SAINT MARY’S UNIVERSITY

BAYOMBONG, NUEVA VIZCAYA, PHILIPPINES

SCHOOL OF HEALTH AND NATURAL SCIENCES

CASE ANALYSIS
G3P2 (3003) 38 WEEKS OF GESTATION

Presented to
The Faculty of the School of Health and Natural Sciences
Saint Mary’s University
Bayombong, Nueva Vizcaya

In Partial Fulfilment of the Requirements of

NCM 109 Related Learning Experience

Submitted to:
Sir. Jethro Mendiguarin, RN
Clinical Instructor

Submitted by:
Marisabel Joy E. Udde-e
BSN 2F

April 2023

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 SAINT MARY’S UNIVERSITY
BAYOMBONG, NUEVA VIZCAYA, PHILIPPINES
SCHOOL OF HEALTH AND NATURAL SCIENCES

TABLE OF CONTENTS
I. PATIENT PROFILE (3P’S)

II. PAST HISTORY

III. PRESENT HISTORY

IV. OBSTETRIC HISTORY

V. ADDITIONAL ASSESSMENT

VI. NURSING CARE PLAN

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 SAINT MARY’S UNIVERSITY
BAYOMBONG, NUEVA VIZCAYA, PHILIPPINES
SCHOOL OF HEALTH AND NATURAL SCIENCES

I. 3PS

A. PATIENT’S PROFILE

Name Mrs. AB
Age 31 years old
Address Brgy. Arwas, Diadi, Nueva Vizcaya
Birthday March 12, 1992
Sex Female
Blood Type A+
Nationality Filipino
Civil Status Married
Religion Roman Catholic
Educational College Graduate
Attainment
Occupation Accountant
Monthly Income 25, 000.00
Language Ilocano, Tagalog, English
Primary Health Care RHU
Age of Gestation 30 weeks
Source of information RHU
Presenting Complain Low back pain radiating at the abdomen
accompanied by nausea and vomiting.
Age of gestation 38 weeks
Date of Admission March 5, 2023
Date of Discharge March 10, 2023
Attending Dr. ML
OB/PHYSICIAN

SIGNIFICANT OTHER’S

Name Mr. CB
Sex Male
Age 32 years old
Birthday February 18, 1991
Address Brgy. Arwas, Diadi, Nueva Vizcaya
Blood type O
Religion Roman Catholic
Civil Status Married
Occupation Engineer
Monthly income 30,000.00
Relationship Husband

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 SAINT MARY’S UNIVERSITY
BAYOMBONG, NUEVA VIZCAYA, PHILIPPINES
SCHOOL OF HEALTH AND NATURAL SCIENCES

II. PAST HISTORY

Mrs. AB stated that she has no history of surgery or bleeding disorders. No
medicine or food allergies. No recognized co-morbid diseases, no prior history of
malignancy, pulmonary TB, diabetes mellitus, or asthma.

III. PRESENT HISTORY

Due to low back pain and complaints of nausea and vomiting, the patient was
brought to the emergency department. In her third pregnancy, she is 38 weeks
along. All required prenatal care has been given to her.

1ST Trimester
After 2 months of missed periods, she performs a pregnancy test at home. She
knew that she was pregnant because it was a planned pregnancy. She visited a
private clinic to get confirmation and was told that she’s 12 weeks pregnant. On
August 5, 2022, she set up an appointment at RHU Hospital. According to routine
blood and urine sample tests, she has a B+. Hemoglobin levels were normal.
There were supplements offered. They assessed her weight and blood pressure.
She shows no fever, rash, vaginal discharge, itching, or dysuria during her 1 st
trimester. The scan was done on August 5, 2022.

2nd Trimester
At 19 weeks, she felt pregnancy flutters, and at 28 weeks, a tetanus toxoid
injection was administered. Her body weight gained normal and blood pressure
are normal. On August 22, 2022, a 2 nd trimester scan was performed with a
normal hemoglobin level.

3rd Trimester
The fetal movement was good. A growth scan was performed, and the results
were normal.

IV. OBSTETRIC / GYNECOLOGIC HISTORY

Mrs. AB said that her menarche began when she was 12 years old, that her
menstruation is regular, lasting 4-6 days, and that the interval was 28–30 days.
She additionally stated that her thelarche happened when she is 15 years old.
When kindly questioned about her coitarche, the patient acknowledged that her
first coitus happened when she was 23 years old, that she has only had one
sexual partner—her husband—and she has no history of dyspareunia, post-coital

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 SAINT MARY’S UNIVERSITY
BAYOMBONG, NUEVA VIZCAYA, PHILIPPINES
SCHOOL OF HEALTH AND NATURAL SCIENCES

bleeding, or sexually transmitted diseases. The contraception that they used is

condom with no past surgery of any reproductive organ. They used condoms as
contraception, with no prior surgery on any reproductive organs.

Patient is a G3P2 pregnancy. Her LMP was June 2022. She first became pregnant
when she was 22 years old. She delivered her first baby normally, and it was
preterm baby girl. At the age of 25, she became pregnant again and delivered a
preterm baby boy. And she got pregnant again at 31 years old.

No. of Delivery Baby at birth Present Age Comments

babies
G1 Normal Cried soon 22 years old Immunization
delivery, after birth, is normal
Government Female, 2.26
Hospital kg, Breast fed
3 years.
G2 Normal Cried soon 19 years old Immunized
delivery, after birth, normal
Government Female
Hospital 2.28kg, Male,
Breastfed 3
years.

V. ADDITIONAL ASSESSMENT
 The patient’s body build is moderate.
 Vital signs (at time of admission)
Temperature: 37.9
Pulse: 120/min
Respiration: 22/min
B.P.: 170/100mm Hg
Hydration: inadequate
Anemia: No
Pallor: No
Heart: NAD
Lungs: NAD
Liver: NAD

The patient is complaining about low back pain radiating at the abdomen thus,
she was hooked to NST machine and oxygen via nasal cannula at 2 lpm. The ER
nurse also noticed that she has facial and peripheral edema. Hence, the OB

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 SAINT MARY’S UNIVERSITY
BAYOMBONG, NUEVA VIZCAYA, PHILIPPINES
SCHOOL OF HEALTH AND NATURAL SCIENCES

doctor ordered Magnesium Sulfate 4 grams IV push for 20 mins, Nicardipine.

Drip 90 :1 to be incorporated with normal saline solution to run for 10 ml per
hour and to be titrated by 5 ml if BP is still high, Furosemide 40 mg IV every 6
hours with BP precaution and metoclopramide 10 mg IV now every 6 hours for
nausea and vomiting.

VI. NURSING CARE PLAN

PREOPERATIVE

Assessment Diagnosis Planning Interventions Rationale Evaluation

Subjective cues: Decreased Short term Assess heart Most patients Outcome met.
cardiac goal rate and have After 3 days
The patient is output After 8 hours blood compensatory of proper
complaining of low related to of proper pressure. tachycardia nursing
back pain radiating decrease nursing and interventions,
at the abdomen, venous interventions, significantly the patient
together with return as the client’s low blood was able to
nausea and evidenced decreased pressure in demonstrate
vomiting. by cardiac response to increased
peripheral output will be reduced cardiac
Objective cues: edema. lessened. cardiac output as
Facial and output. evidenced by
peripheral edema. Long term blood
VS taken as follows: Goal Assess Weak pulses pressure and
B/P: 170/100 After 3 days peripheral are present in pulse within
PR: 120 of proper pulses, reduced normal rate.
RR: 22 nursing including stroke volume
SPO2: 92% interventions, capillary and cardiac
Temp: 37.9 the patient refill. output.
will be able Capillary refill
to is sometimes
demonstrate slow or
increased absent.
cardiac
output. Assess Fatigue and
reports of exertional
fatigue and dyspnea are
reduced common
activity. problems
tolerance. with low
cardiac
output states.
Close

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 SAINT MARY’S UNIVERSITY
BAYOMBONG, NUEVA VIZCAYA, PHILIPPINES
SCHOOL OF HEALTH AND NATURAL SCIENCES

monitoring of
the patient’s
response
serves as a
guide for
optimal
progression
of activity.
If chest pain
is present, These actions
have the increase
patient lie oxygen
down, delivery to
monitor the coronary
cardiac arteries and
rhythm, give improve
oxygen, run a patient
strip, prognosis.
medicate for
pain, and
notify the
physician.

INTRAOPERATIVE

Nursing Diagnosis Interventions Outcome Statement Evaluation

Risk for infection  Classify Surgery is The patient is free
surgical performed using of signs and
wound. aseptic techniques symptoms of
 Perform skin and, in a manner, to infection.
preparations. prevent cross
 Implements contamination.
aseptic
technique.
 Monitor for
signs and
symptoms of
infection.
Risk for impaired Skin remains The patient is free
skin integrity related  Positions the smooth, intact, non- of signs and
to positioning, patients. symptoms of

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 SAINT MARY’S UNIVERSITY
BAYOMBONG, NUEVA VIZCAYA, PHILIPPINES
SCHOOL OF HEALTH AND NATURAL SCIENCES

immobilization, reddened, non- physical injury.

pressure, and/or irritated, and free of
shearing forces. bruising other than
surgical incision.
 Uses supplies
and
equipment
within safe
parameter. Function, sensation,
motion, and
 Implements respiratory status
protective will be maintained
measures to or improved from
prevent skin baseline
or tissue assessment.
injury due to
thermal,
chemical, or
mechanical.

Assessment Diagnosis Rationale Planning Implementation Outcome

Subjective Acute pain Pain is one of Short term Assess pain Goal met. After 2 hours of
cues: is related to the most goal: scale. intervention, the patients state
“Masakit pa disruption complex After 1-2 that the pain has reduced.
rin yung tahi of skin and human hours of Monitor vital
ko” stated by tissue experiences, nursing signs.
the patient. secondary is an invisible intervention,
to cesarean phenomenon the patient Establish a good
section. influenced can rapport.
by the verbalize
interaction reduced of Assess quality,
of emotion, pain or characteristics,
behavioral, discomfort. severity of pain.
cognitive,
and Long term Instructed to
physiologic- goal: support or
sensory Absence of splint the
factors. pain abdominal
Because pain incision when

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 SAINT MARY’S UNIVERSITY
BAYOMBONG, NUEVA VIZCAYA, PHILIPPINES
SCHOOL OF HEALTH AND NATURAL SCIENCES

is a highly moving,
individual coughing, and
experience, deep breathing.
the basis for
pain Health teaching:
management Emphasize
is simply the importance rest
client’s periods after
verbalization every activity.
of pain.
Fundamental
of nursing,
CRAVEN p
1168
POSTOPERATIVE