PLT COLLEGE, INC

SCHOOL OF HEALTH SCIENCES

COLLEGE OF NURSING
IN PARTIAL FULFILLMENT OF THE SUBJECT COURSE REQUIREMENT IN NCM 101
(RLE)
A CASE STUDY
IN
Normal OB (Fetal Growth & Development)
(OB WARD)
Presented by:

I. Romero, Maria Gianne Antonette C-----------------------Introduction

II. Tugguin, Diana Mae B---------------------------------------- Patient’s Profile
III. Tadeo shendee Mae M--------------------------------------- Nursing History
IV. Sion, Ruth Ecclesiastes DG---------------------------------- Physical Assessment
V. Poma, Khate Luzvimin P------------------------------------- 11 Patterns of Functioning
VI. Pagal, Angelica Rose L --------------------------------------- Anatomy and Physiology
VII. Tagure, Samantha Nicole R ---------------------------------Brief Description
VIII. Tan, Vincent Alexsandro G. ---------------------------------Pathophysiology
IX. Tesoro Christine Joy S-----------------------------------------Labaratory Results
X. Sion, Ruth Ecclesiastes DG----------------------------------- Drug Study
XI. Romero, Maria Gianne Antonette C --------------------- Discharge Planning

Presented to:

Romen P, Sales BNS, GM, MSN, RN, MAN MsPh, RM

Ana Rose Castro

Jhon Mark Garma

Arjon Gonzales

AY 2022-2023

1
INTRODUCTION

Fetal Growth and Development Is the process and series of changes that take
place in a woman's organ and tissues as a result of a developing fetus. It is a
condition of having a developing embryo or fetus in the female, when an
ovum is fertilized by spermatozoon. This condition can be ascertain by
checking a sample of your urine or blood for a particular hormone.
Furthermore, pregnancy is the state of female which is produced due to the
implantation of fertilized ovum in the uterine endometrium and ultimately
give rise to a fetus and frequently there ate three stages of prenatal
development.
Within 24 hours after fertilization, the egg that will become your baby rapidly
divides into many cells. By the eighth week of pregnancy, the embryo
develops into a fetus. In just 38 weeks, a fertilized egg (ovum) matures from a
single cell to a fully developed fetus ready to be born. Although different
cultures or religions debate the point at which life begins, for ease of
discussion, all agree fetal growth and development can be divided into three
time periods:
• Pre-embryonic (first 2 weeks, beginning with fertilization)
• Embryonic (weeks 3 through 8)
• Fetal (from week 8 through birth)

2
PATIENT’S PROFILE
Name: Mrs. PS
Address: Purok 2, Maddiangat, Quezon Nueva Vizcaya
Age: 27 years old
Date of birth: October 15, 1995
Place of Birth: Maddiangat, Quezon, Nueva Vizcaya
Status: Married
Educational Background: Vocational
Occupation: House Keeping
Religious Orientation: Roman Catholic
Ward: OB
Bed #: 17
LMP: 01/14/22
EDD: 10/21/22

Admitting Diagnosis: G3P2 (2002) PU AOG 40 weeks 3/7 NO6 Oligohydramnios

Principal Diagnosis:
Attending Physician:
Date and Time of Admission:
Date and Time of Discharge:
G3P3 (3003) pregnancy uterine term cephalic delivered live baby
girl
FLEURJELYN REYNA C. MANANGO MD
October 14, 2022
October 16, 2022

3
 NURSING HISTORY
A. HISTORY OF PAST ILLNESS
Mrs. PS verbalized, that she suffered a usual childhood illness like cough, fever, and
colds. She was usually treated through herbal medicines and water therapy. And she
added that she also consults in the RHU’s.

B. HISTORY OF PRESENT ILLNESS

While resting at their house she felt a pain on her abdomen, that’s why her husband
decided to bring her to the hospital at Region 2 Trauma and Medical Center. Vital signs
taken, FHT monitored and IE done.

C. SOCIO-ECONOMIC HISTORY
As verbalized by her husband, their income comes from being a merchandizer at shopper,
Angel’s supermarket, as a tricycle driver and owner of a sari-sari store. While patient PS
is a full-time house-wife.
The family income ranges from 10,000 to 15,000 (a month).
Food: 6,900 pesos Savings: 2,250 pesos
Electric bills: 3,450 pesos Clothes: 1,200 pesos
Transportation: 1,200 pesos

expenses
transportation
8% food
clothes
8% savings

electric bills

clothes
food
46% transportation

electric bills
23%

savings
15%

4
D. ENVIRONMENTAL HISTORY
Patient PS lives at Purok 2, Maddiangat, Quezon, Nueva Vizcaya. Their house was made
up of concrete materials composing two bedrooms, a kitchen, a living room, and comfort
room. With regards to their source of water, they are buying purified water for drinking
and a faucet powered by electricity for washing. They are using gas range for cooking
and sometimes firewood. They do practice proper waste segregation from biodegradable
to non-biodegradable. The mode of their transportation is by tricycle. The distance of
their house from their RHU is approximately 10 minutes via tricycle.

E. FAMILY HISTORY
Patient PS is the third child among the 5 children of Mr. and Mrs. C. According to her,
her parents and grandparents are healthy and no history of illness like hypertension,
asthma, and diabetes mellitus.

F. OCCUPATIONAL HISTORY
Patient PS is a full time house-wife. Taking care of her family and managing household
chores and their sari-sari store.

G. LIFESTYLE HISTORY
According to patient PS, she spends most of her time taking care of her family.
Sometimes, if she’s have time, she also socialize with her neighbors. And during
Sundays, they were going to church as a family.

H. OB HISTORY
Patient MAR had her menarche at the age of 12, with a regular monthly menstruation that
lasted 4-6 days. When she was 19 years old, she had her first baby via normal
spontaneous delivery and the same with her second child when she was 21 years old.

5
 PHYSICAL ASSESSMENT
A. General Survey
October 15, 2022
During the assessment, the patient looks pale and uncomfortable. She was wearing a
white pajama and a sweater with a black sock. She was in supine position with hep lock
on her right hand. She has a fair skin, a shiny black hair, and spotted some lice and
dandruff.
B. Vital Signs
Vital Signs Normal Range Findings Interpretation
Pulse Rate 60-100bpm 75bpm Normal
Respiration Rate 12-20bpm 18cpm Normal
Temperature 36.5 ºC -37.5 ºC 36.6 ºC Normal
Blood Pressure 120/80 mmHg 90/70mmHg Normal
(systolic)
60-90mmHg
(diastolic)

C. HEIGHT AND WEIGHT

Oct 15, 2021

Area to be Actual Findings Analysis

assessed
Height 149cm Normal
Weight 60 kg Normal
BMI 27.0 overweight

BMI CATEGORIES:
Normal Weight= 18.5-24.9
Overweight= 25-29.9
Obesity= BMI of 30 or greater

Formula: Weight in kg
(Height in m2)

D. CEPHALOCAUDAL
Date: October 19, 2022
Home Visit

6
 PART Normal findings Findings ANALYSIS/
INTERPRETATI
ON
Skin Inspection: Inspection:
-patient’s skin - patients skin reveals
reveals colored colored skin tone w/o - Normal
skin tone w/o unusual discoloration
unusual
discoloration -rough palm is also
noted -Normal

- Skin turgor:
-Skin pinches - Skin turgor:
-Skin pinches easily -Normal
easily and
immediately and immediately
returns to its returns to its texture
texture
Skull and Face Inspection: Inspection: - Normal
-Rounded; -rounded , smooth
smooth skull skull contour
contour.

-Symmetric or Symmetric facial - Normal

slightly feature
asymmetric
facial features,
palpebral
fissures equal
in size,
symmetric
nasolabial
folds.

- Palpation - Palpation: - Normal

-Smooth, - Smooth, uniform
uniform consistency ,absence
consistency; of nodules or masses
absence of
nodules or
masses
Scalp and Hair - Inspection: - Inspection: -
- -Evenly - -hair evenly - Normal
distributed hair distributed.

-Thick hair,
silky, resilient - shiny and silky
hair - -Scalp is wet. -abnormal

7
 -Scalp is clean -dandruff noted
and dry. No - presence of lies
dandruff.
Nails Inspection: Inspection: -Normal
-Nail are -nails are clean
cleaned
- Shape:-there is -Normal
- Shape: normally a 160 degree
- -there is angle between the nail
normally a 160 and the skin
degree angle -Normal
between the - -there is normally a
nail and the 160 degree angle
skin between the nail and
the skin -Normal 
- Capillary refill:
-It takes 1-2 - Capillary refill:
seconds to -It takes 1-2 seconds
return to its to return to its usual
usual color. color.
Eyes - Inspection: Inspection:
-External eye -no lesions and -Normal
structure inflammation noted.
should be free -Both eye blinks
from lesions decently. -Normal
and
inflammation.

Eye lashes Inspection: Inspection: -Normal

-Equally -Equally distributed,
distributed; curled slightly
curled slightly outward.
outward.
Bulbar Inspection: Inspection: -Normal
Conjunctiva -Transparent; -Transparent and
sclera appears sclera is normal
white
Inspection: Inspection:
Cornea -Transparent, -transparent, shiny - Normal
shiny and and smooth details of
smooth details iris are visible.
of iris are
visible
Pupils Inspection: Inspection: -Normal
Accommodatio -With normal -Pupils constricts

8
n and pupillary when focusing on a
Convergence response in near object.
constriction of
the pupils and - -PERRLA
convergence of
the eyes when
focusing on a
near object.
Ears Inspection: Inspection: -Normal
-Ears are equal -Equal in size
in size bilaterally.
bilaterally
(normally 4-
10cm)
Ear Auricles - Inspection: - Inspection: -Normal
-Color same as -Color is same as
facial skinny facial skin,
symmetrical symmetrical and
and auricle aligned of the corner
aligned with of each eye.
the cornea of
each eye and
about 10 degree
from vertical.

Palpation:
- -Mobile, firm, - -Normal
Palpation:
and not tender:
-Mobile, firm and not
pinna recoils
tender.
after it is
folded.
Eternal - Inspection: - Inspection: -
Auditory Canal - -A small - -Odorless, moist - -Normal
amount of discharge.
odorless
cerumen
(earwax) is the
only discharge
normally
present. - -Normal
Cerumen - -pink in color,
maybe yellow, absence of nodules.
and soft, moist,
dry, flaky, or
even hard.
- -Canal walls
should be pink

9
 and smooth and
without
nodules
Tonsils - Inspection: - Inspection: -
- -Pink and - -Normal size, pink, - -Normal
smooth no smooth and no
discharge, of discharge.
normal size.
- Palpation: - Palpation: - -Normal
- -palpable - -palpable
- - -
Neck - Inspection: - Inspection: - -Normal
- -Head hyper - -Head flexes 45º,
extends 60º, head hyper extends
head flexes 45º, 60º, laterally flexes
head laterally 40º, head laterally
flexes 40º, and rotates 70º.
head laterally
rotates 70 º.

Trachea - Palpation: - Palpation: -

- -Central - -Central placement in - -Normal
placement in midline and spaces
midline of are equal on both
neck; spaces sides.
are equal on
both sides.
Thyroid Gland - Inspection: - Inspection: -
- -Thyroid - -As the client - -Normal
cartilage, swallows, the thyroid
cricoid cartilage, cricoid
cartilage, and cartilage and the
thyroid gland thyroid gland move
move upward upward symmetrically
symmetrically - -with 7 (vertebrae
as the client prominent) palpable. - -Normal
swallow

- -With 7
(vertebrae
prominent)
visible/palpable

10
Arms - Inspection: - Inspections: -
- -Arms are - -arms are bilaterally - -Normal
bilaterally symmetric with
symmetric with minimal variation in
minimal size and shape
variation in size - -No edema or
and shape prominent venous
- -Normal
patterning.

- -No edema or - Palpation:

prominent - -Warm to touch
venous bilaterally - -Normal
patterning.

- Palpation:
- -Skin warm to - -Radial pulse have - -Normal
touch equal strength
bilaterally from bilaterally
finger tips to
upper arms. - -Normal
- -Radial pulses - -Brachial pulses have
have equal equal strength
strength bilaterally - -Normal
bilaterally - -palpable

- -The ulnar - -The ulnar pulses may

pulses may not not be detectable
be detectable
- -Brachial - -Brachial pulses have
pulses have equal strength
equal strength bilaterally
bilaterally
Abdomen - Inspection: - Inspection: -
- -Abdomen is - -Abdomen is rounded. - -Normal
flat, rounded or - Linea Nigra and striae
scaphoid gravidarum noted

- Palpation: - Palpation: - -Normal

- -No palpable - -no palpable masses
masses are are present.
present.

Legs - Inspection: - Inspection: -

- -Hair covers - -Hair covers the skin - -Normal
the skin on the on the legs and
legs and appears on the surface
appears on the of the toes

11
 dorsal surface
of the toes -
- -Normal
- -Legs are free - -No lesions or
of lesions or ulcerations noted. - -Normal
ulcerations
- -Identical size - -Same size and shape
and shape - -Normal
bilaterally - Palpation:
- Palpation: - -No edema
- -Normal
- -No edema
present in the - -They are equally
legs warm bilaterally
- -Normal
- -Toes, feet and
- -Strong and equal
legs are equally
bilaterally
warm -
bilaterally - -Normal
- -Femoral - -Bilaterally strong
pulses strong
and equal -Normal
bilaterally
- -It is not
unusual for the
popliteal pulse
to be difficult
- -Normal
or impossible
to detect, and - -Strong tibia pulses
yet circulation
to be normal
- Dorsalis Pedi’s
pulses are
bilaterally -Normal
strong
- -The posterior
tibial pulses
should be
strong
Female - Note for the - Lochia noted. - Normal
Genitalia color of the
skin or
presence of
rashes

12
Anus - Inspection: -
- Anal opening - Anal opening moist, - Normal
should be and hairless as claim
visible, moist by the patient
and hairless.
No
hemorrhoids or
lesions.
Perineal skin
should be
smooth and
free lesions

13
 11 PATTERNS OF FUNCTIONING
PATTERNS BEFORE DURING INTERPRETATION/
HOSPITALIZATION HOSPITALIZATION ANALYSIS
HEALTH -Mrs. PS stated that she -Mrs PS still considered - Health is a state of
PERCEPTION is healthy for he can herself healthy because being that people
AND HEALTH perform daily activities she delivered a healthy define despite in
MANAGEMENT actively and positively. baby via normal delivery. relation to their own
values, personality,
and lifestyles. Health
can include
conditions
previously
considered to be
illness.
(Fundamentals of
Nursing 7th edition,
Potter-Perry.
page 69)

NUTRITION -Mrs. PS takes her meal -she follows the orders of - Her diet changed.
AND three times a day the doctors and nurses. Because those food
METABOLISM without any restriction. - she eats foods that help in the milk
-she consumes 8-10 contains a lot of soup production.  
glasses of water daily. -diet as tolerated - Nutrition is what a
- She usually eats person eats and how
suitéd foods such as the body uses it.
meat and vegetables. (Kozier, Erb Blais
Wilkinsonz) 5th edition
page.1015

ELIMINATION -she urinates for atleast -While confined, she - Theres presence of
6-8 times a day, in urinates 3-4 times with a color in her urine due
yellowish color. presence of streak blood to post-partum (lochia)
color. -frequent urination due
to the compression of
-she defecates once a -she cannot defecate due the gallbladder caused
day with a semi-solid to her environment. by the growth of baby.
consistency and is -The patient is
brownish in color. experiencing difficulty
of defecation due to
psychological effect
and some of
environmental factors.
ACTIVITY AND -in her daily exercise - her walking exercise -changed daily routine

14
EXERCISE and activity she do lessen due to her post- activity due to post-
walking and finishes all partum pain. partum pain.
household chores. -regular physical
activity and exercise
contribute to both
physical and emotional
well-being.

Source: fundamentals
of nursing page 787
COGNITION - She can respond to - She can answer all the -The patient has no
AND stimuli verbally and questions properly. cognitive dissonance
PERCEPTION physically, and does memory deficit and no
not have any deficit signs of mental
senses. impairments.
(Nurses pocket guide
11th edition by
Doenges, Moor house
page 45-54)

SLEEP AND - According to her, she - While staying in the -sleep disturbance due
REST maintains her sleep for hospital, she said that she to some procedures
7-8 hours and having a has lacks of sleep usually such as vital signs
nap for atleast 30 2-4 hours. taking and also to
minutes a day. check and feed her
baby.
-Sleep provides healing
and restoration(mccane
and huether 2006)
-Achieving the best
possible sleep quality is
important for the
promotion of good
health as well as the
recover from illness. Ill
clients often requires
more sleep and rest
than healthy clients.

SELF -she’s well groomed -verbalized that she feels -Healthy self concept
PERCEPTION with proper hygiene uncomfortable due to her has a high stability and
AND SELF everyday environment. generates positive
CONCEPT feeling toward her self.
(Fundamentals of
Nursing 7th edition by
potter-perry page 491)
ROLE AND - As a good and loving - Despite of her situation, -no matter what are the

15
RELATIONSHIP wife, she’s taking care she’s still doing her circumstances or
of their children and responsibilities as a situation that you may
helping them in every mother and a supporting encounter, you can still
problems and activities wife to her loving show your love to them
of daily living. husband. because love is
everything.
Each individual
experiences life
through relationships
with others. 
(Fundamentals of
Nursing by Potter-
Perry page 102)

SEXUALITY -according to her, they -she stated that during - Changes occured due
AND had a sexual satisfying her hospitalization, she to her current situation.
REPRODUCTIO relationship. still express her love to -Sexuality is a part of
N her husband by hugging, individual’s identity
and doing holding and includes biological
hands. sex, gender role, and
sexual partner
preference.
(Fundamental of
Nursing 7th Edition by:
Potter-Perry page 441)

COPING AND -she prefer to stay - she considers her new -having a new member
STRESS quiet, and sometimes baby as her stress of the family can
TOLERANCE she talks to her husband reliever. reduce stress.
or play with her kids. -People experience
stress as a consequence
of daily life events and
experience. Stress is
helpful by stimulating
thinking process and
helping people stay
alert to the environment
furthermore, stress
results in personal
growth and facilitates
development.
(fundamentals of
Nursing by Potter-
Perry page 486)

VALUES AND -they are a part of - Despite her difficulties, -A persons health
BELIEFS Roman Catholic nothing changes in her depends on a balance

16
religion and goes to faith to God. But instead of physical,
church during Sundays. it becomes stronger as psychological, cultural,
With regards to her her days in the hospital sociological,
values and beliefs, she goes by. developmental and
sometimes follow the spiritual factors.
advices of elders’ -Spirituality is an
beliefs but making sure important factor that
not to affect her helps individuals
relationship with God. achieve the balance
needed to maintain
health and well being
and to cope with
illness.
(Fundamentals of
Nursing 7th edition, by
Potter Perry, page 444)

17
ANATOMY AND PHYSIOLOGY

Female Reproductive System

 The female reproductive system has external and internal components just like for
male reproductive system.
 Gynecology is the study of the female reproductive organ.
 Structures that form the female external genitalia are termed the vulva.

18
External structures:
 Mons veneris located over the symphysis pubis, the pubic bone joint.
 Labia minora posterior to the mons veneris spread two hairless folds of connective
tissue
 Labia majora two folds of tissue, fused anteriorly but separated posteriorly, which
positioned laterally to the labia minora and compose of loose connective tissue
covered by epithelium and pubic hair.
 Clitoris small rounded organ of erectile tissue at the forward junction of the labia
minora approximately 1 to 2 cm.
 Hymen tough but elastic semicircle of tissue that covers the opening to the vagina
during childhood.
 Fourchette is the ridge of tissue formed by the posterior joining of the labia minora
and labia majora.

Internal structures:

 FALLOPIAN TUBES

 The fallopian tubes serve as the pathway of the egg cells towards the uterus.

 It is a smooth, hollow tunnel that is divided into four parts: the interstitial, which is 1
cm in length; the isthmus, which is2 cm in length; the ampulla, which is 5 cm in
length; and the infundibular, which is 2 cm long and shaped like a funnel.

 The funnel has small hairs called the fimbria that propel the ovum into the fallopian
tube.

 The fallopian tube is lined with mucous membrane, and underneath is the connective
tissue and the muscle layer.

 The muscle layer is responsible for the peristaltic movements that propel the ovum
forward.

19
  The distal ends of the fallopian tubes are open, making a pathway for conception to
occur.

 UTERUS

Is a hollow muscular, pear-shaped organ located in the lower pelvis, posterior to the bladder
and anterior to the rectum.

It is about 5 to 7 cm long, 5 cm wide and its widest pat is 2.5 cm deep.

Uterus is used to receive the ovum from the fallopian tube, provides a place for implantation
and nourishment, furnish protection to a growing feus and at the maturity of the fetus.

Uterus consist of 3 divisions; body or corpus, isthmus and cervix.

 CERVIX

It is the part of the female reproductive system that connects the uterus to the vagina.
It is the lower part of the uterus and is made up of strong muscles.
The function of the cervix is to allow flow of menstrual blood from the uterus into the
vagina, and direct the sperm into the uterus during intercourse.
The opening of cervical canal is normally very narrow. However, under the influence of body
hormones and the pressure from the fetal head, this opening widens to about 10 cm during
labor, to allow birth of the baby. If the opening is loose, as observed in some women, it can
lead to miscarriage during pregnancy.

Physiology External Structures

Mons pubis is a pad of fat that is located at the anterior, over the pubic bone. After puberty, it becomes
covered in pubic hair.
The labia majora (labia = “lips”; majora = “larger”) are folds of hair-covered skin that begin just
posterior to the mons pubis. Serves as protection for the external genital; they shield the outlet to the
urethra and vagina.
The thinner and more pigmented labia minora (labia=“lips”;minora=“smaller”) extend medial to the
labia majora. Although they naturally vary in shape and size from woman to woman, the labia minora
serve to protect the female urethra and the entrance to the female reproductive tract.
Clitoris it’s covered by a fold of skin and it’s the center of sexual arousal and orgasm in a woman.
Fourchette it is stretches during child birth to allow the engagement of the vagina and passage of the
fetal head

20
Physiology Internal Structures
Ovaries to produce, mature and discharge ova. Also produce estrogen and progesterone and initiate and
regulate menstrual cycle. Ovarian function is for the maturation and maintenance of the secondary sex
characteristics in females.
Uterus is the one to receive the ovum form the fallopian tube; provide a place for implantation and
nourishment; furnish protection to a growing fetus; and maturity of fetus, expel from it from a woman
body.
The Placenta
The placenta (Latin for “pancake,” which is descriptive of its size and appearance at term) grows from a
few identifiable trophoblast cells at the beginning of pregnancy to an organ 15 to 20 cm in diameter and
2 to 3 cm in depth, covering about half the surface area of the internal uterus at term (Huppertz &
Kingdom, 2012).

21
THE BREAST

A. The breasts are specialized organs, which are located on the anterior chest wall.

B. The female breast is more developed than male breast, as their primary function is to produce
milk for nutrition of the infant and baby.

The Anatomy and Physiology of the Breast

The breasts comprise glandular, connective and fatty tissue. Within these tissues are milk-producing
cells. Tiny openings in the nipple allow milk to flow. Surrounding the nipple is the areola, an area of
darker skin that becomes both larger and darker during pregnancy. Montgomery glands located on the
areola secrete a lubricant to help clean the area.

The nipple is stimulated when the baby sucks; muscular tissue surrounding the nipple causes it to
become erect. When the nipple is stimulated, the brain's pituitary gland secretes the hormone prolactin,
which triggers the breast's milk gland cells to produce milk. This does not occur until the baby and
placenta are delivered.

22
 The hormone oxytocin is then released, helping to relax the mother, and causing the milk gland to
contract and push milk out of the nipple. This is called letdown or milk ejection reflex. Letdown may
take several minutes, especially when the mother is tired or tense.

Ovum- From ovulation to fertilization

Fertilization- (also referred to as conception and impregnation) is the union of an ovum and a

23
spermatozoon. This usually occurs in the outer third of a fallopian tube, termed the ampullar portion
(Taylor & Badell, 2011).
Zygote- From fertilization to implantation
Embryo- From implantation to 5–8 weeks.
Fetus- From week 8 through birth

24
BRIEF DESCRIPTION

25
LAB RESULTS
October 14,2022
Urinalysis report
Physical analysis
Color Light yellow
Transparency Clear
Chemical analysis
Protein Trace Normal
Glucose Negative Normal
PH 6.0 Normal
Specific gravity 1.023 Normal

Microscopic examination
Epithelial cells Rare Normal
Pus cells 0-2/hpf Normal
Red blood cells 0-2/hpf Normal
Mucus threads Rare Normal
Bacteria Rare Normal
Amorphous urates Few
Others:

Test Result Normal values interpretation

AST(aspartate 58 units/L 17-59 units/L normal
Aminotranferase
ALT(alanine 48 units/L 0-50 units/L normal
aminotransferase)
ALP(alkaline 115 units/l 38-126 units/L normal
phosphate level test)

Hematology report
Test Result Ref. Value Interpretation/analysis
Hemoglobin(Hgb) 152 g/L 135-180 g/L normal
Hematocrit (Hct) 44 % 40-50% normal
RBC count 4.5 million 4.5-5.9 million normal
cells/microliter cells/microliter
WBC count 7.35 microliter 5-10/ microliter normal
DIFFERENTIAL

26
COUNT

Neutrophils
0.55 0.40-0.70 normal
Lymphocytes 0.35 0.20-0.40 Normal
Monocytes 0.03 0.00-0.06 normal
Platelet count 240 150-450 normal

RBC INDICES
MCV Mean 92.3 picograms/cell 82.0-95.0 pg/c normal
Corpuscular Volume
MCH mean 29.2 27.0-31.0 normal
corpuscular
hemoglobin
MCH mean 346 320-360 normal
corpuscular
hemoglobin
concentration
RDW 12.35% 11.6-14.6% normal

Blood typing- O POSITIVE

Serology-Immunology
Hepatitis B surface Immunochomatography Non-reactive
antigen(HBSAg)

27
 DRUG STUDY
Admitted drug
Classification: Oxytocics
Brand Name: Pitocin
Generic Name: Oxytocin
Doctor’s Order: Incorporate 10 units oxytocin to new 1L x 6-8 gtts/minutes then hooked to ct6 after 20
minutes
Date Ordered: October 15 2022; 12:15 am
Mode of Action Indication Contraindication Side Effect Nursing Implication
-Stimulate uterine -Induction of -Contraindication -CNS: seizure -Assess character,
smooth muscle labor at term IV in patient duration, and frequency of
producing uterine -IM. postpartum hypersensitivity -CV: hypotension uterine contraction, resting
contractions control of to drug. uterine tone, and FTH
similar to those in bleeding after -F and E: frequently throughout
spontaneous labor. expulsion of the hypochloremia, administration.
placenta. hyponatremia
-Has a vasopressor -Monitor maternal BP and
and antidiuretic -Misc: increase urine pulse rate frequently.
effect. motility, decrease
uterine blood flow, -Monitor patient Signs and
-Control of hypersensitivity. symptoms (drowsiness,
postpartum listlessness, confusion,
bleeding. head ache and anuria) and
notify physician and other
health care professional if
they occur.

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Discharge Drugs
Classification: Vitamin
Brand Name: Folate
Mode of Action Indication Contraindication Side Effect Nursing
Implication
-Required for -Prevention and -Uncorrected -CNS: -Assess for
protein synthesis treatment of pernicious, aplastic, Irritability, megaloblastic
and real blood cell megaloblastic and or normocytic difficulty of anemia (Fatigue,
function. macrocytic anemias anemias (neurologic sleep, weakness,
damage) will malaise, dyspnea) Before
-Stimulate the -Even during progress despite confusion and periodically
production of red pregnancy to correction of throughout
blood cell, white promote fetal hematologic -MISC: Fever, therapy.
blood cell, and development abnormality.
platelets. -Skin- rash -May cause
decrease serum
-Restoration and concentration of
maintenance of other B Complex
normal Vitamins when
hematopoiesis. given in high
continues process.

Generic Name: Folic acid

Doctor’s Order: Folic acid 400mg OD
Date Ordered: Oct.16, 2022

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Classification: Anti-anemic
Brand name: Feratab
Generic name: Ferrous sulfate
Doctor’s order: 200mg OD
Date ordered: October 16, 2022
Mechanism of Indication Contraindication Side Effect Nursing
Action consideration
-Ferrous sulfate -Prevention of -Contraindication is -GI: nausea, -Advice pt. To
is an essential treatment of iron patient receiving take medication
component of deficiency blood transfusions. -PO: properly, and do
hemoglobin, anemia due to -Constipation, not double
myoglobin and inadequate, diet, -Primary in diarrhea, abdominal dosses.
enzymes. malabsorption hemochromatosis. pain.
pregnancy, and -Monitor daily
- It is necessary
blood loss. -Hemolytic anemias -Respiration: pattern of bowel
for effective
erythropoiesis and other anemia not Hyperventilation. activity and
and transport or due to iron stool
utilization of deficiency. consistency.
oxygen.
-Advice pt. that
stool may
become dark
and green or
black and this
change is
harmless.

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Classification: Analgesic
Brand name: Ponstan
Generic name: Mefenamic acid
Doctors order: 500mg 1 tab. OD
Date Odered: October 16, 2022
Mechanism of Indication Contraindication Side Effect Nursing
Action consideration
-Anti- -Relief of -With -CNS: headache, -Assess for history
inflammatory moderate pain hypersensitivity to dizziness, of pt. allergies to
analgesic and when therapy aspirate allergic, insomnia. NSAIDS.
anti-pyretic will not exceed and as treatment of -GI: nausea, GI
activities relatedone week. perioperative pain pain, diarrhea, -Educate pt.
to inhibition of -Mefenamic with coronary constipation. regarding desired
prostaglandin
acid is given to artery bypass -GU: dysuria, and adverse effects.
synthesis.
pt. for relief of grafting. renal impairment.
-Exact mechanism acute to -Educate pt. that
of action are not moderate severe -Respiratory: prolong use of
known. pain. dyspnea, drug, follow
hemoptysis, exactly as prescribe
pharyngitis. and indicated.

-Advice pt. to do
not increase or
double the dose.

-Then do not
administer with
anticoagulant and
other drug that
cause GI upset.

-Instruct pt. to
discontinuation of
medication if
adverse effect
occur.

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Classification: vitamin
Brand name: Cecon, vitamin C
Generic name: ascorbic acid
Doctor’s order: 500mg OD
Date ordered: October 16, 2022
Mechanism of Indication Contraindication Side Effect Nursing
Action consideration
-Increase -Dietary -Contraindication -CNS: headache -Advice pt. To
protection supplement in use of sodium in high doses take medication
mechanism of ascorbate in pt. n on right timing.
the immune -Frank and -GI: nausea,
sodium reaction.
system, thus subclinical vomiting, -Inform pt.to be
supporting scurvy. heartburn and cautious of the
wound healing. diarrhea. side effects of
-To prevent
drugs.
vitamin C in pt. -Hematologic:
with poor acute hemolytic -Instruct pt.
nutrition habits. anemia. about the
possible side
-To acidify urine -Others:
effects of the
dizziness, mild
drugs.
soreness.
-Advice pt. to eat
food rich in
vitamin C like
guava, papaya,
oranges,
tomatoes, bell
pepper and other
food.

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DISCHARGE PLANNING

Medication
 Mefenamic acid 500 mg TID
 Ascorbic acid 500mg OD
 Folic Acid 400mg OD +
 Ferrous Sulfate 200mg OD
Exercise/environment
 Walking at least 5-10 minutes.
Treatment
 Exercise
 Get plenty of rest
 continue medication
Health teaching
 Encourage to increase fluid intake
 Attend follow up check-up on October21, 2022.
 Proper hygiene (hand hygiene before and after eating, take a bath daily, wipe/wash the mother’s
nipple before and after breastfeeding the baby.
 Advice mother to eat greater amount and variety of healthy foods, such as meat, fish, beans,
vegetables, milk to help her feel strong.
 Advice the mother not to smoke cigarettes and avoid the baby to expose to smokers.
 Advice the mother to minimize the amount of soap, shampoo, and other cleansers that may
contact the nipples.
 Practice family planning.
 Avoid alcohol, caffeine when breastfeeding.
 Advice the mother to avoid hard physical works.
 Do not use any medication without prescription of the doctor.
 Do not expose the baby to direct sunlight beyond 8:00 am and beyond.
 Always watch for any signs of hunger of the baby such as restlessness, sucking motions and lip
movements.
OPD appointment
 Follow-up check-up on October 21, 2022
Diet
 More in soup in order for the mother to produce more milk.
 Eat fruits and vegetables.
 Limit junk foods.

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  Drink plenty of water.
 Eat foods that have protein such as milk, meat, fish, and beans.
 Limit eating chocolates and spices
Spirituality/Sexuality
 Always seek protection from Almighty God.
 Wait 4-6 weeks before having sex.
 Practice family planning.

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