFENAMIC ACID moderate and mild discomfort is treated.

• OMEPRAZOLE cures stomach ulcers, acid reflux, heartburn, and

indigestion. 75

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• ONDANSETRON avoids medically caused nauseous and vomiting

treatments.

• KETOROLAC after surgery or a procedure, relatively severe pain is relieved.

Treatment

• As directed by the nurse, continue to thoroughly examine the surgical

incision.

• Consume only the foods that are permitted and avoid unrecommended foods
for wound healing as directed by a doctor.

• Enabling more movement will aid in your rehabilitation.

• Take your meds as prescribed by your doctor on time.

• During healing, get enough sleep and rest.

Nutrition

You must follow the nutritional advice for wound healing as seen in the following:

• Continue permitting yourself to eat white bread, unpeeled fruit, and servings
of 1/2 cup per meal during the six weeks of rehabilitation.

• Maintain hydration by consuming 6 to 8 glasses of water per day, which is

essential for delivering nutrients and oxygen to the wound region to aid in faster
healing.

• Continue to consume enough calories to help the healing process.

• Eat more protein-rich foods including meat, eggs, dairy, tofu, almonds, and
beans because they help the body repair wounds by promoting collagen production,
skin structure, and tissue remodeling.

• Eat less food that is high in sodium, sugar, and fat because they do not aid in
the healing process and may have other negative effects on your health.

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