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A

CARE STUDY

ON

NORMAL SPONTANEOUS VAGINAL DELIVERY

Submitted to:

MR. BARLUTCH L. CENTILLAS

BSN Level III Clinical Instructor

Barili District Hospital

In Partial Fulfillment

Of the Requirements in the subject:

NCM 501201 – A

Submitted by:

MARIO C. ALUMBRO II

BSN Level III Section G

Student

SEPTEMBER 11 , 2008
TABLE OF CONTENTS
PAGES
I. Introduction…………………………………………………………………….. 1
II. General Data……………………………………………………………………. 2
III. History of present Illness………………………………………………………. 3
IV. Past health history……………………………………………………………… 4
V. Nursing Review of Systems…………………………………………………… 4
VI. Family, Personal, Social and Environmental History…………………………. 6
A. Immediate family member
B. Personal and Social History
C. Environmental History
D. Heredo-Familia History

VII. Physical assessment……………………………………………………………. 7


VIII. Developmental data……………………………………………………………. 10
IX. A. Anatomy and Physiology of the system involved:
Female reproductive system…………………………………………………... 12
B. Conceptual framework on the pathophysiology of myomectomy……………… 16
C. Discussion on the pathophysiology…………………………………………….. 17
D. Symptomatology……………………………………………………………….. 18
X. Medical management………………………………………………………….. 21
A. Treatment and procedures………………………………………………… 22
B. Medications……………………………………………………………….. 22
C. Diagnostic procedures…………………………………………………….. 23
D. Diet………………………………………………………………………... 23
XI. Nursing management
A. Actual care given………………………………………………………….. 23
B. Problems encountered during the implementation of nursing care………... 24
C. Restorative measures used………………………………………………… 24
D. Evaluation…………………………………………………………………. 25
E. Patient teaching…………………………………………………………… 25
XII. Conclusions and Recommendations………………………………………….. 26
XIII. Implication of the study to
A. Nursing education………………………………………………………… 27
B. Nursing practice………………………………………………………….. 28
C. Nursing research…………………………………………………………. 29

APPENDICES:

APPENDIX A: Permit Letter


APPENDIX B: NCP
APPENDIX C: DISCHARGE PLAN
APPENDIX D: DRUG STUDY
APPENDEX E: DOCUMENTATION

BIBLIOGRAPHY
I. INTRODUCTION:

Pregnancy is the carrying of one or more embryos or fetuses by female mammals, including humans,

inside their bodies. In a pregnancy, there can be multiple gestations (e.g., in the case of twins, or

triplets). Human pregnancy is the most studied of all mammalian pregnancies. Human pregnancy lasts

approximately 9 months between the time of the last menstrual cycle and childbirth (38 weeks from

fertilization). The medical term for a pregnant woman is genetalian, just as the medical term for the

potential baby is embryo (early weeks) and then fetus (until birth). A woman who is pregnant for the

first time is known as a primigravida or gravida 1: a woman who has never been pregnant is known

as a gravida 0; similarly, the terms para 0, para 1 and so on are used for the number of times a

woman has given birth.

In many societies' medical and legal definitions, human pregnancy is somewhat arbitrarily divided

into three trimester periods, as a means to simplify reference to the different stages of fetal

development. The first trimester period carries the highest risk of miscarriage (natural death of

embryo or fetus). During the second trimester the development of the fetus can start to be

monitored and diagnosed. The third trimester marks the beginning of viability, which means the

fetus might survive if an early birth occurs.

The study of maternal and child care nursing during the various phases of childbearing includes

the study of anatomic and physiologic adaptations to human reproduction and, the full meaning,

the study of human growth and development and the many interdependent relationships

concerned. Maternal and childcare nursing involves directly personal ministrations to maternity

patients and their newborn infants, or related activities on their behalf during the various phases of

the childbearing experience.


1

Begetting children is a family-affair, thus the nursing care of childbearing patients is

basically a family-centered activity. In most situations today, the maternity patient is usually a

healthy woman involved in the normal physiologic process of childbearing. It is always

emphasized that it is best for the baby to be born vaginally.

Pain during labor is inevitable. That is why, as future nurses, it is a must for us to know how to

lessen the agony felt by our patients. This study will serve as our guide on what possible

interventions we can render, for them not to be traumatized. Through this, we will be able to

adhere to the different circumstances that women have undergone in relation to childbearing. They

will optimistically know that pain is just a fraction of this meticulous process, and the satisfaction

of ushering a new entity will overshadow the pain experienced.

As you scan and read the content of this study, I sincerely hope you can obtain knowledge and

curiosity out of it. May this be a helpful tool in motivating us on how important nurses are during

those critical times of labor, and even during the postpartum period. May we continuously

remember that we are there not just to administer medications and monitor their general condition,

but we are also there to serve as their teacher, their confidant, and their friend.

II. GENERAL DATA

PATIENTS DEMOGRAPHIC DATA

Patient name: R. C. J.

Age: 24 years old

Address: Goloctog, Barili Cebu

Race: Filipino

Sex: Female
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Civil Status: Married

Religion: Roman Catholic

Date of Birth: August 16, 1983

Place of Birth: Barili, Cebu

Hospital No: 03-95-33

Physician: Dr. Garaygay

SIGNIFICANT MEMBERS OF THE FAMILY

Husband’s name: Eugenio

Age: 26 years old

Sex: Male

Race: Filipino

Place of birth: Barili, Cebu

Occupation: OFW

Civil Status: Married

III. HISTORY OF PRESENT ILLNESS

Prior to admission of the patient in BDH, she was complaining of bloody vaginal

discharges, the baby was noted to be cephalic. And was being consulted and advised for

admission.

She has a history of hypertension at material side, there is not known for allergies in either

food or drugs, She had her menarche at 15 years old from 3-4 days duration with regular intervals.

There was (-) potential spotting (+) dispareunea. Non-smoker and non-alcoholic beverage drinker
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had previous hospitalization as well due to fever. Her last menstrual period was on November 7,

2007 . Age of gestation is 39 weeks and 4 days and the expected date of confinement is on August

14, 2008.

IV. HISTORY OF PRESENT CONDITION:

She had been hospitalized. A history of hypertension and no history of diabetes mellitus

and other diseases. She had her series of pre-natal check up at BDH. OPD from first prenatal

check-up was when 1st month of pregnancy until 9 months. She was able to visit the clinic one-

week prior to her delivery to Dr. Garaygay. It was noted cephalic presentation of the baby.

EDUCATIONAL BACKGROUND:

Finished elementary and high school Barili High School.

V. NURSING REVIEW OF SYSTEMS

(GORDON’S FUNCTIONAL HEALTH APPROACH)

• HEALTH PERCE[TION AND HEALTH MANAGEMENT

Patient’s perception to health is the state of an individual being free


from any

illnesses and is capable of doing her daily activities without any discomforts.
Patient was

able to do her daily activities but with guidance and limitation. During any
illnesses, she

self-medicate herself with any over-the-counter drugs applicable for that


illness. She

takes rest and drinks lots of fluids.

• ACTION AND EXERCISE


Patient experienced fatigue due to delivery. While she was still
pregnant, she had

her exercise by walking. Since the store where she worked at as a saleslady,
is only a

walking distance from her house, the morning walk is consider as her daily
exercise.
4

• NUTRITIONAL METABOLISM

Patient normally eats 3 times a day. Food and fluid consumed by the
patient

adequate for her metabolic needs and pattern indicates adequate local
nutrient supply.

Patient had experienced occasional likes and dislikes of food during the first 3
months of

pregnancy. She had shared that there would times she would ask her
husband to bring her

that food (or fruit) because she feels wanting to eat it.

• ELIMINATION

Patient experiences burning pain sensation upon voiding because of


the surgical incision from delivery. In an ordinary situation, patient is able to
urinate at least 4-5 times

a day and defecate at least once a day. Since voiding is painful, normal
urination has been

altered.

• SLEEP AND REST

During first contact with the patient, sleepiness is evident. Patient


was able to

rest and take naps at free time. She would just wake up if the baby cries or if
there is a

visitor or when there is a need for us to perform any needed nursing


procedure like

changing IVF and during vital signs taking. Patient’s normal sleep pattern is 6-
8 hrs

nightly. Since, a new member of the family has come, it is experienced that
her normal

sleep pattern would be altered.

• COGNITION AND PERCEPTION

Patient has no sensory deficits. Sensory organs are functioning


normally. Patient

is oriented to time, place, date, and person. She was able to respond
coherently yet she’s

tired.

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• SELF-PERCEPTION AND SELF-CONCEPT

Patient shows concern on the newborn and verbalizes acceptance of


the new role

being a mother. She verbalizes understanding on the proper way of


breastfeeding and was

knowledgeable about immunizations of the baby.

• ROLES AND RELATIONSHIP

Patient is married and is very close to her family. Patient show


eagerness during

breastfeeding, thus showing her excitement of being a first-time mother.

• COPING AND STRESS TOLERANCE

Fatigue is evident to patient yet she was still able to perform care
towards her

baby. And patient was able to void despite of the burning sensation she might
felt. Hence,
she was able to cope up with the stressful situation she had encountered.

• SEXUALITY AND REPRODUCTION

Patient has been married once, it’s expected that his husband was his
only sexual

partner. Pregnancy was never planned but it doesn’t mean they got
disappointed. They

practices Natural Family Planning Method, specifically, condom.

• VALUES AND BELIEF

Patient is a Roman Catholic. She is active in church activities like she


would

attend masses during Sunday. The couple would baptize their baby soon.

VI. FAMILY, PERSONAL, SOCIAL AND ENVIRONMENTAL HISTORY

The Patient is living presently in her house with extended family. Her husband is working in Saudi
Arabia as a factory worker. She has no work. Her husband decides in terms of health and finances
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in the family.

PERSONAL AND SOCIAL HISTORY

The patient starts her day early by taking a warm bath, cooks breakfast for family. Usually wakes
up at 5:30 in the morning. Her afternoon routine includes doing household chores. Spends her free
time taking a nap or watching T.V. together with her sister or reading about tips in preparing for
her babies arrival. Client usually retire at 9 or 10 pm. Client also keeps a good and clean
environment. She seldom strolls in market unless needed.
ENVORONMENTAL HISTORY

Patient lives in her house. Situated near the street. There are trees around, with lots of
leaves falling at the ground. Water supply runs throughout the town through pipelines and supplies
their home. They also have an electricity line connected. Garbage is collected by the maintenance
of there house.

HERIDO – FAMILIAL HISTORY

Patient’s history of family diseases includes hypertension at paternal side.

VII. PHYSICAL ASSESMENT

GENERAL SURVEY: Conscious, coherent, a febrile: responsive, cooperative and ambulatory.

With the vital signs of:

Blood Pressure : 110/70 mmHg


Pulse : 72 bpm
Respiration : 16 cpm.

Body Temp. : 36.80C/ axilla

7
GENERAL HEALTH:
- Patient is slowly regaining strength.
- And is able to ambulate a few meters away
SKIN:
- fair skin
- no presence of rashes
- no presence of lesions
- has good skin turgor
- No signs of abnormalities on I.V. site
HAIR:
- has evenly distributed hair
- shiny black, signifies adequate nutritional intake
NAILS:
- normal nail color
- normal nail growth
- no presence of breaks
HEAD:
- symmetrical
- normocephalic
- no birth defects
EYES:
- Eyebrows free from scaling
- External eye structures are normal, eyes are symmetrical
- conjunctiva is reddish pink in color and is noted normal
- Client gazed at the six cardinal signs

EARS:
- External ear contains some cerumen, with no lesions, exudates or swelling.
- external ears are symmetrical
- firm smooth and free from lesion
- client was able to repeat words clearly following voice test.
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NOSE:
- No noted pain or tenderness upon palpation
- Without swelling and lesions, deformities/deviations
- Located symmetrically at midline lf the face
- Nostrils are both patent
- Client was able to distinguish common scents

MOUTH AND THROAT:

- Lips are smooth with no lesions or nodules


- Breath smells fresh, because client just took a bath and brushed her teeth.
- Lips are pinkish and moist and closes symmetrically

NECK:

- No tenderness noted
- No masses

BREAST and AXILLA:


- firm and soft
- no lumps noted
- no secretions

HEART:
- Heart rate within normal range

ABDOMEN AND GASTROINTESTINAL TRACT:

- Bowel sound has returned to normal and is present.


- Patient’s abdomen is slightly round presence of underlying fat tissues. BACK:
- no lesions
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- no presence of skin infections, rashes and redness

FEMALE GENITALS:

- Evenly distributed pubic hair. Vagina had little reddish discharges.

PEPIPHERAL VASCULAR SYSTEM:

- No presence of edema, redness or tenderness.


- Leg Veins are evident due to white skin color and with few varicosities.
NEUROLOGIC SYSTEM:

- Patient was conscious and coherent. Well oriented with time and place. All reflex were
present and noted normal.

VIII. DEVELOPMENTAL DATA

AGE Developmental Characteristics Patient Characteristics


Task
Infancy Trust versus Visual acuity is fairy The patient reported of
(birth to 18 mistrust established. The child being shared by her
months) can pick up small beads mother that she
and places them in a demonstrated physical
receptacle. Understands growth within normal
the word “no”. range; she was responsive
to her parents through
body movements and
vocalizations. She was
breastfed. She cannot
remember the exact age
of her teething.
Toddler Autonomy versus Toddlers can hold a The patient reported of
(18 months shame and doubt spoon and put it into their being able to walk alone
to 3 years) mouth correctly. They at about two and a half
are able to run; their gait years old. She was also
is steady; and they can toilet trained during this
balance on one foot. time.
Preschooler Initiative versus They are able to wash During this period, the
(4 and 5 Guilt their hands and face, patient started to play
years old) brush their teeth. Able to with other children. She
take responsibility for was capable of washing
independent toileting. herself and had
They enjoy interactive established bowel and
activities. urine control.
School age Industry versus They enjoy both group At this period she
age 6 – 12 Inferiority. and individual activities preferred the sating at
years old socially, they want to be home or going out with
accepted by their peers family. Patient also
and enjoy having a expressed the need for
bestfriend. Prefers to do privacy and would often
personal things alone for ask her other to leave her
privacy when taking a bath of
changing clothes
Adolescent Self-Identity versus Both primary and It was during these times
12 – 18 role diffusion secondary sex that the patient started
years old characteristics develop. development crushes and
They are concerned with puppy loves. The patient
their bodies, their also started to take notice
appearances and their of her body changes and
physical abilities. Peer worry about her
groups assume a great appearance. She started
importance. Of the Having her period and at
opposite sex starts. the first, did not want
anybody to know.
Early adult Intimacy versus They are more focused The patients have had no
20 – 40 isolation on reality and usually luck on making their
years old interested in meeting baby due to the fact that
their health needs. her husband had a
problem on his sperm
count. The patient also
had experienced death on
her 1st husband. And
then came her present.
Middle Generativity versus Hair begins to thin and Patient claimed to have
Adult 40 – Stagnation gray hairs appear. Skin an increasing no. of gray
65 years old turgor and moisture hairs, loss of muscle tone
decreases. Metabolism and decreased sexual
slows. Hormonal changes desire. Though she really
take place. longs for at least one
child. And prays for it
every time.

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IX. A. Anatomy and Physiology of the system involved:

Female Reproductive System

EXTERNAL GENITALIA
Mons Verenis

The area above the female's pubic bone, near the top of her pubic hair. The mons is a soft area

which is usually covered in pubic hair, and it is very sensitive to touch and pressure.

Labia Majora

The outer lips of the vagina. The labia majora are the lips closest to the thighs, and are usually

lightly covered in pubic hair. They surround the labia minora, urethral, and vaginal opening.

Clitoral Hood (prepuce)

The clitoral hood is formed by the upper junction of the labia minora. This fold of skin

usually covers the clitoris and protects it.

Clitoris

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The clitoris is made up of the external shaft and glans and the internal crura. The crura is the root

of the clitoris from which the shaft extends. The glans is the tip of the external clitoris..

Sometimes covered by the clitoral hood, the clitoris becomes erect during stimulation and sexual

arousal. There are many nerve endings in the clitoris, making it very sensitive. In fact, there are

about the same number of nerve endings in the external parts of the clitoris as there are in the head
of the male penis. The glans is particularly sensitive to stimulation. Direct stimulation may be too

intense, and even painful. Gentle, indirect stimulation, however, may be very pleasurable and may

result in orgasm.

Labia Minora

The inner lips of the vagina. They are usually hairless and protrude from between the labia

minora. They meet at the clitoris as an especially sensitive area called the frenulum of the clitoris.

Urethra

The tube through which urine passes from the bladder to leave the body at the urethral opening.

Introitus

The introitus is the opening of the vagina. It is located between the urethral opening and the anus.

It may be partially covered by the Hymen.

Perineum

The perineum is the smooth area of skin between the introitus and the anus. There are many

nerves in the perineum and it is sensitive to touch. During childbirth, an incision, called an

episiotomy, is sometimes made in the perineum to prevent tearing of the tissues as the baby’s head

passes through the birth canal.

Anus

The opening through which feces (human solid wastes) leaves the body.

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INTERNAL GENITALIA
Vagina

The vagina extends from the vaginal opening to the cervix - the opening to the uterus. The vagina

receives the penis during sexual intercourse, and is the birth canal through which the baby passes

during labor. The average vaginal canal is three inches long, possibly four in women who have

given birth. This may seem short in relation to the penis, but during sexual arousal the cervix will

lift upwards and the fornix (see illustration) may extend upwards into the body as long as

necessary to receive the penis. After intercourse, the contraction of the vagina will allow the

cervix to rest inside the fornix, which in its relaxed state is a bowl-shaped fitting perfect for the

pooling of semen.

At either side of the vaginal opening are the Bartholin's glands, which produce small amounts of

lubricating fluid, apparently to keep the inner labia moist during periods of sexual excitement.

Further within are the hymen glands, which secrete lubricant for the length of the vaginal canal.

Cervix

The cervix is the opening to the uterus. It varies in diameter from 1 to 3 millimeters, depending

14

upon the time in the menstrual cycle the measurement is taken. The cervix is sometimes plugged

with cervical mucous to protect the cervix from infection; during ovulation, this mucous becomes

a thin fluid to permit the passage of sperm.

Uterus

The uterus, or womb, is the main female internal reproductive organ. The inner lining of the uterus
is called the endometrium, which grows and changes during the menstrual cycle to prepare to

receive a fertilized egg, and sheds a layer at the end of every menstrual cycle if fertilization does

not happen. The uterus is lined with powerful muscles to push the child out during labor.

Ovaries

The ovaries are situated on the side of the uterus just below the finger like projections of the

fallopian tubes The ovaries perform two main functions: production of female sex hormones

-estrogen and progesterone, and the production of mature ova, or eggs every month after puberty.

Of the two female hormones produced by the ovaries, estrogen is responsible for development and

maintenance of all secondary sex characters such as breast, shape of the body, and maturity of the

reproductive organs such as vagina, uterus, fallopian tubes, etc. Progesterone is produced after the

ovum has been released. It is essential for maintenance of pregnancy and is responsible for regular

menstruation and maintaining normal menstrual flow. High progesterone levels suppress

menstruation. At birth, the ovaries contain nearly 400,000 ova, and those are all she will ever

have. However, that is far more than she will need, since during an average lifespan she will go

through about 500 menstrual cycles. These premature eggs are formed when baby is growing in

the uterus itself and may be damaged due to x-rays or exposure to toxic substances. After

maturing, the single egg travels down the fallopian tube, a journey of three or four days-- this is

the period during which a woman is fertile and pregnancy may occur. Eggs that are not fertilized

15

are expelled during menstruation along with the inner layer of uterus. Even if there is no damage

to the premature eggs in the uterus, those that are released after the age of thirty-five years are

"old" and therefore the risk of congenital abnormalities increases.


Fallopian Tube

Fallopian tube is the duct through which the egg must pass to reach the uterus. The tube is about

4” long and hangs freely in the pelvic cavity. They are not directly connected to the ovaries but its

end widens into a wide flower like opening that lies adjacent to the ovary.

B. Conceptual Framework on the Physiology of Pregnancy Uterine

Full- Term

MALE FEMALE

production of viable sperm production of viable

oocytes

transport down the male duct system ovulation

deposited in the female vagina capture of the oocyte by the

uterine tube

16

movement through the female’s transport down the uterine tube


reproductive tract

meeting of sperm and oocyte in the uterine tube

union of sperm and egg

implantation in properly prepared endometrium

fetal growth and development for 37-40 weeks AOG

birth

C. Discussion of the Physiology of Pregnancy

Every human being starts out as two separate germ cells, or gamete. The female gamete

is the ovum, and the male gamete is the spermatozoon, or sperm for short. Only a man and a

woman capable of producing these germ cells are involved in fertilization. Though every man is

capable of producing sperm some of them has low production and has weak sperms leading to

17
faster death once it has traveled in the female reproductive tract. Also, there are those that are

not really capable of contributing into fertilization. Thus, such condition enables the man to be

not part of the fertilization. For women, there are some who do not ovulate regularly thus giving

them difficulty to bear a child. As soon as the woman had her menarche, the chance of

conceiving is already with her. Same with men, there are also those who unfortunately cannot

bear a child.

Furthermore, in the diagram, “viable” was clearly indicated due to the above-mentioned reasons.

When the sperm and the ovum meet through sexual contact, thus fertilization occurs. This has

started a new life formed in the woman’s womb.

There are some cases wherein pregnancy was not continued due to miscarriage or the

developing fetus was not properly implanted in the uterus but stayed in the fallopian tube

instead. This condition is called the Ectopic pregnancy. For this study, uterine pregnancy will be

focused. The developing fetus would be it he uterus of the mother in about 37-40 weeks or nine

months. From a single cell, it will be developing everyday and changes by week could be

noticed through ultrasound. In the whole gestation, the fetus is totally dependent with the

mother. What the mother has taken in would also go to the developing fetus. Once the fetus

matures and its system is already capable of functioning outside the uterus, hence would result

to birth. Birth is a natural process that cannot be controlled by the mother itself. Only for special

cases wherein the physician would decide to take the baby out when either mother both the

mother and the baby are at risk. But, if the fetus goes out from the mother and has reached its

age from 37 weeks-40 weeks it would be called full- term.

D. SYMPTOMATOLOGY

18
SIGNS AND
SCIENTIFIC
SYMPTOMS MONTH OCCURRED
BASIS
MANIFESTED

PRESUMPTIVE SIGNS Amenorrhea One month after contact Because of the


with husband suppression of
follicle-stimulating
hormone.
(Pilliterri, 1999;
210).

Nausea and First up to the fifth High levels of


vomiting month estrogen,
progesterone, and
chorionic
gonadotropin may
trigger nausea and
vomiting.
(Broadribb et. al.,
1973; 73-74)

First 5 months Because the basal


Fatigue metabolic rate
gradually falls to a
low of approximately
– 10.
(Broadribb et. al.,
1973; 73-74)

6th month These increases in


Linea nigra pigmentation are due
to melanocyte-
stimulating hormone
secreted by the
pituitary.
(Pilliterri, 1999; 212)

A woman’s statement
3rd month
Quickening that she feels life
cannot be accepted as
any more than a
presumptive sign.
Occasionally, the
movement of gas in
the intestine may
stimulate such a
sensation.
(Pilliterri, 1976; 56)
The expanding uterus
Frequent urination 1st until the 3rd trimester puts pressure on the
base of the bladder,
causing woman to
feel frequently as
though she needs to
urinate.
(Pilliterri, 1976; 55-
56)
PROBABLE SIGNS
Softening of the
3rd month during visit to
Goodell’s sign cervix due to
obstetrician
increased vascularity.
(Broadribb et. al.,
1973; 72)

Painless intermittent
Not specifically noted by
Braxton Hicks contractions occur
contractions patient, around 1st or 2nd which enable the
trimester muscles of the uterus
to enlarge to
accommodate the
growing fetus.
(Broadribb et. al.,
1973; 72)

Not noted
Between the 3rd and
Ballottement
4th month, the
growing uterus rises
out of the pelvis can
be felt above the
symphysis pubis. As
am abdominal organ
the uterus may be felt
as a soft fluid-filled
sac.
(Broadribb et. al.,
1973; 86)
Not noted
Fetal outline felt by About the 6th month
examiner of pregnancy, the
uterine wall has
become thinned to
such a degree that a
fetal outline may be
palpated.
POSITIVE SIGNS (Pilliterri, 1976; 57)
6th month
Sonographic In the event of
evidence of fetal pregnancy, a
outline characteristic ring,
indicating the
gestational sac, will
be revealed on the
oscilloscope.
(Pilliterri, 1999; 199)
6th month
Audible fetal heart Audible by
tone auscultation of the
abdomen with an
ordinary stethoscope
only at about 18 to 20
weeks of pregnancy.
Rate usually ranges
between 120-160
BPM.
Fetal movement felt (Pilliterri, 1999; 199)
by examiner
Not noted May be felt by the
20th to 24th week of
pregnancy.
(Pilliterri, 1999; 199)

X. MEDICAL MANAGEMENT

The patient was admitted last Aug. 9, 2008, 5:25 pm. The patient complaints was labor pain, hypo

gastric pain and vaginal discharges. The rationale for this is to prevent further complication during

labor. The internal examination is fully dilated, fully effaced membrane. The rationale for this is

examining the internal side of the abdomen. The patient vital signs are as follows: T= 36.8 °C/

axilla, PR= 72 bpm, RR= 16 cpm, BP= 110/70 mmHg. The rationale for this is to ensure the

safety of the patient. The internal examination done by Dr. Gian Carlo Garaygay @ IE room,

labor watch done, transported @ delivery and assisted the patient in lithotomy position, baby out

@ 5:03 pm, placental out @ 5:08 pm, assisted in episioraphy repair @ 5:17 pm. The patient’s

present illness prior to admission noted gradual onset of persisting hypogastric pain with
contraction thus sought consult hence admission. The rationale for this is to know when the

21

labor happens.

The patient was discharge last Aug. 11, 2008, 9:00 am. The patient has no take home medications.

The rationale for this is the patient’s vital organ is back to normal.

A. TREATMENT AND PROCEDURES

1. Immunization with Tetanus Toxoid – a process by which resistance to an infectious disease is

reduced or augmented. It is a process of producing immunity by introducing a vaccine through

injection or oral administration. Tetanus toxoid is an active immunization agent prepared from

detoxified tetanus toxin that produces on antigenic response in the body, conferring permanent

immunity to tetanus infection. It is prescribed for primary active immunization against tetanus.

For pregnant mothers, it is usually given during the last trimester.

2. Episiotomy – an incision through the perineal tissues design to enlarge the vulvar outlet, during

delivery. A median episiotomy was performed on the patient. The incision followed the natural

line of incision of the perineal muscles.

3. Episiorraphy – the perineal repair was done after the delivery of the placenta.

4. Perilite treatment - is the management and care for one’s disorder by means of electric candles,

inflated lamp and incandescent lamps.

5. Intravenous Fluid Therapy - is an efficient and effective method of supplying fluids directly

into the intravascular fluid compartment


B. Medications

During Pregnancy
22
The general principle regarding medication use during pregnancy is that all medications cross

the placenta and can potentially harm the fetus. No medication, including over-the-counter

medications and herbal remedies should be used without the express approval of increasing

needs the body requires. The primary care provider. Before any medication is taken, a careful

appraisal of risk versus benefit should be made. Yet, vitamins and other food supplements are

usually given to the pregnant woman so as to compensate with the

increasing needs the body

After Delivery

Medications ordered by the physician are as follows requires.

• Cefalexin (Cefalin)

• Mefenamic Acid (Dolfenal)

• Ferrous Sulfate (Beneforte)

C. DIAGNOSTIC PROCEDURES

The patient has a laboratory result.

D. DIET

The patient was give full diet. The regular or full diet contains the essential requirements

our body needs. It is the initial diet prescribed by the physician to a newly admitted postpartum

patient who does necessitate a diet modification. The patient was advised to take foods that are

rich in vitamins and minerals for supplementation and replacement.

X. NURSING MANAGEMENT
ACTUAL CARE GIVEN

During my shift, only few procedures were to be implemented. First and foremost, I
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assessed my patient of her latest condition. Part of this was the taking of vital signs and the

physical examination. After assessing, planning of actions was then done.

First, I did my aesthetic care. I assisted the patient to carry out oral hygiene and combing

of her hair. I also made some arrangements of their things to achieve a therapeutic environment.

Looking on the patient’s chart, I implemented on the doctor’s orders. One of this is the

administration of medications. I also encouraged the patient to continue self perineal care. I was

not able to perform perilite treatment, but I believe she had undergone the procedure.I also

encourage my patient to ambulate in order for her to achieve defecation. I also did my patient

teaching.

PROBLEMS ENCOUNTERED DURING IMPLEMENTATION OF

NURSING CARE

There were no problems encountered during the implementation of nursing care except on

the administration of oral medication sometimes. This was due to the sleeping pattern of the

patient that sometimes her medications she had to take in at a

particular time would be delayed because she was still asleep. Other than this, there

were no problems encountered because the patient was very cooperative.


RESTORATIVE MEASURES USED

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Restorative measures designed to promote client recovery and prevent complications

include positioning the patient, deep breathing exercise every 10-15 minutes on her waking hours,

leg exercise every two hours, turning from side to side and early ambulation with assistance from

bed to chair to promote good circulation. Hydration was maintained as she was ordered sips of

water.

The patient was also encouraged some time for rest and sleep to relieve fatigue so she can

gain control, thus improving the chance for early recovery. After delivery, as expected, the patient

was very exhausted. Yet she was still encouraged to ambulate if she could manage. She was

ordered by the doctor to take ferrous sulfate to restore her iron reserves in the body. She was also

encouraged to include fiber in her diet to prevent her from constipation. Also, intake of plenty of

fluids was also emphasized.

EVALUATION OF CARE

To evaluate good achievement and the effectives of the nursing interventions, the

following were noted on the patient. The patient’s vital signs are stable, re-establishment of fluid

intake and output, performance and effectiveness of deep-breathing and leg exercises, and client

was able to perform activities well with ambulation.

The patient was glad and grateful of the care rendered to her. She complied with all the

instructions given to her. Due to this very good attitude of my patient, her health restored easily

and even didn’t complain of pain even though she repeatedly emphasized her exhaustion during
the labor process.

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PATIENT TEACHING

As a post operative patient, she was encouraged to do deep breathing exercises, 5-10

deep breaths, let exercises by extending the knees and ankles to prevent circulatory stasis. She was

taught gradual ambulation and sit up on bed for lung expansion. The patient was also taught how

to do breast care, care for newborn, assessment of her incision wound, wound care, how to take

her medication and take-home medication regularly.

Every procedure done to my patient has a teaching that goes along with it; especially, on

the administration of the medicines. Due to this, she understood further the importance of the

procedures and was able to comply with them easily.

I encouraged her to breastfeed her baby, for it is very advantageous not only to her baby,

but also to her. Since she was a first time mother, I also taught her the feeding and burping

techniques.

Since she made verbalizations about not being able to achieve defecation, I encouraged her

to drink plenty of fluids, and eat foods rich in fiber. Ambulation was also encouraged, yet her

exhaustion made her non-compliant.

XI. SYNTHESIS AND SUGGESTIONS

A. CONCLUSION

For a health care provider who participates in maternal care, adequate knowledge of the

anatomy and physiology of the reproductive organs and the development of the newborn child
from conception to birth is a basic requirement for understanding.

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One of the primary goals of nursing care is the safe delivery of the baby. Should

circumstances arise that threaten this goal, the obstetrician has several methods to assist the

delivery and prevent harm to come about to the infant and mother.

The significance of this study therefore is to provide the best of medical and nursing

science to protect the life and health of the mother and the fetus, and to ensure a satisfying and

growth-promoting experience for the woman and her family. Nurses provide essential care to the

woman, and thus, the effectiveness of such nursing care is determined by outcomes for the mother

and family.

B. RECOMMENDATION

This care study is the product of good rapport with the patient. I conclude that even with

very limited time, we could still give out our best to our patients. Even we are not guided by

nursing care plans, we could still give a systematic care to them only if we give our heart to our

job. I know this care study could not reach the best remark, but I believe I have learned many

things in making this possible. I still have many things to improve on, so I recommend to myself

to work harder especially in gathering all the data. It is the most important factor to make this kind

of study. Without these data, this study would not be possible.

XII. IMPLICATIONS OF THE STUDY TO:

A. NURSING EDUCATION
The study is designed to upgrade the knowledge and skills of the student nurse.

Educational changes have to keep pace with health care reform so that nurses and health carte
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providers are prepared for this responsibility. Mother and child health recognized as a need for

preventive and restorative care as this is one of the expanding areas in the broadening scope of the

nursing profession. Thus, nursing education includes perceptions of the pregnancy and childbirth

as periods of wellness in the life of a woman and the importance of knowledge in the area of

childcare and development.

The study also centers on the primary focus of the first semester of the school year –

Maternal and Child Health Nursing. For about three months, varied discussions were conducted in

the school and in different area assignments. The above data show a brief glimpse of what

Maternal and Child Health is all about. It would give us a direction on what to do when we, in the

future, will be faced with the same circumstances. May this study further increase our knowledge,

for us to give the optimal care that our patients expect from us.

B. NURSING PRACTICE

Learning is limitless. It is not confined in the four-corners of a room. So, what we

have learned should then be put into practice. This study is the product of that practice. This is the

application of the things obtained in school.

Though cases vary from one person to another, commonly, the same procedures are

applied to intra-postpartum patients. So this would be a good guide for us student nurses in order

to prevent minor errors that may be detrimental to our patients.

The utilization of the nursing process (i.e., Nursing Care Plan) is an important
concept of this study that helps and improves the student nurses’ preparation in the clinical area,

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so he/she can focus his/her care planning and apply principles to practice. Nursing care planning is

essential for individualized care planning because this aids the student to apply theory to practice

and make use of critical thinking skills. Thus, student nurses can emphasize the specific needs of

clients, and the need to delegate care even in the midst of the proliferation of the variety of new

care settings and the diversity of the roles of nurses in the nursing field of practice.

C. NURSING RESEARCH

Care for the childbearing woman and her child does not only end after delivery. It

follows the family from the pregnancy period, through labor and delivery and postpartum period,

it follows the child in the family from birth to adolescence.

Primary care is the main focus of the mother and child nursing as well as secondary and

tertiary care, thus emphasis on research is placed on health care provision to the mother and child.

As what I have learned, nursing is now a big and a growing profession. Our scope

broadens which was brought about by constant research. Though this study does not employ the

steps in doing research, the data presented are relevant and could be a good ground for further

study. In this way, we could, in actual fact, appreciate the diversity of our profession even more.

So, through constant research, we could become competent nurses in this Information

Era.
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