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E.

Aguinaldo Highway, Talaba IV, Bacoor Cavite

School of Nursing and Allied Health Studies In partial fulfillment of the requirements in Nursing Care Management 104

A Case study on a Post Partum Care of a Normal Spontaneous Delivery (NSD) Submitted by: Janer, Ivy Monica P. Ladan, Danra-Ann R.

BSN 3A Group 4

Submitted to: Ms. Tita B. Buenaobra, RN, MAN December 14, 2011

Normal Spontaneous Delivery


LEARNING OUTCOMES For at least four weeks of duty, I have encountered several constraints with regards to the implementation of interventions. It was not that easy specially that what I am dealing with are lives, lives through which if jeopardized, can either put me in an obnoxious situation or be blameworthy for any complications. Three days of multi-tasking and time management, the OB- NURSERY ward exposure has taught me how to appropriately handle pregnant and post partum women. The idea of caring for mothers and newborns which is not in my lineage is hard. Hard, because some of the patients are uncooperative and non compliant. It isnt that smooth to establish an interacting relationship specially that most of the patients admitted in the institution has a low educational attainment. Therefore, I cannot expect them to fully comprehend the instructions I have imparted. However, it was a marvelous experience since I was exposed to various kinds of maternal paragons and procedures which werent return demonstrated yet. Fortunately, there is our clinical instructor who persistently supervised us and assisted us to make it through with just minimal errors. Now, let me get this straight. This is my first time to manage an individual case study. Adding to that is the fear of making a physiologic structure of my opted case. One false move and I am screwed. I have learned to thoroughly assess my patient to comply with the requisites. Also, I have acquainted myself with regards to establishing rapport with my patient to have a trusting relationship

BUBBLE SHE
BREAST Patients breasts are slightly unequal in size, left breast is slightly larger, rounded in shape and generally symmetric. Fullness feeling in the left breast as verbalized by the client. Skin is intact, dry and has no discoloration. No lesions and scars noted. There was presence of striae on both breasts. Patient verbalized slight pain, 2 out of 5, on left breast. Areolas are round, dark brown in color, equal in size, bilaterally the same and bigger than the normal. Nipples are not inverted, equal in size and similar in color. Skin on axilla is dark, hairless and odorless, no masses or tenderness noted. UTERUS The fundus of the uterus was firm and one fingerbreadth below umbilicus. BLADDER When the hypogastric region was palpated, bladder was not distended. BOWEL 20 25 bowel sounds per minute noted upon auscultation. LOCHIA Dark red discharges in minimal amount noted on the diaper pad as verbalized by Mrs. Lopez. EPISIOTOMY Patient refused to be assessed on the genitourinary area. We were not able to inspect the episiotomy for redness, edema, ecchymosis, discharges and approximation. HOMANS SIGN To test for Homans Sign, the leg was extended and the foot was dorsiflexed. No pain on both legs as verbalized indicating negative Homans Sign. EMOTION We observed that our client was very dependent as evidenced by asking for the remote, for water and many things. Since it is her first baby, she still needs the assistance of her mother in caring of the infant.

Upon the interview of our clients she shared to us that she is very happy that the delivery of the baby was finish. She said that she still feels the experience of labor and delivery through the pain of her surgical incision in the perineum. STAGES OF LABOR Childbirth, also called parturition, is the culmination of pregnancy. It usually occurs within 15 days of the calculated due date. The series of events that expel the infant from the uterus are referred to collectively as labor. The four stages of the childbirth process are based on changes in the uterus and cervix as labor progresses. Stage 1. Dilatation and Effacement First stage of labor which is the longest begins with the onset of regular contractions which progress to cervical dilatation and effacement. There are three phases on the first stage: the early or latent phase, the active phase and the transition phase. At the end of the first stage, the cervix is dilated to 10 centimeters. In mothers having their first child, this stage usually lasts 12 to 16 hours and shorter on subsequent pregnancies. Early or Latent Phase. During the early or latent phase, the cervix dilates to 4 centimeters. The duration of the first phase is the longest, averaging around 8 hours. Contractions may be irregular, progressing to rhythmic and methodical. The pain felt at this early stage may be similar to menstrual pain: aching, fullness, cramping and backache. Active labor is marked by regular contractions that become longer, stronger and closer together over time. The cervix is 4-7 centimeters dilated. It is recommend that you go to the hospital when the contractions are five minutes apart, lasting more then 60 seconds for at least an hour. Measuring the contractions from the start of one contraction to the beginning of the next must be done. A tightening feeling in the pubic area and increasing pressure in the back is felt. Breathing techniques may already begin. Pain medication is often given at this stage. Transition is the most difficult phase of labor, and fortunately, the shortest, lasting from 30 minutes to two hours. The cervix is opening the last few centimeters, from 8 to 10 centimeters. The pain may be intense, as the cervix stretches and the baby descends into the birth canal. Stage 2. Expulsion Stage This begins with delivery of the newborn and ends with delivery of the placenta. Average length for first time mother ranges from one to two hours and shorter on subsequent births. At the beginning of the normal second stage, the head is fully engaged in the pelvis; the widest diameter of the head has successfully passed through the pelvic brim. Ideally it has successfully also passed below the interspinous diameter. This is the narrowest part of the pelvis. If these have been accomplished, all that will remain is for the fetal head to pass below the pubic arch and out through the introitus. This is assisted by the additional maternal efforts of bearing down. The fetal head is seen to crown as the labia part. At this point the woman may feel a burning or stinging sensation. This is also known as the ring of fire. Stage 3. Placental Stage This begins with the birth of the baby and ends with the delivery of the placenta. Average length for all vaginal deliveries ranges from five-to-fifteen minutes. Maternal blood loss is limited by contraction of the uterus following delivery of the placenta. Normal blood loss is less than 600 ml. The third stage can be managed either expectantly or actively. Expectant management (also known as physiological management) allows the placenta to be expelled without medical assistance. Breastfeeding soon after birth and massaging of the top of the uterus (the fundus) causes uterine contractions that encourage delivery of the placenta. Active management utilizes oxytocic agents

and controlled cord traction. The oxytocic agents augment uterine muscular contraction and the cord traction assists with rapid delivery of the placenta. Stage 4. Recovery Stage This begins with the delivery of the placenta and ends from one to four hours after birth. In this stabilization phase, the uterus makes its initial readjustment to the nonpregnant state. The primary goal is to prevent hemorrhage from the uterine atony and the cervical or vaginal lacerations.

Mechanism of Labor
The ability of the fetus to successfully negotiate the pelvis during labor involves changes in position of its head during its passage in labor. The mechanisms of labor, also known as the cardinal movements, are described in relation to a vertex presentation, as is the case in 95% of all pregnancies. Although labor and delivery occurs in a continuous fashion, the cardinal movements are described as 7 discrete sequences, as discussed below.[2]

Engagement
The widest diameter of the presenting part (with a well-flexed head, where the largest transverse diameter of the fetal occiput is the biparietal diameter) enters the maternal pelvis to a level below the plane of the pelvic inlet. On the pelvic examination, the presenting part is at 0 station, or at the level of the maternal ischial spines.

Descent
The downward passage of the presenting part through the pelvis. This occurs intermittently with contractions. The rate is greatest during the second stage of labor.

Flexion
As the fetal vertex descents, it encounters resistance from the bony pelvis or the soft tissues of the pelvic floor, resulting in passive flexion of the fetal occiput. The chin is brought into contact with the fetal thorax, and the presenting diameter changes from occipitofrontal (11.0 cm) to suboccipitobregmatic (9.5 cm) for optimal passage through the pelvis.

Internal rotation
As the head descends, the presenting part, usually in the transverse position, is rotated about 45 to anteroposterior (AP) position under the symphysis. Internal rotation brings the AP diameter of the head in line with the AP diameter of the pelvic outlet.

Extension
With further descent and full flexion of the head, the base of the occiput comes in contact with the inferior margin of the pubic symphysis. Upward resistance from the pelvic floor and the downward forces from the uterine contractions cause the occiput to extend and rotate around the symphysis. This is followed by the delivery of the fetus' head.

Restitution and external rotation


When the fetus' head is free of resistance, it untwists about 45 left or right, returning to its original anatomic position in relation to the body.

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

A. DEMOGRAPHIC DATA 1. Client's Initial: 2. Gender: 3. Age: 4. Birthday: 5. Civil Status: 6. Religion: 7. Address: 8. Educational Background: 9. Occupation: 10. Usual source of Medical Care:

Ms. S.G. Female 26 yrs old November 24, 1985 Married Christian Poblacion, Muntinlupa City College Graduate Call Center agent Hospital

B. SOURCE AND RELIABILITY OF INFORMATION The source of information was exactly the patient who is reliable and capable in giving data. We also gather information from the mother-in-law of the patient and from the chart of patient. C. CHIEF COMPLAINT 1. Labor pain Pain scale of 7/10 2. Uterine contraction Humihilab ang tiyan ko, As verbalized by the patients daughter D. HISTORY OF PRESENT ILLNESS Prior to admission, patient felt of giving birth at that time because of labor pain and uterine contraction that she was experience. According to the patient, when she tells to her husband that she felt pain, they decided to go to Ospital ng Muntinlupa. She admitted on December 5, 2011 at 3oclock am with vital sign of temp:36.5, PR: 90bpm, RR: 22cpm and BP:140/80 in the emergency room. They made internal examination and the fetus is 1cm dilated, beg. Eff positive bow, cephalic floating. E. PAST MEDICAL HISTORY OF PAST HEALTH According to the patient, her childhood illnesses were common cough, colds and fever. She didnt experienced any injuries or accidents. Her first hospitalization is when she knows that she is pregnant, thats the time she went to hospital. She diagnose for having UTI when she had a regular check-up on April 2011, 1 month after she was pregnant. She also completed her vaccination with her 1 brother. The patient doesnt have any allergies in medications, foods and environment. She doesnt smoke and drink alcohol. She takes Ferrous sulfate, vitamin C and antibiotics when the doctor prescribed it to her.

F. FAMILY HISTORY

Mrs. Z (Mother) Mr. X Mr. M (Husband) (Brother)

Mr. Y (Father)

Ms. S.G.

Baby C

LEGEND:
Female

Baby Patient

Male

Ms S. G is the first child of Mrs. Z and Mr. Y. According to Ms. S.G, on history of mother side, they had history hypertension, while on his father is diabetes mellitus G. SOCIO-ECONOMICS-INCOME According to the patient, she and her husband provides for the necessity of their starting family with the help of their family, especially their parents. Ms. S.G. is a call center agent while her husband, Mr. M is a sales representative. But when she know that she is pregnant, she quit on her job to take a rest and care for being pregnant. She belong in middle class.

H. DEVELOPMENTAL HISTORY Ms.S.G. 26 years old Call center agent

Theory Erik Erickson (Psychosocial Theory) Intimacy vs. Isolation (Young Adults, 20 to 40 years)

Description The Intimacy vs. Isolation stage of Young is the ability to form intimate relationship requires that the person has achieved the sense of trust. The sense of trust provide the base on which the person will feel safe and secure to give affection and expect the same affection in return for the ultimate purpose of establishing a permanent intimate relationship.
 

Patient Started a new stage of life, parenting Decide with her partner about the things happen in their life. Use leisure time creatively for her bonding and enjoyment. Give time and effort for a family.

I.

OB GYNE History Assessment of a Pregnant Woman Health History: Name: Ms. S.G. Address: Poblacion, Muntinlupa city Age: 26 years old Civil status: Married Religion: Christian Chief complaint: Labor pain and uterine contraction History of Present Condition: Menarche: 14 years old Length and duration of menstrual cycle: 5 days duration (regular) Reg cycle: 3 pads per day Obstetric History LMP March 4, 2011 EDC December 11,2011 AOG Upon admission G1P0(0000)

Final diagnosis G1P1(1001) NEWBORN RECORD Name: Baby boy G. Date of birth: December 5, 2011 Time: 09:54 am Diagnosis: term male 39weeks delivery via NSD wt. 3.05kg AGA Weight: 3.05kg Body length: 50cm Head circumference: 33cm Abdominal circumference: 28cm Hepatitis B vaccine right thigh 12-5-11 Apgar Scoring 12-5-11 Heart rate Respiratory effort Muscle tone Reflex irritability Color Total: Ballard 39weeks Maturity Activity Tone Cry Color Temperature Spine Reflexes Anus 1 min 2 2 2 2 1 9 5 min 2 2 2 2 1 9

Term good good good pinkish hypothermic no deformities positive moro,grasp, Babinski patent

II.

REVIEW OF SYSTEM Procedure Done: December 5,2011 Time: 6am-3pm shift

Vital Signs: Temp: 36.5oC PR: 90 bpm RR: 22 cpm BP: 140/80 mmhg Weight: 140kg A. General Physical Survey

The patient is conscious and coherent but weak. During the interview and physical examination the patient had an eye to eye contact and he was cooperative. Inspection: y Color of skin is white but shes a bit pale than usual and lighter colored of palms and soles. y Few pigmentation on face y No lesions and bruises seen Palpation: y Soft and smooth skin y Dry and warm to touch y Skin returns immediately to original position when it pinch y Her hands have slight edema. Inspection: y Hair distributed equally y Hair color is black y No parasite seen Inspection: y No clubbing of fingers Palpation: y capillary refill is normal from 2 seconds Inspection: y The patients head is proportionate to the body size. y (-) tenderness in the scalp. y Her head is round and symmetrical.

B. Integumentary Skin

Hair

Finger/Nail

C. Head

D. Eyes

E. Ears

F. Nose and sinuses

G. Mouth and throat

H. Neck

I. Breast and Axillary

J. Respiratory

y Symmetric facial movement Palpation: y No nodules and masses palpated Inspection: y Pupils are equal, round and reactive to light and accommodation y Palpebral conjunctiva is shiny and pinkish in color y The pupils shape is round and color black. y The eye brows are evenly distributed. Inspection: y Located symmetrically y Patient responds to medium voice stimulation y No discharge seen on both ears Palpation: y Firm and not tender Inspection: y Placed symmetric and straight y no discharge seen Palpation: y No tenderness of frontal sinus Inspection: y Complete teeth, dry and dark lips with pinkish gums y The color of the hard and soft palate is pink and is intact. Inspection: y Presence of pigmentation in some areas on her neck. Palpation: y No enlarge gland and inflamed nodes palpated y Smooth, firm and not tender Inspection: y chest appearance is symmetrical y Areola is large and dark in color. Palpation: y warm to touch y no palpable mass and lesions Inspection: y The chest expansion is symmetrical. y When percussed the sound is resonance.

K. Cardiovascular

L. Gastrointestinal

M. Urinary N. Genitalia

O. Musculoskeletal

P. Neurologic

Palpation: y Symmetrically expanded on upper and lower tract when breathing upon palpated. Auscultation: y When auscultated murmurs and crackles are absent. Inspection: y Patient blood pressure is 130/80 mmhg y capillary refill is normal from 2 3seconds Auscultation: y Distinct sound heard when auscultated the heart y Rhythm is regular y Patients heart rate is 82 bpm y PMI is located in the apical pulse. Inspection: y Presence of Striae gravidarum y Large due to fundus which 2 breaths away from the umbilical cord. Auscultation: y Theres pain upon palpation Inspection: y Urinates 8 times a day. Inspection: y Lochia is red y Patient still in pain Inspection: y Patient stand with assistant y Slow movement, weakness Inspection: y The patient is conscious and cooperative but weak y Patient is alert, spontaneous and oriented

III.

Laboratory results


PHYSICAL Color: light Yellow Reaction: 7.0 Transparency: SL. Turbid

URINARY TEST CHEMICAL Microscopic Pus Cells/Hpf: 6-10 RBC/Hpf: 2-5

Specific Gravity: 1.010

Epithelial cells: Moderate Bacteria: few Mucus thread: Moderate Crystals A. phosphate: Moderate

J. FUNCTIONAL ASSESSMENT 1. Health Perception Health management Pattern Ms. S.G. had always taking care of herself by exercise and proper diet. When she got pregnant, she quit on her job and she started walking, especially when they are going to mall, its also her exercise. She stated that health is very important so she maintain for having no vices. She is just only practice sleeping late at night but she did things that are good for health. She stated that she follows doctors order by taking medications and have a good habit. 2. Nutritional / Elimination According to the patient, she had a good appetite for eating. She eats three times a day plus having a midnight snack. She drinks 8-10 glasses of water a day and takes vitamins. She prefers to drink milk every morning. There was no change in her appetite even after or before her pregnancy. She eats healthy foods because she wanted to have a healthy baby. She doesnt have allergies and has no preferences when it comes to food. The foods that she eat every day are fish and vegetables because it is rich in fiber and minerals. Her urine and bowel elimination are good. She eliminates 8 times a day and defecates once a day but characteristics were not stated. When she was diagnose UTI, she drink plenty of water and had a proper hygiene always.

3. Activity Exercise pattern Ms. S.G. has a daily exercise by walking. She usually had a bonding everyday by the people in their house. She quit working in a call center when she knows that she is pregnant. She prefers walking in the mall with her mother-in-law. She has full self-care in her ability for feeding, bathing, dressing, toileting, grooming and general mobility. 4. Sleep / Rest Pattern Ms. S.G. practiced sleeping late at night. According to her its because of her work that she is a night shift time. She tried to take a nap at least two hours in the afternoon. He does not use any sleeping pills. 5. Self-Esteem, Self-Concept / Self Perception Pattern According to Ms. S.G. she made decision by herself and her husband. They always go to church every Sunday and they love to be with God. Prayers helped her to become strong. She fears to have illness that she cares for herself and for her baby. 6. Sexuality Reproductive Pattern

Ms. S.G. menstruation started when she was 14 years old and it was usually last for 5 days and in moderate amount. She had a good relationship with her husband. 7. Personal/ Social History Ms. S.G. is a simple person. She doesnt drink and smoke. She and her husband support also their family in financial aside from their parents. She works as a call center agent. But when she knows that shes pregnant, she quit in her job to have a rest and taking herself for her baby. She focus to her family and be a good wife. She goes to church every Sunday. 8. Environment History Ms. S. G stated that they live in Muntinlupa city. Ms. S. G is living in a house with his family and other relatives. They are nine people in their house and composed of helper with her granddaughter. Their house is near the Puregold, Mercury, KFC and Red ribbon. Vehicles and cars pass in their street.

VII. DISCHARGE PLANNING Content 1. Compliance y M - Medication Strategy

Take home drugs for continue medication : Co-amoxiclav Mefenamic Acid Senokot tab Avoid lifting objects

Prescribed dosage: 625mg BID for 7days 500mg TID OD for 5 days  Avoid lifting anything heavier than the baby for 3-4 weeks.  Encouraged patient to have exercise by exercise every morning.  Strengthened the pubococcygeal muscles  Advised patient to take all the medications prescribed by the physician  Reduce stress and anxiety  Encourage environmental modification to enhance safety and prevent injury.  advised her to comply with the orders of her doctor including all her medications.  Health teaching about lochia, rubra first day, serosa above 48 hours and alba for 1 week.  Instructed patient to massage the breast and clean before breast feeding, alternate use of each breast.  Apply hot and cold compress to promote healing  Advised patient to have adequate sleep and rest and

E Exercise

Walking and deep breathing Kegels exercise at home

T - Treatment

Drug maintenance, take all the medication with exact time and dosage.

H Healthy teachings

Adequate rest; Proper diet

eat only the foods that are indicated for her.  Advised the client how to have a healthy lifestyle.  Instructed patient to eat green leafy vegetables and increased fluid intake.  Instructed mother to clean the umbilicus with 70%alcohol and cotton.  Instructed mother to change diaper of the baby as needed.  Instructed mother to expose sunlight daily and dont apply manzanilla on babys body  Instructed mother to burp baby after each feeding.  Advised mother to assess reflex and proper hygiene. y O - OPD Follow up Check-up 1week after discharge December 13-14,2011 High in iron  Advised patient to have her regular check-up.  Encouraged patient to eat foods high in iron like meat and green leafy vegetables.  Upon discharge, check for any changes happen in the body.

D - Diet

S Signs and Symptoms

Observe if complication happen

2. Follow up/Check-up Check-up, 1 week after discharge.

VIII. ONGOING APPRAISAL December 5,2011 03:00am - patient admitted on emergency room

- Received patient 27 years old female with chief complaint of labor pain with pain scale of 7/10 and uterine contraction - patient was conscious and coherent - taken and recorded V/S as follows *T:36.5 0C *PR: 90 bpm *RR: 22 cpm *BP: 140/80 mmHg - Instructed NPO - watch out for any bleeding -Transferred patient to DR table safely - Hooked to O2 via nasal cannula 2-3lpm and D5LR + 10u oxy - Placed patient to lithotomy position - Initial vital sign taken and hooked to cardiac monitor. - Induction of anesthesia done 09:54am - Procedure started - Baby out 10:10am - procedure finished - vaginal pack inserted - post-operative care was rendered -endorsed to private ward December 6,2011 - patient was lying on bed sleeping - conscious but weak - on DAT diet - monitored vital sign every 4 hour - positioned patient in comfortable position - Provided complete bed rest Instructed patient to increase fluid intake - Monitored input and output - gave medication Co-amoxiclav 625mg BID for 7days Mefenamic Acid 500mg TID Senokot tab OD for 5 days -provided interaction and communication -physical assessment to observe overall condition. -provide health teaching to the client. - provided breastfeeding to the baby - instructed mother to clean the umbilicus of the baby with 70%alcohol and cotton.

- Instructed mother to burp baby after each feeding. Provided bonding between mother and the baby - Advised mother to assess reflex and proper hygiene of the baby. -may go home -provided bed rest while waiting

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