Republic of the Philippines

PAMANTASAN NG LUNGSOD NG MAYNILA

(University of the City of Manila)
Intramuros, Manila

In Partial Fulfillment in
Maternal and Child Health Nursing I
(Lecture)

Submitted by:
Mary Rose E. Melicor
2014-10525

Submitted to:
Prof. Ronnie M. Tiamson, RN, RM, MAN, MSN
 Table of Contents

Title Page

Introduction

I. General Objectives

II. Demographic Profile

III. Chief Complaint

IV. History of Present Illness

V. Past Medical History

VI. Social History

VII. OB History/Scoring

VIII. Physical Examination

IX. Review of Systems

X. Course in the Ward

XI. Drug Study and Analysis

XII. Laboratory Results and Analysis

XIII. Nursing Care Plan

 INTRODUCTION

Labor is the series of events by which uterine contractions and abdominal pressure

expel a fetus and placenta from a woman’s body. Regular contractions cause progressive

dilatation (enlargement or widening of the cervical canal) and create sufficient muscular

force to allow a baby to be pushed from the birth canal (or vagina). It is a time of change,

both an ending and a beginning, for a woman, a fetus, and her family. (Maternal and Child

Health Nursing 6th Edition Adele Pillitteri)

Childbirth is painful and stressful event in women’s life, a women that is undergoing

a labor and birth needs all the psychological and physical coping methods she has

available. Having a child is one of the most amazing and memorable thing a women could

have and experience. However, due to some prejudice and lack of knowledge about labor,

often prevents some women to enjoy the experience. Giving an adequate knowledge

about labor is a must so that they would now that different thing about signs of labor and

about labor and delivery in general, so that they will somehow know what to do when it

manifest.

The emotional, physical, social, spiritual and psychological well-being of a woman

is very crucial in having a successful labor. She will need all the support that she could

receive from her family, relative and medical professionals like nurses and physician.

Receiving emotional support from someone is very important for the woman in labor for

she comes to think that she is not alone and it also helps her to be strong and confident

because she is seeing that her loved ones is there for her. According to study, a woman

who are receiving emotional, physical, psychosocial and spiritual support are less pain for

they feel comforted by the received support, compared to the woman who doesn’t received

any.
 Hearing encouragement and assurance from the people around her helps her to

alleviate the pain and help her have a speedy recovery. We can say and understand that

there are different factors in labor pain for it involves, emotional, sensorial, environmental

and existential factors. Our role as a nurse is to relieve the labor pain being experience by

the mother by encouraging her and keep on supporting her, in this case we can reduce

the use of riskier medication or analgesics to relieve the pain and potentially improved the

labor progress. Giving an holistic care as a nurse to the woman in labor helps a lot in

alleviating the pain experience of a woman.

I. General Objective:

The case study aims to determine and identify the general health and

needs of a postpartum woman who has an admitting diagnosis of G1 P0

(T0 P0 A0 L0) pregnancy uterine 37 6/7 weeks of gestation, cephalic in labor

and with gestational hypertension to provide an adequate plan of care in

order to alleviate the pain, to promote an environment susceptible for

recuperation to help the patient go back to her non-pregnant state and to

her optimal health before childbearing.

Specific Objectives:

 To build a nurse-patient relationship as well as to the

patients relative to have an effective data gathering.

 To apply interpersonal communication skills to be able to

collect the veracious demographic profile and other

pertinent data of the patient about her past medical, family,

and psychosocial history.

 Conducting a thorough and effective physical examination

to the patient to have a baseline data to provide an adequate

nursing intervention.

 To formulate a nursing care plan based on the gathered

data, the objective cues and subjective cues gathered.

II. Demographic Data

Name: Patient OB Age: 31 years old

Address: Sta. Cruz, Manila Gender: Female

Birthday: January 14, 1986 Birthplace: Cabanatuan

Occupation: CSA Marital Status: Married

No. of Children: 1 Religion: Roman Catholic

Educational Attainment: College Graduate

Height: 152 cm Weight: 69.2 kg BMI: 26.09

Admitting Diagnosis: G1 P0 (T0 P0 A0 L0 M0) pregnancy uterine 37 6/7

weeks of gestation cephalic in labor and with gestational hypertension

Informant: Patient

Date & Time of Admission: September 5, 2017/ 07:30AM

III. Chief Complaint:

Labor pain.

IV. History of Present Illness

The patient said that she’s at home watching the television when she felt

discomfort and pain but didn’t bothered about it at first for it is still tolerable.

At around 6:30 am, she felt the pain more intensely and wasn’t able to tolerate

it anymore. She described that the pain is coming from her lower back and radiating

in front of her abdomen with the severity that she can’t tolerate and decided to go to

the hospital.
 At 7:30 am, they arrived at the hospital with the positive signs of labor and a

discharge from the genitals.

V. Past Medical History

The patient acquired illnesses such as chickenpox, mumps and measles during

childhood.

The patient has a family history of Hypertension, Heart Disease, Asthma,

Diabetes and Pulmonary Tuberculosis. The patient has no allergy related to food, drug

and animals.

VI. Social History

The female patient is 31 years old and second to the eldest of the four siblings.

They are 6 in the family. He has an older brother and 2 younger sisters. Her family is

still complete, and her mother and father is together with her husband accompanying

her. The patient has been married to her husband for 5 years already and said that

the baby girl that just been delivered is their first child.

VII. OB History/Scoring:

The patient’s pregnancy was planned and said that they’ve been expecting a

child because they aren’t getting any younger, that’s why they are very happy to finally

have a child especially a baby girl. Her last menstrual period is December 14, 2016

based on what se recall. The OB History of the postpartum woman before the delivery
 is G1 P0 (T0 P0 A0 L0); gravida is 1, parity is 0, term is 0, pre-term is 0, abortion is 0

and living child is 0.

The patient was 12 years old when she had her first menstrual flow (menarche),

she stated that she have a regular period of menstruation and with an interval of one

month in every cycle, the duration of her period is 4-7 days. She uses 4 pads a day

during menstruation and she also stated that every period she’s experiencing

dysmenorrhea.

VIII. Physical Examination

The patient’s skin is color brown, has now skin lesions, but some pigmented

area, due to production of melanocytes during labor that cause some pigmentation on

patient’s face and abdomen. Striae gravidadum is also present on the patient’s

abdomen.

There is no presence of edema on the lower and upper extremities of the

patient and can move freely. The nails are symmetrical and short, it has a good

circulation. There is no presence of clubbing on the fingers.

The patient’s hair is evenly distributed, thick and color black. No lesions on the

scalp, and there is no lice or nits.

The head is normocephalic and smooth, has uniform consistency, no presence

of masses or nodules palpated on the head. The patient’s eyes are even, no

discoloration or presence of edema. Both eyes moved coordinately in unison.

 The ears of the patient are symmetric in position and aligned to the outer

canthus of the eyes. Has an even color same with the facial skin. No presence of

tenderness or experiences pain when palpated.

The patient’s nose is symmetric and uniform in color. There is no presence of

obstruction that can hinder the patient’s breathing. No tenderness when palpated, and

no presence of lesions.

The patient’s lips are essentially normal, pale pink in color, the patient’s teeth

is incomplete due to cavity. The patient’s tongue is normal as well.

There is no inflammation of nodes in the patient’s neck, has a smooth

movement and coordinated.

The patient’s chest is symmetric and there is no signs of difficulty in breathing

when inhaling and expiring.

The abdomen is slightly big however essentially normal, normal in color, but

has an uneven distribution of color due to pigmentation and there is presence of stretch

marks.

The patient’s breast is symmetrical, has a round shape. There is no

tenderness, nodule or masses during palpation.

The patient’s genitals is slightly dark in color and has a few pubic hair for it has

been cut due to labor. There is lochia secretions. There is no pubic lice present.
IX. Review of Systems

The patient’s general status is that she experienced body malaise and a

shortness of breath because of the episiorrhaphy during the delivery. The patient is

coherent and well-oriented, but verbalized experiencing pain due as an effect of the

labor that undergone.

No skin lesion have been observed on the patient’s skin, except for the

presence of scar in the lower right leg due to injury. The patient also has a pigmentation

on the abdomen and striae gravidadum caused by the stretching of the skin in the

abdomen due to pregnancy.

There is no other verbalized feeling of discomfort aside from the after pain

experiences because of the episiorrhaphy. The patient stated that she can hear clearly

and loud. There is no complications when it comes to the patient’s vision, there is no

presence of cataracts, no blurring or other infections. There is no presence of edema

as well.

There is no presence of edema in any part of the body. The breasts of the

patient are tender and engorge. She doesn’t experience chest pains, but experiences

shortness of breath.

The patient can move comfortably and does not experience any muscle pain,

stiffness or joint pain, however the patient stated feeling of pain and slight difficulty in

moving because of the episiorrhaphy.

X. Course in the ward

The first time that I saw the patient is on the second day of my duty, she

appears normal and looks like she already regained some of her strength however she

verbalized slight difficulty when she moves because of the episiorrhaphy.

In my stay in the ward I was able to handle her for that particular day only for

we don’t have our duty after that day. First is that our CI introduced us to each of our

patient, and then she assigned us to different patients. Before I start gathering

information from her, what I did at first is introduced myself and tell her what I am going

to do. I build rapport first, between the patient and me, so that both of us won’t have a

hard time being uncomfortable with each other. After getting the patient’s trust I was

able to talk to her comfortably and it slightly become easier for me. What I did after

building rapport with my patient is that I took her vital signs as well as her baby’s vital

signs for 4pm, to have a baseline data. After taking their vital signs I plot the data

gathered as instructed by our CI. After that I let the patient to rest and for some time

let her feed her baby girl whenever she’s hungry. After 4 hours, I again took the

patient’s, as well as her baby’s vital signs for 8pm. And after that I plot the data

gathered again as I was instructed.

I interviewed her, but asked first if it would be fine if I used her case in my

case study and she said that it’s fine. So I started asking significant information

needed, and she answered it honestly. After I interviewed her, I happily say thank you

and say good bye to her for I won’t be seeing her again tomorrow for we don’t have

our duty. The next week after that, I wasn’t able to see her for she’s already been

discharge.
XII. Lab Results with Analysis

Ultrasound Report

Date: February 01, 2017 Age: 31

Name: Patient OB LMP: December 08, 2016

Diagnosis: PU 7 weeks 6 days EDD: September 14, 2017

FIRST TRIMESTER ULTRASOUND REPORT

GESTATIONAL SAC: 3.08 cm = 8 weeks 0 days

Regular, thick, high
YOLK SAC: 0.21 cm

EMBRYO/FETUS
CRL: 0.41 cm = 6 weeks 1 day

CARDIAC ACTIVITY: 120 bpm

AVERAGE ULTRASONIC AGE: 6 weeks 1 day

EXAPECTED DATE OF DELIVERY: September 26, 2017

ADNEXA:

RIGHT OVARY: 2.24 x 1.43 x 1.01 cm.

Normal size and echotexture

LEFT OVARY: 2.65 x 2.35 x 2.17 cm.

With a corpus luteum 1.54 x 1.14 cm.

CERVIX: 2.80 x 2.48 x 2.98 cm.

OTHERS: Uterus is inverted measuring 5.95 x 5.35 x 5.02 cm.

IMPRESSION:

Single live intrauterine pregnancy 6 weeks 1 day gestation by crown rump

length normal ovaries with a corpus luteum on the left.

Ultrasound Report

Date: May 26, 2017 Age: 31

Name: Patient OB LMP: December 14, 2016

Diagnosis: PU 23 weeks 2 days EDD: September 20, 2017

SECOND AND THIRD TRIMESTER ULTRASOUND REPORT

General Survey:

Number = Singleton

Presentation = Cephalic

Cardiac Activity = 153 beats per minute

Placenta = Anterior, Grade II, High Lying

SVP = 4.28 cm
Fetal Biometry

BPD = 5.71 cm. = 23 weeks 3 day

OFD = 7.43 cm =

HC = 29.7 cm. = 23 weeks 4 days

AC = 28.2 cm. = 23 weeks 0 days

FL = 6.6 cm. = 23 weeks and 3 days

ESTIMATED FETAL WEIGHT: 570g (1lb 4oz)

AVERAGE ULTRASONIC AGE: 23 weeks 3 days

EXPECTED ATE OD DELIVERY: September 19, 2017

Impression:

Pregnancy uterine 23 weeks and 3 days gestation by fetal biometry, live,

cephalic. Singleton, fetus with good cardiac and somatic activity.

Estimated fetal wight is appropriate for established age

Biometric Ratios within normal limits

Normohydramnios

Placenta Anterior, Grade II, High Lying

 Hematology

Laboratory Test Normal Values Results

Hemoglobin F 12-14 g/dl 13.1 g/dl

M 14-16 g/dl

Hematocrit F 0.37-0.47 0. 36

M 0.40-0.57

WBC Count 4.8-10.8 x 10 7.8

Segmenters 60-70% 75

Lymphocyte 30-40% 25/100

Platelet Count 130-400 x 100 326

BLOOD TYPE: O Rh positive

Urinalysis

CLINICAL MICROSCOPY

PHYSICAL RESULTS NORMAL

Color Yellow Yellow

Transparency Hazy Clear

Reaction 6 4.8-7.8

Specific Gravity 1.015 1.015-1.025

Microscopic

Pus Cell 0-2/hpf 0-2/hpf

Red Blood Cell 0-1/hpf 0-1/hpf

Epithelial Cell Few Few present

 LABORATORY EXAMINATIONS

EXAMINATIONS RESULTS

HEPATITIS B SCREENING NON-REACTIVE

RPR NON-REACTIVE

HIV ANTIBODY SCREENING TEST

HIV 1. NON-REACTIVE
HIV 2. NON-REACTIVE