Case With Page Numbers FINAL

I.
INTRODUCTION
This case study is all about Mrs. RN a 17 year old woman residing at Tuktukan, Guinguinto Bulacan. The client was admitted last August 28, 2009 at 4
a.m in the Ospital ng Guiguinto and Discharge last September 01, 2009 at 5 p.m. she undergo a normal spontaneous delivery.
Normal Spontaneous Delivery is birth of an infant without any aid from an attendant or vaginal birth occurring without the mechanical assistance of
obstetric forceps or vacuum aspirator. This is the common delivery of the fetus if the mother doesnt have any complication in their pregnancy. This is the
required delivery because it must be safe for the mother and the baby. There is another delivery like caesarean section or birth accomplished through an
abdominal into the uterus, is one of the oldest types of surgical procedures known. The mother must be give birth in the hospital to secure her safety, and
her baby.
In the Ospital ng Guiguinto there are 4 out of 5 women whose undergo the Normal Spontaneous Delivery in there OB Ward.
Children that are born between the 36th and 39th week (38 and 41 weeks after the LMP) are considered as being normal deliveries. Statistically, only
2/3 of all children are born within the 3 weeks around the calculated date of birth and around 80 % within a month around the predicted date of birth.
Antenatal Care Nine in ten mothers received care from medical professional during their pregnancy; 50 percent received care from a nurse or a midwife
and 38 percent from a doctor. Traditional birth attendants provide antenatal care to 7 percent of women. Six percent of pregnant women received no antenatal
care. These figures show little change from those recorded in the 1998 NDHS. The Philippines Department of Health (DOH) recommends that all pregnant
women have at least four antenatal care visits during each pregnancy. The 2003 NDHS data show that seven in ten women with a live birth in the five years
before the survey had the recommended number of antenatal care visits during the pregnancy for the last live birth. The DOH further recommends that for
early detection of pregnancy-related health problems, the first antenatal check up should occur in the first trimester of the pregnancy. More than half (53
percent) of women who had at least one live birth in the five years before the survey adopt this recommendation. For three in ten women, the first visit was
made when their pregnancy was 4-5 months, while one in 10 had the first antenatal care when they were 6-7 months pregnant. Information about the
danger signs of pregnancy. Five in ten of women with live birth in the five years preceding the survey were informed about the danger signs of pregnancy
complications. This is an increase from 33 percent in 1998. Tetanus toxoid injections. The DOH also recommends that women receive at least two tetanus
toxoid (TT) injections during their first pregnancy. The 2003 NDHS shows that 37 percent of women who had a live birth in the five years before the survey
met this recommendation. TT coverage in 2003 is similar to that recorded in the 1998 NDHS (38 percent). Delivery care. Thirty-eight percent of live births in
the five years before the survey were delivered in a health facility and 61 percent were born at home. These figures show an increase in proportion of births
occurring in a health facility from 34 percent in 1998 and a decline in percentage of births delivered at home (66 percent in 1998). Assistance during
delivery Six in ten births in the five years before the survey were assisted by health professionals; 34 percent by a doctor and 26 percent by a midwife or a
nurse. While coverage of births attended by a health professional has increased in the last five years from 56 percent in 1998, it remains lower than the target
set by DOH (80 percent by 2004). Postnatal care. The DOH recommends that mothers receive a postpartum checkup within two days of delivery. Women
who delivered in a health facility are assumed to receive post natal care. One in three women who delivered outside a health facility had their first postnatal
checkup within two days of delivery. With another 17 percent of women receiving their first postnatal checkup from 3 to 6 days after delivery, 51 percent of
women received a postnatal checkup within six days of delivery. Combined with 38 percent of women delivering their last birth in a health facility, a total of 89
percent of women received postnatal care in the 6 days after delivery. This percentage is higher than the target set by the DOH (80 percent).
During labor many of us feel helpless when it comes to comforting a laboring woman. Knowing a couple of right things to do and say is always helpful,
as well as knowing a few tips on what not to do.
1
1. Massage her face to help release stress and relax her.

2. Remind her to go to the bathroom every hour. A full bladder is not only uncomfortable but can stall labor.
3. Try cool compresses on her neck and face. Even lightly washing her face can feel good when she's working so hard.
4. Encourage her to drink fluids and eat to comfort if her care providers will allow it. Eating and drinking will help restore used energy for the marathon
of labor.
5. Help her change positions to encourage the progress of labor. Some positions will provide pain relief, others may feel more painful. Do what works
for her.
6. If her back is hurting do counter pressure with your hands on the small of her back (or wherever she says to do it) as hard as she likes. Doing this in
the hands and knees position will also help with the pain.
7. Be there for her. Even when she may say that she doesn't wish to be touched, being there for her is very important. Just stand near her so that she
can feel your presence and verbally encourage her.
8. Try the shower or tub. Water in labor is very good for pain relief of all sorts.
9. Use a heat pad, rice sock or warm blanket to her lower back, limbs or perineum (at the end) to help her.
10.
Remind her of why she's doing this: The baby
Stages of Labor
A. First Stage (Stage of Cervical Dilation) onset of regular contractions and ends with complete dilation and effacement
a. Latent Phase
b. Active Phase
c. Transition Phase
B. Second Stage (Stage of Expulsion) begins with complete cervical dilation and effacement and ends with delivery of the fetus.
C. Third Stage (Placental Stage) begins immediately after fetus is born and ends when the placenta is delivered.
Sign of placental separation
a. uterus becomes globular
b. Calkins sign
c. Lengthening of the cord
d sudden gush of blood from the vagina.
Types of placental delivery
Schultz - shiny/fetal side; placenta separates at center first and last at its margins
Duncan- dirty/maternal side; placenta seprates at margins and last at its center
D. Fourth stage (Maternal Homeostatic Stabilization Stage) begins after the delivery of the placenta and continues for 1-4 hours after delivery.
Mechanisms of labor
1. Engagement
5. Extension
2. Descent
6. External Rotation (Restitution)
3. Flexion
7. Expulsion
4. Internal Rotation
2
REASON FOR CHOOSING SUCH CASE STUDY

The practice of nursing care and management of a normal spontaneous delivery of women requires knowledge and skills or specialties in
whatever settings patients is in. It many are home, care giving institutions or in the community nursing entails well founded foundation to assure
satisfaction of the mother and quality of nursing care.
The study is significant in many ways for the students who are concerned of studying NSD. The study of the coitus, fertilization, pregnancy and labor
and delivery. Nursing management provide the possible occurrence of Abnormal Delivery. Furthermore, those will enable to plan and implement
nursing care plan that would meet the challenges to care for the pregnant women.
OBJECTIVE
GENERAL
The students involve in the case study should be able to perform a comprehensive review in the patients condition and develop and plan of care that
would be appropriate for the client. This case study is all about understanding NSD.
SPECIFIC
1. To have knowledge about the client condition.
2. To have knowledge to the client medication and be familiar to that medication.
3. To study the process of pregnancy and development through NSD.
5. To present a thorough assessment through NHH, Gordons typology II Functional Pattern and Physical Assessment.
6. To discuss the anatomy and physiology, physiology of the patients condition.
7. To create and implement a nursing care plan for patients of NSD.
8. To provide health teaching to the mother after delivery and evaluate by return demonstration and verbalization.
9. To teach the mother on proper way of laboring and give assistance during delivery.
II. NURSING ASSESSMENT

A. PERSONAL HISTORY
1. Demographic Data
Date of Assessment: September 01, 20009
Name: Mrs. RN
Address: Tuktukan, Guiguinto Bulacan
Age: 17 years old
Sex: Female
Marital status: Live-in
Birthday: April 23, 1992
Birth place: Balagtas, Bulacan
Position in the family: Eldest daughter
Nationality: Filipino
Race: Asian
Occupation: None
Religious orientation: Roman Catholic
Health care financing and usual source of medical care: Philhealth
Educational attainment: High school undergraduate
Date of admission: August 28, 2009 4AM
Date of discharge: September 1, 2009 5PM
Initial diagnosis: G1P0 pregnancy uterine 27 1/7 weeks in premature labor
Final diagnosis: G1P1 pregnancy uterine 27 1/7 weeks in a NSD premature live baby boy
B. CHIEF COMPLAINT OR REASON FOR VISIT

She was confined to the hospital several hour prior to admission patient experienced Labor pain with bloody discharged. Persistence of the
above s/s coordinated.
C. HISTORY OF PRESENT ILLNESS
Based on the data collected, client started being moody. She easily gets irritated and felt worthless whenever she do something and not satisfied.
She experienced labor pain, uterine contractions occurring at irregular intervals and decrease in duration and intensity. Until it become the sign of true labor.
She delivered her baby within 12 hours according to her. LMP: February 14, 2009; EDC: November 21, 2009; BOW ruptured: 4:00pm artificial; Dilated: 4:30;
Delivered: 4:46 pm cephalic; Placenta delivered: 4:51 pm; Episiotomy: RMLE with local Anesthesia. She dont drink vitamins or medication when she was
pregnant The management given in the hospital were Cefalexin 500mg 1 cap TID, Methergin 1 tab TID, Mefenamic acid 500mg TID prior to pain, Betadine
flushing every 12 hours. She give birth to a baby boy on August 28, 2009 4pm
D. PAST MEDICAL HISTORY
Based on the data collected, client doesnt have any childhood diseases except for simple fever, cough and flu during rainy and cold
seasons. She doesnt have complete immunization. She has allergy to mongo beans. No any accidents and injuries before according to her.
She has never been hospitalized before. Her usual medications taken includes over the counter drugs such as biogesic, neosep, tuseran,
diatabs, lomotil and herbal medicine.
E. FAMILY HEALTH ILLNESS HISTORY
Based on the data gathered, her grandfather died because of lung disease. While her grandmother was a breast cancer survivor. Her
mother named Marilou Paderan died at the age of 41 because of difficulty of labor. Her father name Roldan Paderan Nicholas is alive but having a
heart problem. Her siblings are alive and in good condition namely: Romel Nicholas, 14 years old, Ronald Nicholas, 11 years old and her siblings to
her mother side namely Maricris Hilario, 7 years old and Mariz Hilario, 5 years old. There was no family incidence of arthritis/ rheumatic fever,
diabetes or mental health illness.
See the familys genogram on the next page
GENOGRAM
PATERNAL SIDE
MATERNAL SIDE
70
years
old
73 years
old
65
Y/O
65
Y/O
GRAND MOTHER
GRAND FATHER
41
y/o
41 years
old
LEGEND:
DECEASED BECAUSE OF LUNG

DISEASE
MOTHER DECEASED
BEACAUSE OF DIFFICULTY IN LABOR
ILLIGITIMATE SISTERS
14y/o
11y/o
17y/
o
7y/o
5y/o
CLIENT
BROTHERS
FATHER WITH HEART PROBLEM
SURVIVOR OF BREAST CANCER
CLIENT NEWBORN
CLIENT HUSBAND
18Y/O
GORDONS 11 FUNCTIONAL PATTERN

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1. HEALTH PERCEPTION/HEALTH MANAGEMENT PATTERN

Prior to Hospitalization
During Hospitalization
The general condition of the client was fine; she had a cough and cold
in the past. She believed in health related superstition like faith healer.
She also uses herbal plants/medicines as an alternative for medicine
whenever she cant afford to buy one. She didnt drink alcohol beverages
before her pregnancy, even cigarette or any drugs. She is performing selfbreast examination according to her.
She complains vaginal pain related to episiotomy. She still believes in the
faith healer. She drinks her medicine on time and follows the doctors order.
2. NUTRITIONAL METABOLIC PATTERN

The client intake was fish, vegetable, rice and pandesal. She drinks
water, coffee and milk. According to her, she gained weight during
pregnancy. She has a good appetite. No eating discomforts or diet
restrictions
As what we observed during the interview, Mrs. Nicholass skin is

moistened, there is no presence of skin problems. She was NPO on August 28,
2009. She had a DAT on August 29, 2009 where she can eat rice, biscuits etc.
According to the data gathered, our clients daily food intake includes rice, fish,
chicken, pancit, sopas, pandesal; drinks include water and milk. She had a
good eating habit even if she was in the hospital.
DAYS DIETARY CALL

DATE OF ASSESSMENT: SEPTEMBER 1, 2009
BREAKFAST
LUNCH
DINNER
August 29, 2009

Day 1
280 ml of water
1 cup of rice
1 egg
250 ml of milk
280 ml of water
1 cup of rice
1 bowl of caldereta
August 30, 2009

Day 2
280 ml of water
1 cup of rice
1 egg
250 ml of milk
280 ml of water
1 cup of rice
1bowl of paksiw
September 01, 2009

Day 3
250 ml of juice
1 Bowl of Lugaw
Skyflakes
280ml of water
1 cup of rice
2 pcs of fried chicken
280ml of water
280 ml of water
1 cup of rice
1bowl of tinola
280 ml of water
1 cup of rice
1 bowl of chopsuey
280 ml of water
1 cup of rice
1 bowl of pinakbet
3.
ELIMINATION PATTERN
Character Color
Odor
Frequency Discomfort
Stool
3cm in
Brown
has foul 7 times a
no discomfort
diameter
odor
day
and
immerse in
the bowl
Urine
Regular
yellowish no foul
5 times a
No discomfort
urination
odor
day
Perspiration : she had a perspiration every time she is doing the household
4.
The patient urinated on August 29, 2009 around 6am to 6pm at

600cc on 6pm to 6am her urine output is 300c.On August 30, 2009 from
6am to 6pm she had 400cc urine, on 6pm to 6am she had 200cc. on
August 31, 2009 her output on 6am to 6pm are 400cc, on 6pm to 6am
she urinated 800cc and was not yet eliminated stool.
ACTIVITY/EXERCISE PATTERN
Walking every morning is the exercise of the client. She can perform
activity of daily living like shopping, bathing, dressing, cooking, and eating.
Standing and walking at nearside of her bed became her exercise. She
requires assistance or supervision from another person when bathing and
dressing.
Feeding =0
Bathing =0
toileting =0
dressing =0
grooming =0
bed mobility =0
Feeding =0
Bathing =2
toileting = 2
dressing = 2
grooming = 0
bed mobility = 0
LEGEND:
0- Full Self Care
1- requires use of equipment or device
2- requires assistance or supervision from other person
3- requires assistance or supervision from other person/ device
4 dependent and does not participate
5. SLEEP/REST PATTERN
The client sleeps at 10 to 11 pm in the evening and wake up at 9 am in

The client had a difficulty in her sleep after her delivery as she cant slept
morning. She had a nap in the afternoon for 2- 3 hours. The client doesnt regular hours, she doesnt have a nap in the afternoon and she sleep late at
have any problem in her sleep, she can sleep continuously. She watches night like 12 to 1am, because of caring of her child. She just watches her
television for her to relax.
newborn and play a little bit to him. And sometimes talk or make a chat to the
other mother in the ward.
6. COGNITIVE PERCEPTUAL PATTERN

The client was not wearing corrective eye glasses. Her memory is
The client was not wearing corrective eyeglasses. She was merely feeling
functioning well. She doesnt have difficulties in hearing according to her.
discomfort or pain due to her episiotomy. She cleans her episiotomy as what
the doctors order. Her memory is still functioning well.
7. SELF-PERCEPTION PATTERN
9
She was a first time mom. She always thinks what will be their child.
She encourages herself to be able to breastfeed her baby boy. Although
She also thinks sometimes the event that her mother and father get there were changes in her body during and after her pregnancy, she didnt
separated. She was happy to have a baby boy, she always take care of mind it instead she was very happy because she delivered a well baby boy
him during our visit.
according to the client she have a poor diet because of lack of their income.
8. ROLE RELATIONSHIP PATTERN
She was a first time mom, she is worried on how she will deliver
She is worried on how she will nourished her first child at a very young
her first child because of her young age. She is the oldest daughter age and how she will perform her role as a wife to her husband. She also
of her parents.
think how to adjust to her new role as a mother.
9. SEXUALITY REPRODUCTIVE PATTERN

Her menarche is at the age of 13. She had no menstrual problem at

all. She became pregnant and will be giving a birth to a baby boy. She and
her husbands dont use any contraceptives. The couple having sex twice a
week as she live with her husbands house but they decrease intercourse
as she get pregnant. She had a 28 days regular cycle of menstruation She
uses 2 pads of napkin per day. Her LMP was February 14, 2009, she had a
G1P0.
The client gives birth to a live baby boy. She had a G1P1 (1001). And she
undergoes in a Normal Spontaneous Delivery at 4:46pm with the type of
episiotomy Right Medio lateral episiotomy (RMLE). And used a local
anesthesia. Her placenta delivered at 4:51pm with complete cotyledons. She
uses 2-4 pads of napkin per day.
10. COPING STRESS TOLERANCE

10
The patient was able to cope up during times of problems

She is happy but a bit of nervous when she gives birth to a healthy baby boy. And
because they work things out by having a good conversation to that happiness allays her feelings.
whomever it is related. Even though that her parents are separated
and she grew up in her grandmother custody. She talks to other
people that may relate to her problem.
11. VALUES BELIEF PATTERN
G.
The patient was a Roman catholic; she was able to attend

She always pray to God to have her child a healthy condition and also her, she
mass during Sunday. During times of difficulties, only God provide also believes that her child was a gift from Him.
them comfort and blessings. The client believes that God help her in
her life, she go to the church and pray for guidance, health and
security of their family.
GROWTH AND DEVELOPMENT

Erick Erickson
Sigmund Freud
The conscious mind
Adolescence:(13 to 19 years)
Jean Piaget
12 years to adolescence or
early adulthood
James Fowler
Identity vs. Role Confusion
Formal Operational Period
Early Adult
Individuative-reflective
Harry Stack Sullivan
Stage 4
11
DEFINITION:
DEFINITION:
DEFINITION:
DEFINTION:
DEFINITION:
The adolescent is newly

concerned with how he or she
appears to others. Superego
identity is the accrued
confidence that the outer
sameness and continuity
prepared in the future are
matched by the sameness and
continuity of one's meaning for
oneself, as evidenced in the
promise of a career. The ability
to settle on a school or
occupational identity is
pleasant. In later stages of
Adolescence, the child
develops a sense of sexual
identity.
Includes everything that we

are aware of. This is the
aspect of our mental
processing that we can think
and talk about rationally. A part
of this includes our memory,
which is not always part of
consciousness but can be
retrieved easily at any time
and brought into our
awareness. Freud called this
ordinary memory the
preconscious.
Sigmund
Freud
theory
introduced a number of
concepts about development
that are still use today. The
concepts of the unconscious
mind, defence mechanism,
and the id, ego and superego
are Freuds. The unconscious
mind is the part of the persons
mental life that a person is
aware of. This concept of the
unconscious is one of Freuds
major contributions to the field
of psychiatry. The id resides in
the
unconscious
and,
operating on the pleasures
principle, seeks immediate
pleasure and gratification. The
ego, operating on the reality
principle,
balances
the
gratification demands of the id
with the limitations of social
and physical circumstances.
Characterized by hypotheticodeductive reasoning (Inhelder

& Piaget, 1958). Hypotheticodeductive reasoning involves
posing possible explanations
of events, and then mentally
combining and separating
possible variables in a
systematic way in order to see
if the explanations hold. Some
authors argue that cognition
continues to develop beyond
formal operations, but Piaget,
who saw equilibration as a
driving force, regarded formal
operations as an end stage,
because logical equilibrium is
achieved in formal operation.
The sense of identity and

outlook on the world are
differentiated and the person
develops explicit systems of
meaning.
The spiritual component of
growth
and
development
refers
to
individuals
understanding
of
their
relationship with the universe
and their perceptions about
the direction and meanings of
life. James Fowler describes
the development of faith as a
force that gives meaning to a
persons life. He uses the term
faith as a form of knowing, a
way of being in relation to an
ultimate
environment
to
Fowler, faith is a relational
phenomenon; it is an active
mode-of-being in-relation to
another or others in which we
invest commitment, belief,
love, risk and hope.
Sullivan called his approach

an interpersonal theory of
psychiatry because he
believed psychiatry is the
study of what goes on
between people. This is in
contrast to Freuds paradigm
that focuses on what goes on
inside people. Freuds is a
drive model while Sullivans is
an interpersonal model. Freud
postulated that the personality
is made up of id, ego, and
superego with the id being the
source of the action. We are
driven by inner instinctual
urges, especially sexual and
aggressive ones, and our
prime motivation is to
maximize pleasure while
minimizing pain. We are pretty
autonomous monads who
cathect or connect to others
who happen to meet our
needs. Instincts appear first,
then relationships develop
because they satisfy our
needs.
For Sullivan, relationships are
primary. Personality is a
hypothetical entity that cannot
be observed or studied apart
from interpersonal situations
wherein it is made manifest.
The only way personality can
12
The methods the ego uses to

fulfil the needs of the id in a
socially acceptable manner
called defence mechanisms,
or adaptive mechanisms as
they are more commonly
called today, are the result of
conflicts between the ids
impulses and the anxiety that
attends these conflicts due to
environment restrictions. The
third aspect of the personality,
according to Freud, is the
superego.
The
superego
contains the conscience and
the ego idea. The conscience
consists of societys donts
usually as a result of parental
and cultural expectations. The
ego ideal compromises the
standards of perfection toward
which the individual strives.
Freud proposes that the
underlying
motivation
to
human
development
is
dynamic,
psychic
energy,
which he called libido.
According to Freuds theory of
psychosexual
development,
the personality develops in five
overlapping stages from birth
to adulthood. The libido
changes
its
location
of
emphasis within ht body from
one
stage
to
another.
Therefore, a particular body
area has special significance
to a client at a particular body
be known is through the

medium of interpersonal
interactions. Therefore the
unit of study is not the
individual person, but the
interpersonal situation. Since
personality is defined by what
it does in an interpersonal
field,
13
area has special significance

to the client at a particular
stage. The first three stages
(oral, anal and phallic) are
called the pregenital stages.
The culminating stage is the
genital stage. If the individual
doe not achieve a satisfactory
progression at each stage, the
personality becomes fixated at
that
stage.
Fixation
is
immobilization or the inability
of the personality to proceed
to the next stage because of
anxiety.
EXPLANATION:
EXPLANATION:
EXPLANATION:
EXPLANATION:
The
client
is
in
the
Adolescence stage where 12
to 20 years of age their central
task is identity versus role
confusion, the indicators of
positive resolution is coherent
sense of self plan to actualize
ones abilities, the indicators of
negative resolution is feelings
of confusion, indecisiveness,
and
possible
antisocial
behaviour. The client passed
the other stage which is the
infancy (birth to 18 months),
early adulthood (18 months to
3 years), late childhood (3 to 5
years), and school age(6 to 12
years). After giving birth to her
child she must passed her
The newborn have to pass the

five stages of development by
Freud which are first oral
stage (birth to 1 years)
mouth is the centre of
pleasure (major source of
gratification and exploration);
the mother should feeds her
baby because feeding
produces pleasures and sense
of comfort and safety. It must
be provided and pleasurable
when required; the mother
must have conflict in weaning.
Second is anal stage (1 to 3
years) anus and the bladder
are the source of pleasure
(sensual satisfaction, self
control) controlling and
Cognitive development refers

to the manner in which people
learn to think, reason, and use
language. It involves a
persons intelligence,
perceptual ability, and ability to
process information. Cognitive
development represents a
progression of mental abilities
from illogical to logical
thinking, from simple to
complex problem solving, and
from understanding concrete
ideas to understanding
abstract concepts. According
to Piaget, cognitive
development is an orderly,
sequential process in which a
variety of new experiences
The client has a strong

spiritual component because
she always believes that God
is in her side and along her
growth there are struggles that
along to it.
Sullivan called his approach

an interpersonal theory of
psychiatry because he
believed psychiatry is the
study of what goes on
between people. This is in
contrast to Freuds paradigm
that focuses on what goes on
inside people. Freuds is a
drive model while Sullivans is
an interpersonal model. Freud
postulated that the personality
is made up of id, ego, and
superego with the id being the
source of the action. We are
driven by inner instinctual
urges, especially sexual and
aggressive ones, and our
prime motivation is to
maximize pleasure while
minimizing pain. We are pretty
14
adolescence stage where the

stage she get pregnant she
must know her identity and
role as a mother in early as
she can. She must not be
confused in her abilities so she
can give her newborn a proper
care. She might be felt
confuse as her early age
giving birth but she must know
her responsibility as a mother
as she go to another stages of
development
as
young
adulthood(18 to 25 years),
adulthood(25 to 65 years) and
maturity(65 years to death).
expelling feces provide

pleasure and sense of control.
Toilet training should be
pleasurable experience the
major conflict that may
encounter is toilet training.
Third phallic (4 to 6 years) the
childs genitals are the centre
of pleasure. Masturbation
offers pleasure. Other
activities can include fantasy,
experimentation with peers
and questioning of adults
about sexual topics. The child
identifies with the parent of the
opposite sex and the later task
on a love relationship outside
the family the parents must
encourage identity. The major
conflict in this stage is the
Oedipus and electra where the
males child attract to her
mother and have hostile
attitude to her father and
Electra where the daughter
attract to her father and get
hostile attitude to her mother.
Fourth is the latency stage (6
to puberty) energy is directed
to physical and intellectual
activities. Sexual impulses
tend to be repressed. Develop
relationships between peers of
the same sex. The parents
must encourage their child
with physical and intellectual
pursuits. Encourage sports
and other activities with same
(stimuli) must exist before

intellectual abilities can
develop. Piagets cognitive
development process is
divided into five major phases:
the sensorimotor phase (birth
to 2 years), the preconceptual
stage (2 to 4 years), the
intuitive phase (4 to 7 years),
concrete operations phase (7
to 11 years), and formal
operations stage (11 to 15
years). A person can develop
through each of these phases;
each phase has its unique
characteristic. In each phase,
the person uses three
primarily abilities: assimilation
the process through which
humans encounter and react
to new situations by using the
mechanisms they already
possess. In this way, people
acquired knowledge and skills
as well as insights into the
world around them.
Accommodation is a process
of change whereby cognitive
processes mature sufficiently
to allow the person to solve
problems that were unsolvable
before. This adjustment is
possible chiefly because new
knowledge has been
assimilated. Adaptation, or
coping behaviour, is the ability
to handle the demands made
by the environment
autonomous monads who

cathect or connect to others
who happen to meet our
needs. Instincts appear first,
then relationships develop
because they satisfy our
needs.
For Sullivan, relationships are
primary. Personality is a
hypothetical entity that cannot
be observed or studied apart
from interpersonal situations
wherein it is made manifest.
The only way personality can
be known is through the
medium of interpersonal
interactions. Therefore the
unit of study is not the
individual person, but the
interpersonal situation. Since
personality is defined by what
it does in an interpersonal
field,
15
sex peers. Last stage is the

genital stage (puberty and
after) energy is directed
toward full sexual maturity and
function and development of
skills needed to cope with the
environment. Encourage
separation from parents,
achievement of independence,
and decision making
III. ANATOMY AND PHYSIOLOGY

A. Anatomy of the female reproductive system
16
Female External Reproductive System
Female Internal Reproductive Parts
Female
Reproductive System
The female reproductive system is designed to carry out several functions. It produces the female egg cells necessary for reproduction, called the
ova or oocytes. The system is designed to transport the ova to the site of fertilization. Conception, the fertilization of an egg by a sperm, normally occurs in
the fallopian tubes. The next step for the fertilized egg is to implant into the walls of the uterus, beginning the initial stages of pregnancy. If fertilization and/or
implantation do not take place, the system is designed to menstruate (the monthly shedding of the uterine lining). In addition, the female reproductive
system produces female sex hormones that maintain the reproductive cycle.
During menopause the female reproductive system gradually stops making the female hormones necessary for the reproductive cycle to work. When
the body no longer produces these hormones a woman is considered to be menopausal.
17
What Parts Make-up the Female Anatomy?

The female reproductive anatomy includes internal and external structures.
The function of the external female reproductive structures (the genital) is twofold: To enable sperm to enter the body and to protect the internal genital
organs from infectious organisms. The main external structures of the female reproductive system include:
Labia majora: The labia majora enclose and protect the other external reproductive organs. Literally translated as "large lips," the labia majora are
relatively large and fleshy, and are comparable to the scrotum in males. The labia majora contain sweat and oil-secreting glands. After puberty, the labia
majora are covered with hair.
Labia minora: Literally translated as "small lips," the labia minora can be very small or up to 2 inches wide. They lie just inside the labia majora, and
surround the openings to the vagina (the canal that joins the lower part of the uterus to the outside of the body) and urethra (the tube that carries urine from
the bladder to the outside of the body).
Bartholin's glands: These glands are located next to the vaginal opening and produce a fluid (mucus) secretion.
Clitori s: The two labia minora meet at the clitoris, a small, sensitive protrusion that is comparable to the penis in males. The clitoris is covered by a fold of
skin, called the prepuce, which is similar to the foreskin at the end of the penis. Like the penis, the clitoris is very sensitive to stimulation and can become
erect.
Mons pubis: (Latin for "pubic mound"), also known as the mons veneris (Latin, mound of Venus) or simply the mons, is the fatty tissue lying above the
pubic bone of adult women, anterior to the symphysis pubis. The mons pubis forms the anterior portion of the vulva.
Anus: is an opening at the opposite end of a humans digestive tract from the mouth. Its function is to expel feces, unwanted semi-solid matter produced
during digestion, which, depending on the type of animal, may be one or more of: matter which the animal cannot digest, such as bones;[1] food material
after all the nutrients have been extracted, for example cellulose or lignin; ingested matter which would be toxic if it remained in the digestive tract; and dead
or excess gut bacteria and other endosymbionts.
Hymen: is a fold of mucous membrane which surrounds or partially covers the external vaginal opening. It forms part of the vulva, or external genitalia. A
slang term for hymen is "cherry", as in "popping one's cherry" to mean losing one's virginity.] Despite this, it is not possible to confirm that a woman is a
virgin by examining her hymen. In cases of suspected rape or sexual abuse, a detailed examination of the hymen may be carried out; but the condition of
the hymen alone is often inconclusive or open to misinterpretation, especially if the patient has reached puberty. In children, although a common
appearance of the hymen is crescent-shaped, many variations are possible. After a woman gives birth she may be left with remnants of the hymen called
carunculae myrtiformes or the hymen may be completely absent.
The vulval vestibule is the anatomical name for the entrance to the vagina (it is the boundary between the external genitalia (vulva) and internal genitalia
(vagina), where the Bartholin's glands are located).
18
The internal reproductive organs in the female include:

Vagina: The vagina is a canal that joins the cervix (the lower part of uterus) to the outside of the body. It also is known as the birth canal.
Uterus (womb): The uterus is a hollow, pear-shaped organ that is the home to a developing fetus. The uterus is divided into two parts: the cervix, which is
the lower part that opens into the vagina, and the main body of the uterus, called the corpus. The corpus can easily expand to hold a developing baby. A
channel through the cervix allows sperm to enter and menstrual blood to exit.
Ovaries: The ovaries are small, oval-shaped glands that are located on either side of the uterus. The ovaries produce eggs and hormones.
Fallopian tubes: These are narrow tubes that are attached to the upper part of the uterus and serve as tunnels for the ova (egg cells) to travel from the
ovaries to the uterus. Conception, the fertilization of an egg by a sperm, normally occurs in the fallopian tubes. The fertilized egg then moves to the uterus,
where it implants to the uterine wall.
B.
ANATOMY OF
MENSTRUAL
CYCLE
19
What Happens During the Menstrual Cycle?

Females of reproductive age experience cycles of hormonal activity that repeat at about one-month intervals. (Menstru means "monthly"; hence the
term menstrual cycle.) With every cycle, a woman's body prepares for a potential pregnancy, whether or not that is the woman's intention. The term
menstruation refers to the periodic shedding of the uterine lining.
The average menstrual cycle takes about 28 days and occurs in phases: the follicular phase, the ovulatory phase (ovulation), and the luteal phase.
20
There are four major hormones (chemicals that stimulate or regulate the activity of cells or organs) involved in the menstrual cycle: follicle-stimulating
hormone, luteinizing hormone, estrogen, and progesterone.
Follicular Phase
This phase starts on the first day of your period. During the follicular phase of the menstrual cycle, the following events occur:
Two hormones, follicle stimulating hormone (FSH) and luteinizing hormone (LH) are released from the brain and travel in the blood to the ovaries.
The hormones stimulate the growth of about 15-20 eggs in the ovaries each in its own "shell," called a follicle.
These hormones (FSH and LH) also trigger an increase in the production of the female hormone estrogens.
As estrogen levels rise, like a switch, it turns off the production of follicle-stimulating hormone. This careful balance of hormones allows the body to limit the
number of follicles that complete maturation, or growth.
As the follicular phase progresses, one follicle in one ovary becomes dominant and continues to mature. This dominant follicle suppresses all of the other
follicles in the group. As a result, they stop growing and die. The dominant follicle continues to produce estrogens.
Ovulatory Phase
The ovulatory phase, or ovulation, starts about 14 days after the follicular phase started. The ovulatory phase is the midpoint of the menstrual cycle, with the
next menstrual period starting about 2 weeks later. During this phase, the following events occur:
The rise in estrogens from the dominant follicle triggers a surge in the amount of luteinizing hormone that is produced by the brain.
This causes the dominant follicle to release its egg from the ovary.
As the egg is released (a process called ovulation) it is captured by finger-like projections on the end of the fallopian tubes (fimbriae). The fimbriae sweep
the egg into the tube.
Also during this phase, there is an increase in the amount and a change in the consistency of mucus produced by the cervix (lower part of the uterus.) If a
woman were to have intercourse during this time, this receptive mucus captures the man's sperm, nourishes it, and helps it to move towards the egg for
fertilization.
Luteal Phase
21
The luteal phase begins right after ovulation and involves the following processes:
Once it releases its egg, the empty follicle develops into a new structure called the corpus luteum.
The corpus luteum secretes the hormone progesterone. Progesterone prepares the uterus for a fertilized egg to implant. If intercourse has taken place and
a man's sperm has fertilized the egg (a process called conception), the fertilized egg (embryo) will travel through the fallopian tube to implant in the uterus.
The woman is now considered pregnant.
If the egg is not fertilized, it passes through the uterus. Not needed to support a pregnancy, the lining of the uterus breaks down and sheds, and the next
menstrual period begins.
How Many Eggs Does a Woman Have?
During fetal life, there are about 6 million to 7 million eggs. From this time, no new eggs are produced.
The vast majority of the eggs within the ovaries steadily die, until they are depleted at menopause. At birth, there are approximately 1 million eggs;
and by the time of puberty, only about 300,000 remain. Of these, 300 to 400 will be ovulated during a woman's reproductive lifetime. The eggs continue to
degenerate during pregnancy, with the use of birth control pills, and in the presence or absence of regular menstrual cycles.
REVIEW OF SYSTEMS
22
23
24
IV THE PATIENT AND HIS ILLNESS

Physiology of Normal Spontaneous Vaginal Delivery
MODIFIABLE FACTORS
G1P1 February 14, 2009
Cephalic presentation
NON MODIFIABLE FACTORS

17 Y/O
Female
Menarche:13 y/o
25
Puberty
Duration of Pregnancy
27 i/7 weeks AOG
LABOR PROCESS
Date of Onset
Cause of Onset:Oxytoxin Theory
Labor, considered a stressful event,
Stimulate the hypophysis to produce
Oxytoxin from the posterior pituitary
Gland. Oxytoxin cause contraction of
Smooth muscle of the body.
Uterine contractions occurring at regular intervals and increase

In duration and intensity
Cervical dilation and effacement
26
Pain in the back that radiates at the abdomen
Bloody show
First stage of Labor (latent, active, transition)
Second stage- Stage of expulsion

-cervial dilation complete at 10cm
-cerical effacement is 100%
-duration is 20-50 min.
-uterine contractions are very strong
-less than 2-3 min apart and last 60-90 sec
-vaginal discharge is very copius bloody mucus
-fetal descent continues at a rate of 1cm/hr in primipara
-urge to push begins
-crowning occurs
Woman reaction during labor:

Latent Stage:
-alert, talkative, nervous, excited
with some degree of apprehension
but still with the ability to
communicate
Active Stage:
-With fears of losing control of self
becoming less outgoing, more
introvert concentrating on breathing
Techniques
Transition Stage:
-Mood suddenly changes, fatigue
Mechanisms of Labor
-engagement
-descent
-flexion
27
-internal rotation
-extension
-external rotation
-expulsion
Newborn baby via vaginal delivery
Placental Stage
-Calkins Sign
-lengthening of the cord
-sudden gush of blood
-Brandt Andrews manuever
Rooming in concept
PHYSICAL ASSESSMENT
Patient Name: Mrs. RN
Age: 17 yrs. Old
Date of assessment: September 1, 2009
BODY PART
ASSESSED
TECHNIQUE
Vital signs:
BP: 120/80 mmHg
Temp. 36.5 C
BMI: 23 NORMAL
NORMAL FINDINGS
ACTUAL FINDINGS
RR: 20 CPM
PR: 80 BPM
REMARKS
28
A.GENERAL
APPEARANCE
1.Body built
2.Posture
INSPECTION
INSPECTION
Proportionate
Relaxed, erect posture
Proportionate: Mesomorph
Not relaxed, Not erect posture
3.Gait
4.Dress, grooming,
hygiene(odor)
INSPECTION
INSPECTION
Coordinated movements
Clean, neat, no bad odor
Coordinated movements
Clean, with slight body odor
5.Obvious physical
deformities
6.Height
7.Weight
B. VITAL SIGNS
1.Temperature
2.RR
3.PR
4. BP
C. MENTAL STATUS
INSPECTION
No deformities :healthy
appearance
No deformities :healthy
appearance
55
65kg
Normal
Deviation from
normal(Due to
perineal suture)
Normal
Deviation from
normal(Due to non
therapeutic
environment)
Normal
INSPECTION
INSPECTION
BMI 18-25
PALPATION
INSPECTION
PALPATION
PALPATION
37 C
16-20 RPM/CPM
75-120 BPM
120/80 mmHg
36.5C
20 RPM/CPM
80 BPM
120/80 mmHg
Normal
Normal
Normal
Normal
1.Level of
consciousness
INSPECTION
INSPECTION
INSPECTION
Responsive: responds to
questions clearly and
appropriately
Cooperative
Understandable; exhibits
thought association
Normal
2. Orientation
3. Language and
Communication
D. SKIN AND NAILS
1.Examine the expose
part
2. Nails
Responsive: responds to
questions clearly and
appropriately
Cooperative
Understandable; exhibits
thought association
Convex curvature: smooth
texture, intact epidermis
Highly vascular and pink in
color, prompt return to pink
color in 2-3 seconds
Convex curvature: smooth

texture, intact epidermis
Highly vascular and slightly
pale in color, prompt return to
pink color in 2-3 seconds
Normal
Normocephalic and
Normocephalic and
Normal
E. HEAD AND FACE

1.Skull condition and
INSPECTION
INSPECTION
INSPECTION AND
PALPATION
INSPECTION
Normal
Normal
Normal
Normal
Normal
29
proportion
2.Palpate for mass,
presence of infestation;
tenderness and hair
conditions
3.Face(symmetry and
movements)
PALPATION
INSPECTION
F. EYES
1.Eyebrows
INSPECTION
INSPECTION
2.Eyelids
INSPECTION
3.Blinks response
INSPECTION
4.Eyeballs symmetric
movement
INSPECTION
5.Conjnctiva(bulbar and
palpebral)
6.Sclera
7.Pupils
INSPECTION AND
PALPATION
INSPECTION
INSPECTION
symmetrical ;smooth skull

contour
Smooth: uniform consistency;
absence of nodules or masses
symmetrical ;smooth skull

contour
uniform consistency; absence
of nodules or masses
Symmetrical facial features and

movements; palpebral fissures
equal in size
Symmetrical facial features and

movements; palpebral fissures
equal in size
Normal
Hair evenly distributed: skin

intact; eyebrow symmetrically
aligned: equal movement
Skin intact: no discharge; no
discoloration: lids close
symmetrically
15-20 involuntary blinks per
minute; bilateral blinking
Symmetric movement
Hair evenly distributed: skin

intact; eyebrow symmetrically
aligned: equal movement
Skin intact: no discharge; no
discoloration: lids close
symmetrically
19 involuntary blinks per
minute; bilateral blinking
Symmetric movement
Normal
Bulbar; transparent; capillaries

sometimes evident. Palpebral;
shiny: smooth: pink orvred
White
Black in color; equal in size:
round: briskly reactive to light
and accommodation
Reaction to light: illuminated
pupil constricts (direct
response): no illuminated pupil
constricts (consensual
response)
Reaction to accommodation:
pupils constricts when looking
at near objects: pupils
converge when object is move
Bulbar; transparent; capillaries

sometimes evident. Palpebral;
shiny: smooth: pale in color
Porcelain white
Black in color; equal in size:
round: briskly reactive to light
and accommodation
Reaction to light: illuminated
pupil constricts (direct
response): no illuminated pupil
constricts (consensual
response)
Reaction to accommodation
Normal
Normal
Normal
Normal
Normal
Normal
Normal
30
8. Lacrimal apparatus
9. Visual acuity
G. EARS
1.auricles
2.Pinna
INSPECTION AND
PALPATION
INSPECTION
PALPATION
PALPATION
3.External Canal
4.Heaing Acuity
H. NOSE
5.Septum
6.Mucous membrane
7. Patency
INSPECTION
INSPECTION
8. nasal cavity
9.Sinuses
I. MOUTH
1.Lips
INSPECTION
PALPATION
INSPECTION
INSPECTION
PALPATION
INSPECTION
toward the nose. Peripheral

vision is intact
No edema or tearing
Noted edema or tearing
Normal
Able to read news print
Able to read news print
Normal
Color same as facial skin:

symmetrical: aligned with the
lower cantus of the eye
Mobile: firm: pinna recoils after
it is folded
No discharge
Normal voice tone audible
Color same as facial skin:

symmetrical
Normal
Mobile: firm: pinna recoils after

it is folded
No discharge; dry cerumen
Normal voice tone audible
Normal
Intact and I midline

Pinkish
Air moves freely in and out of
the nasal cavities
No obstructions
Not tender
Intact and I midline

Pinkish
Air moves freely in and out of
the nasal cavities
No obstructions
Not tender
Normal
Normal
Uniform pink color: moist:

smooth texture: symmetry of
contour
Dry, pale in color and rough
2. Mucosa
INSPECTION
Uniform pink color
Not really moist and smooth
3.Tongue
INSPECTION
Central position: pink color,

moves freely: no tenderness
Central position: pink color,

moves freely: no tenderness
Normal
Normal
Normal
Normal
Deviation from
normal(Decrease
fluid volume due to
labor process)
Deviation from
normal(Due to lack
of water intake)
Normal
31
2. Lung expansion
PALPATION
3. Fremitus
PALPATION
4.Breathing pattern
5. Breath sound
6. Costal angle
N.
CARDIOVASCULAR
1.Precordium
a. Aortic and
4. Teeth
pulmonic
b. Tricuspid
INSPECTION
AUSCULTATION
INSPECTION AND PALPATION
Full and symmetric chest

expansion
Bilateral symmetry of vocal
fremitus
Quiet, rhythmic, effortless
Vesicular and bronchovesicular
Less than 90
Full and symmetric chest

expansion
Bilateral symmetry of vocal
fremitus
Quiet, rhythmic
Vesicular and bronchovesicular
Less than 90
Normal
Normal
Normal
Normal
Normal
INSPECTION AND PALPATION No Pulsation

No Pulsation
Normal
INSPECTION
32 permanent teeth, smooth,
Smooth, off white teeth with
Deviation from
shiny white tooth enamel
dental carries
normal(Due to poor
INSPECTION AND PALPATION No Pulsation; no lifts or heaves No Pulsation; no lifts or heaves dental hygiene)
Normal
5. Gums
INSPECTION
gums, visible
moist firm
texture
Gums
in color, not really
Deviation
from
c. Apical
INSPECTIONAND
ANDPALPATION
PALPATION Pink
Palpation
in 50%
of
No lift pale
or heave
Normal
moist
firm
texture
normal
(lack
of water
adult and palpable I most PMI
th
intake)
in 5 LICS at or medial to MCL:
J.PHARYNX
No lift or heave
1.Uvula
INSPECTION
Midline
Midline
Normal
d. Epigastric
INSPECTION AND PALPATION Aortic pulsations
Aortic pulsations
Normal
2.Mucosa
INSPECTION
Pinkish
Pinkish
Normal
e. Auscultating the AUSCULTATION
S1: usually heard at all sides.
S2: usually heart at all sites,
Normal
3.Tonsils
INSPECTION
Pink
ad
smooth:
no
discharge
Pink
ad
smooth:
no
discharge
Normal
heart areas
Usually louder at apical area
louder at the base of the heart
4.Gag reflex
INSPECTION
Present
Present
Normal
above
S2: usually heart at all sites,
K. Neck
louder at the base of the heart
1.Muscle strength
INSPECTION AND RANGE OF Coordinated:
smooth
Coordinated: smooth
Normal
S3: in children
and young
MOTION
movement
with no discomfort
movement with no discomfort
adults
2.Trachea
INSPECTION AND PALPATION Central
placement
Normal
S4: older
adults in midline of Central placement in midline of
the
neck
the
neck
2. Carotid artery
PALPATION AND
Symmetric
pulse volume, full
Symmetric
pulse volume,
Normal
3.Palpate Thyroid
INSPECTION
AND PALPATION Lobes
are notthrusting
palpablequality
Lobes
are quality
not palpable
Normal
AUSCULTATION
pulsations:
thrusting
remain same
remain same when client
when client breaths
L.BREAST AND
breaths, turns head and
AXILLA
changes
sitting
to supine Even with the chest wall,
1.Breast symmetry
INSPECTION
Breast
are from
round
and generally
Normal
position: elastic
arterial wall
and contour
symmetric:
no tenderness,
generally symmetric: no
3. Jugular vein
INSPECTION
Veins not
Veins not visible
Normal
masses
andvisible
lesions
tenderness,
masses and
lesions
O. ABDOMEN
2.Skin
INSPECTION
uniform
in color; skin
Skin
uniform
in color;
skin of
Normal
1.Skin characteristics
condition
INSPECTIONAND PALPATION Skin
Uniform
in color
Uniform
in color;
presence
Normal
smooth and intact
smooth
andlinea
intactnigra
strea and
3.Nipple
INSPECTION
round
and dark
Dark
bow inand
color,
Bilaterally
Normalfrom
2.Contourcondition
and
INSPECTIONAND PALPATION Bilaterally
Symmetric
contour
Rounded
enlarged
Deviation
and
presence of
brown in color: no presence of
round with presence of milk
symmetry
normal (fundus is
discharge
discharge
above the level of
the umbilicus)
M. CHEST AND
LUNGS
3.Abdominal bowel
AUSCULTATION
Audible bowel sounds
Audible bowel sounds
Normal
sounds and
1.Shape
INSPECTION
Anteroposterior to transverse
Spine is vertically aligned
Normal
configuration
ratio of 1:2; Spine is
4. Presence of muscle INSPECTION AND PALPATION diameter
No Tenderness
No Tenderness
Normal
guarding, extension
32
V.
DOCTORS ORDER
August 28, 2009
3:30PM Pls. Admit to DR
Secure consent for management/NSD
TPR q 4 record
NPO
BP: 159/100 IVF D, LR +L +10units oxytocin at 20 gtts
36.6C Monitor progress of labor, FHT
Refer Accordingly
03:43pm
Post Partum order
Back to room
V/S q 15 min until stable
DAT when fully awake
IVF to consume
Cefalexin 500mg 1 cap TID
Methergin 1 tab TID
Mefenamic Acid 500mg TID prior to pain
Betadine flushing q 12 hours
Refer Accordingly
August 29, 2009-09
7:00pm Methergin 2 cap IV STAT
TF D5LR 500cc at 10-15 gtts +10 units oxytocin
8:55 am Captopril 25g SL STAT
Nifedipine 5g 1cap BID
9:00 am
IVF to consume
August 30, 2009
MGH
Hmeds
7:15 am
Cefalexin 500mg TID x 7 d
Mefenamic Acid 500mg TID prior to pain
Methergin 1 tab x 3d
Ferrous sulphate OD
Follow up check-up Sept. 5, 2009 2pm
August 31, 2009
08:50 pm
BP: 150/110>Captopril 25g/ SL STAT
33
THE PATIENT AND HIS CARE

A. MEDICAL MANAGEMENT
a. IVF, BT, NEBULIXATION, NGT, TPN, OXYGENATION THERAPHY, ETC.
Medical Management
Treatment
I.V. D5LR 500ml/cc
incorporated of oxytocin 10
units at 10-15 gtts.
Date Ordered/ Date

performed/Date
Change or DC
Date Ordered: Aug. 28,
2009
Date Performed: Aug.
28, 2009 (8:55 am)
DC: August 29, 2009
General Description
Intravenous therapy or IV therapy is

the giving of liquid substances directly
into a vein. It can be intermittent or
continuous; continuous administration
is called an intravenous drip. The
word intravenous simply means
"within a vein", but is most commonly
used to refer to IV therapy. Therapies
administered intravenously are often
called specialty pharmaceuticals.
Compared with other routes of
administration, the intravenous route
is the fastest ways to deliver fluids and
medications throughout the body.
Some medications, as well as blood
transfusions and lethal injections, can
only be given intravenously.
Indications/Purposes
A. To administer fluids /
medications (or as a
TKO line in potentially
unstable patients who
may require
fluids/medications)
Clients Response to
the Treatment
After 1 day of
rendering treatment
the client will gain the
lost blood after
delivery.
B. To obtain blood
specimens for laboratory
analysis
C. To insert invasive
monitoring instruments
(In Hospital).
D. They maintain the
daily requirements for
fluid (for the patient who
gets nothing by mouth
[NPO] or who is
nauseated and
vomiting), replace lost
fluid in the postoperative
patient), provide large
amounts of fluid rapidly
(for the patient who has
34
taken a drug overdose),

and serve as a vehicle
for medications, most
commonly antibiotics.
Nursing responsibilities:
Prior to: Verify written prescription and make IV label
Observe 10Rs when preparing and administering IVF.
Explain procedure to patient and significant others.
Perform hand washing and prepare all the materials needed.
During: Assist patient vein and choose appropriate site.
Check the sterility and integrity of IV solutions, IV set and other devices infusion.
Open the seal of the IV aseptically, disinfect rubber cork with cotton balls and alcohol.
Open the roller clamp and spike the container aseptically.
Fill drip chamber at least half and prime it with IV fluid aseptically to expel air bubbles.
Check the regulation of the IVF
After: perform hand washing and prepare all the materials needed for removing of IV insertion.
35
B. Drugs
36
Name of Drug
(Generic and
Brand Name)
Generic Name:
Cefalexin
Dosage, Route
and Frequency
Date ordered:
August 28, 2009
Date Performed:
August 28, 2009
Indication:
It is prescribed for oral
treatment of selected
infections caused by
susceptible
bacterial
strains, especially lower
per respiratory tract, urinary
tract, skin and soft
tissue, and bone and
joint infections. It is also
used as a prophylaxis
against
bacterial
endocarditis in high-risk
patients
undergoing
surgical
or
dental
procedures.
Contraindication
Dosage: 500 mg
Route: TID
Brand Name:
Ceporex, Keftab,
Keflex;
Frequency:
orem
Classification:
semisynthetic
cephalosporin
antibiotic
Indication/Action
Action:
Interferes with bacterial
cell-wall
synthesis,
causing cell to rupture
and die. Active against
many
gram-positive
bacteria; shows limited
activity against gramnegative bacteria.
a. Hypersensitivity to
cephalosporins
or
penicillin
b.
Known
hypersensitivity to this
drug
or
to
any
cephalosporin
medication prohibits its
use, as does severely
impaired
renal
function. It is used with
caution in patients who
are allergic to penicillin
or other drugs.
Adverse Effect
Nursing Responsibilities
a. Monitor V/S before,

CNS: fever, headache, during, and after the
lethargy,
paresthesia, activity.
syncope, seizures
b. Refrigerate suspension
After reconstitution;
CV: edema,
discard after 14 days.
hypotension,
c. If total daily dose is
vasodilation,
more than 4 grams,
palpitations, chest pain
parenteral
drugs.
EENT: hearing loss
d. May reduce dosage
GI: nausea,
vomiting, with impaired renal
diarrhea,
abdominal function; or increase for
cramps,
oral severe infections.
e. The tablets for oral
candidiasis, pseudome
suspension
mbranous colitis
are
used to
GU: vaginal
candidiasis, nephrotoxi prepare individual 5- ml
doses.
city
Hematologic: lymphocy
tosis,
eosinophilia, bleeding
tendency,
hemolytic
anemia, neutropenia,
thrombocytopenia,
agranulocytosis, bone
marrow depression
Musculoskeletal: joint
pain
Respiratory: dyspnea
Skin: rash,
maculopapular
and
erythematous urticaria
37
use
Name of Drug
(Generic and
Brand Name)
Generic Name:
Captopril
Brand Names:
Captopril
Classification:
ACE inhibitors
Date ordered:
August 29-30,
2009
Date performed:
August 29-30,
2009
Indication/
Action
Indication;:
CAPOZIDE (capt
opril
and
hydrochlorothiazi
de tablets, USP)
is indicated for
the
treatment
of hypertension.
The blood
pressure lowering
effects of captopril
and thiazides are
approximately
additive.
Action:
Selectively
suppresses
rennin
angiotensin-
Dosage, Route and

Frequency
Dosage must be titrated
according to patient's
response; use lowest
effective dose. Oral:
Adolescents:
Initial:
12.5-25 mg/dose given
every
8-12
hours;
increase by 25 mg/dose
to maximum of 450
mg/day
Adults:
Acute
hypertension
(urgency/emergency):
12.5-25 mg, may repeat
as needed (may be
given sublingually, but
Nursing Responsibities
Contraindication
This
product
is
contraindicated
in
patients
who
are
hypersensitive
to
captopril or any other
angiotensin-converting
enzyme inhibitor (e.g.,
a patient who has
experienced angioede
ma during therapy with
any
other
ACE
inhibitor).
Adverse Effect
Renal: About one of 100 a. Administer 1hr before or
patients
2hr after meals.
developed proteinuria.
b. Monitor the BP of the
Hematologic: Neutrope patient that is secondary
nia/agranulocytosis has to reduction in fluid
occurred.
Cases volume
(excessive
of anemia,
perspiration
and
thrombocytopenia,
dehydration,
vomiting,
and pancytopenia have
diarrhea);
excessive
been reported.
hypotension may occur.
Tachycardia, chest pain,
and palpitations have
each been observed in
approximately 1 of 100
patients.
c. Reduce dosage in
patient who has impaired
renal function.
d. Ensures that the
medication is given at the
right time, right amount,
especially in right patient.
38
aldosteron
no
therapeutic
system;
inhibits advantage
ACE;
prevents
conversion
of demonstrated)
angiotensin I to
angiotensin II
Name of Drug
(Generic and
Brand Name)
Generic Name:
Nifedipine
Brand Name:
Adalat
Afeditab
Nifediac
Nifedical
Procardia
Classification:
Calcium channel
blocking
agent
(antianginal,
antihypertensive)
Date ordered:
August 29, 2009
Date Performed:
Indication/
Action
Dosage, Route and

Frequency
Indication:
Capsules
Treatment
of
vasopastic(printz
metals or variant)
angina,
chronic
stable
angia,
hypertension
(sustained
releases tablets
only)
Individualized.
Initial: 10 mg t.i.d.
(range:
10-20
mg
t.i.d.); maintenance: 1
0-30 mg t.i.d.-q.i.d.
Clients with coronary
artery spasm may
respond better to 2030
mg
t.i.d.-q.i.d.
Doses greater than
120 mg/day are rarely
needed while doses
greater
than
180
mg/day
are
not
recommended.
Action:
Inhibits
calcium
ion influx across
cell
membrane
during
cardiac
depolarization,
Sustained-Release
produces
relaxation
of Tablets :
coronary vascular Initial: 30 or 60 mg
Contraindication
Hypersensitivity
cardiovascular
shock,
combination
with
rifampicin.
Immediate
release
nifedipine
contraindicated
in
unstable angina and after
reenct MI, severe aoaric
stenosis,
severe
hypotension w/ systolic
pressure < 90mmhg,
decompensated
heart
failure pregnancy and
Lactation.
e. Withhold and report to

the doctor; mouth sores,
irregular heartbeat, chills,
swelling of face, eyes,
tongue
and
difficulty
breathing.
Adverse Effects
a. Headcahe
b. Fatigue
c. Dizziness
d. Constipation
e. Nausea
a. Inhibit the movement of
calcium ions across the
cell membrane. Slow
heart contractions, relax
smooth
muscles,
produce
vasodilation.
b. Monitor blood pressure
especially when
administering
the
medicines.
c. Withhold and report; any
adverse effects that the
patient experiencing.
d. Ensures that the
medications
will be given at the right
time,
39
August 29, 2009
smooth
muscle
and
peripheral
vascular smooth
muscles, dilates
coronary vascular
arteries, increase
myocardial
oxygen delivery
with patients wit h
vasopastic
angina.
once
daily
for
Procardia XL and 30
mg once daily for
Adalat CC. Titrate over
a 7- to 14-day period.
Dosage
can
be
increased as required
and as tolerated, to a
maximum
of
120
mg/day for Procardia
XL and 90 mg/day for
Adalat CC.
right route, right amount

and
especiallu
right
patient.
e.
Tell
the
doctor
immediately if
any of these rare but very
serious side effects.
40
Name of Drug
(Generic and
Brand Name)
Dosage, Route
and Frequency
Indication/Action
Contraindication
Adverse Effect
41
Generic Name:
Mefenamic Acid
Brand Name:
Ponstel
Classification:
Anti-inflammatory
drug
Date ordered:
August 28-30, 2009
Date Performed:
August 28, 2009
Acute
Pain
Adults
and
Children (14 yr
or age and older)
PO 500 mg,
followed by 250
mg every 6 h as
needed. Usually
not used more
than 1 wk.
Primary
Dysmenorrhea
Adults
and
Children (14 yr of
age and older)
PO 500 mg,
followed by 250
mg every 6 h
starting
with
onset of bleeding
and associated
symptoms.
Indication:
a. For relief of mild to a. Should not be used in
moderate
pain
to patients
who
have
patients.
previously
exhibited
hypersensitivity to it.
b. For treatment of
primary
b. should not be given to
dysmenorrheal.
patients in whom these
Action:
drugs induce symptoms
Anti-inflammatory
of bronchospasm, allergic
agents that are not rhinitis, or urticaria.
steroids. In addition to
anti-inflammatory
c. Should not be used in
actions, they have patient
with
active
analgesic, antipyretic, ulceration
or
chronic
and platelet-inhibitory inflammation of either the
actions. They are used upper
or
lower
primarily
in
the gastrointestinal tract.
treatment of chronic
arthritic conditions and d. should be avoided in
certain
soft
tissue patients with preexisting
disorders associated renal disease.
with
pain
and
inflammation. They act
by
blocking
the
synthesis
of
prostaglandins
by
inhibiting
cyclooxygenase, which
converts arachidonic
acid
to
cyclic
endoperoxides,
precursors
of
prostaglandins.
a. Administer this medication

with meals, food or milk to
minimize
a. urinating less than GI adverse effect.
usual or not at all.
b. Diabetic patients may
b. pain, burning, or show increased need for insulin.
bleeding when you
c. Notify the physician if the
urinate.
patient
c.
chest
pain, has persistent GI discomfort,
weakness, shortness sore throat, fever or malaise
of
breath,
slurred occur
speech, problems with after the medication given.
vision or balance.
d. Ensures that the medications
d. bruising, severe is given at the right time, right
tingling,
numbness, amount especially in right patient.
pain,
muscle
e. Identify if the client is
weakness.
contraindicated with the
medication
you will administer.
Less
serious
side
effects:
Serious side effects:
a.
dizziness,
headache,
nervousness.
b.
blurred
vision,
ringing in your ears.
c. upset stomach, mild
heartburn or stomach
pain,
diarrhea,
42
constipation; bloating,
gas
Inhibition
of
prostaglandin
synthesis accounts for
their
analgesic,
antipyretic,
and
platelet-inhibitory
actions;
other
mechanisms
may
contribute to their antiinflammatory effects.
Name of Drug
(Generic and
Brand Name)
Indication/Action
Dosage, Route and

Frequency
Contraindication
Adverse Effects
43
Generic Name:
Indication:
Methylergonovine
Management and
maleate
prevention
of
Brand Name:
postpartum
and
postabortal
hemorrhage
by
producing
firm
Classification:
uterine
Oxytocic drug
contractions and
decreasing
Date
Ordered: bleeding.
August 28- 30, During the second
2009
stage of labor
following delivery
of
anterior
shoulder, but only
under full obstetric
supervision.
Tablets: 0.2 mg 3-4 a. Pregnancy

times a day in the
puerperium
foe
a b. toxemia
maximum of one week.
c. hypertension
Route:
d. Ergot hypersensitivity
Per orem
Frequency : TID
Hypertension
1. Identify the reasons why
associated with seizure the
client
needs
to
or headache.
methergine. List all the
drugs consumed.
take
2. Note any side effects

that the client experiencing.
3. Withhold and
Report:
vomiting,
dizziness,
nausea or hypersensitivity.
4. Monitor and withhold
drug
and
report
pulmonary
hypertension, vasoconstriction.
Action:Synthetic
drug related to
ergonovine. Acts
directly on the
uterine
smooth
muscles
to
stimulate the rate,
tone,
and
amplitude
of
uterine
contactions.
44
45
NAME OF DRUG
(GENERIC &
BRAND NAME)
DOSAGE,
ROUTE,
FREQUENCY
GENERIC NAME:
Ferrous Sulfate
DOSAGE:
women-11-50
yrs.
oral
administration
15 mg.
pregnancy-3o
mg.
lactation-15 mg.
BRAND NAME:
Rhea Ferrous
Sulfate
CLASSIFICATION:
Dietary/nutritional
preparations
ROUTE:
Per Orem
Date Ordered:
August 30, 2009
FREQUENCY:
OD
INDICATION/ACTION
INDICATION
Prevention and
treatment of iron
deficiency anemia
ACTION
Provides/replaces
elemental iron, an
essential component in
formation of
hemoglobin in red
blood cell
development.
CONTRAINDICATION
ADVERSE EFFECT
NURSING RESPOSIBILITIES W/
RATIONALE
Hypersensitivity to any
ingredient,
hemosiderosis, hemolytic
anemia.
GI irritation, anorexia,
nausea, vomiting,
diarrhea, constipation,
dark stool. Teeth
staining with liquid
formulation.
1. Obtain baseline assessment of

iron deficiency before starting
therapy.
2. Monitor for adverse effect
3. Evaluate hemoglobin,
hematocrit, and reticulocyte count
during therapy.
4. Assess bowel elimination,
increase water, bulk and activity if
constipation occurs.
5. Identify cause of iron loss or
anemia
6. Assess diet and nutrition amount
of iron diet.
46
Name of Drug
(Generic and
Brand Name)
Generic Name:
Oxytocin
Brand Name:
Pitocin
Classification:
Natural Hormone
Dosage, Route
and
Indication/Action
Frequency
Nasal:
Indication:
Within a few
Oxytocin
is
a
minutes.
natural
hormone
that
causes
the
Intramuscular: uterus to contract.It
3 to 5 minutes is used to induce
labor,
strengthen
labor
contractions
Intravenous;
during
childbirth,
Immediate
control
bleeding
Duration of
after childbirth, or
action:
to
induce
an
Nasal:
abortion.
20 minutes.
Action:
Intramuscular:
2 to 3 hours
The uterine
myometrium
Intravenous;
contains receptors
Uterine
specific to oxytocin.
activity
It stimulates
generally
contraction of
subsides
uterine smooth
within one
muscle by
hour.
increasing
intracellular calcium
Elimination:
Contraindication
a. have or have had
cervical cancer;
b. have an allergy to
oxytocin, other
medications, dyes,
foods, or
preservatives;
c. have eclampsia;
d. have herpes;
Adverse Effect
a. an allergic
reaction (shortness
of breath; closing of
the throat; hives;
swelling of the lips,
face, or tongue;
rash; or fainting);
b. difficulty
urinating; chest
pain or irregular
heart beat;
e. have had more than d. difficulty

7 pregnancies;
breathing;
f. are experiencing
premature labor;
g. have had a
caesarean section (Csection);
e. confusion;
a. Notify the physician when
the infusion rate has reached
the maximum dose of 20
mU/min for 30 minutes.
b. Note any allergic reaction.
c. Withhold and report;
excessive vaginal bleeding,
rash, and difficulty breathing.
d. If it is deemed necessary to
discontinue pitocin infusion
while an epidural is being
inserted, the nurse should
notifiy the OB Service at the
time that this is occurring.
f. sudden weight
gain or excessive
swelling;
g. severe
headache;h. rash;
seizures.
i. excessive vaginal
47
Only small
amounts are
excreted
unchanged
concentrations.
bleeding;
C. DIET
Type of diet
Nothing per orem (NPO)
Date started/Date
changed
Date started: August
28, 2009
Date changed: August
29, 2009
General description Indications/Purposes Specific foods

taken
Medical instruction If you have a full None
meaning to withhold stomach, you could
oral food and fluids vomit while you are
from a patient for sedated and aspirate
various reasons.
the vomit into your
lungs.
Client response to the diet

The patient was unobserved while
under this order.
48
Type of diet
Diet as tolerated (DAT)
Date
started/Date
changed
Date started: August
29, 2009- September
1, 2009
General description Indications/Purposes
Specific foods
taken
Given to the client who Malunggay,
can eat any foods camote tops,
ordered by the doctor. fish,
meat,
milk,
water,
juice.
Client response to the diet
This particular diet is

only given when
client
can
now
tolerate any food she
desires
that
is
nutritious.
The client has gained strength again

and recovered from delivery because
of the nutritious foods she eat.
Nursing Responsibilities:
Prior to: Check on the doctors order and apply the required diet to the right patient.
During: Apply the diet to the right patient and make sure that the patient follows the diet.
After: Encourage the patient to eat nutritious foods that will help her to regain her strength.
D. Activity/Exercise
Type of exercise
Kegel exercise
Date ordered/Date
General description
started, changed
Date ordered: 6 weeks after
delivery
Kegel exercises involve
making small contractions
of the muscles at the
vaginal wall.
Indications/purposes
Client response to the

activity/exercise
These exercise can help The client has regained pelvic floor
strengthen weak pelvic muscle strength.
muscles, which can cause
bladder
control
issues,
which are common in
women postpartum.
49
Type of exercise
Walking/Ambulatory
Date
ordered/Date General description
started, changed
Date ordered: 6 weeks after Healthiest form of exercise
delivery
Indications/purposes
Client
response
activity/exercise
Slow walks can help The client promotes
prepare your body for more circulation.
vigorous exercise, as well
as get you fresh air.
to
good
Nursing Responsibilities:
Prior to: Explain to the client the procedure of the exercise
During: Ask the client to demonstrate the exercise
After: Ask for verbalization on how the exercise helps her
C. NURSING CARE PLAN
ASSESSMENT
DIAGNOSIS
BACKGROUND
KNOWLEDGE
PLANNING
INTERVENTION
RATIONALE
EVALUATION
50
the
blood
S>
medyo
Acute
masakit yung related
tahi ko, as perineal
verbalized by incision.
the client.
O> v/s taken
and recorded
as ff:
Bp120/80mmHg
T- 36.5 C
P- 80bpm
R- 20 cpm
>fixed
movement
>restlessness
Pain > An episiotomy is a

to surgical incision made
in the area between the
vagina
and
anus
(perineum).
This
is
done during the last
stages of labor and
delivery to expand the
opening of the vagina to
prevent tearing during
the delivery of the baby.
>With midline or media
n episiotomy, the cut is
made from the back of
the vaginal opening
straight
toward
the
anus. With mediolateral
episiotomy the cut is
made off to one side
SHORT
TERM
GOALS:
After 30 minutes of
nursing intervention
the patient will able
to: >report that the
pain is lessen from
the scale of 8-3.
>verbalize methods
that provide relief.
1. Identify the patient

and establish rapport.
2.
Explain
the
procedure to the
client.
skills.
3. Anticipate need for
pain relief.
4.
Respond
immediately
to
complaint of pain.
5.
Provide
rest
periods to facilitate
comfort, sleep, and
relaxation.
6.
Eliminate
additional stressors
or
sources
of
discomfort whenever
possible.
- To gain the trust

and cooperation
of the client.
- To gain clients
cooperation.
Early
intervention may
decrease the total
amount
of
analgesic
required.
Demonstrated
concern
for
patients welfare
and
comfort
fosters
the
development of a
trusting
relationship.
- The patients
experiences
of
pain may become
exaggerated
as
the
result
of
fatigue.
- Patients may
experience
an
exaggeration
in
pain or decreased
ability to tolerate
painful stimuli if
environmental,
33intrapersonal
factors
are
Goal met: after 30

minutes
of
nursing
intervention the client
was lessen the pain
from the scale of 8-3.
51
stressing them.
52
ASSESSMENT
S> Nahihirapan
akong tumayo
magisa, as
verbalized by the
client.
O> V/S taken and
recorded as ff:
Bp- 120/80 mmHg
T-36.5 C
P- 80 bpm
R-20 cpm
> generalized
weakness
>restlessness
DIAGNOSIS
BACKGROUND
KNOWLEDGE
Activity
>Activity
intolerance related intolerance: A
to postpartum
person suffering
condition
from a physical or
psychological
inability to
complete daily
activities.
PLANNING
INTERVENTION
RATIONALE
SHORT TERM GOALS:

After 3 hours of nursing
intervention the patient
will able to verbalize
health teachings
regarding activities to
conserve energy and to
balance activity and rest.
> report measurable
increase in activity
tolerance
1. Identify the patient and

establish rapport.
2. Explain the procedure
to the client.
3. Provide emotional
support while increasing
activity.
4. Encourage active
ROM exercises three
times daily. If further
reconditioning is needed,
confer with rehabilitation
personnel.
5. Assess patient's level
of mobility.
6. Refrain from
performing nonessential
procedures.
- To gain the trust

and cooperation of
the client.
- To gain clients
cooperation.
- To promote
positive attitude
regarding abilities.
- Exercises maintain
muscle strength and
joint ROM.
- This aids in
defining what
patient is capable
of, which is
necessary before
setting realistic
goals.
- Patients with
limited activity
tolerance need to
prioritize tasks.
EVALUATION
Goal met: After 3
hours of nursing
intervention the
patient was able to
maintains activity
level within
capabilities
53
ASSESSMENT DIAGNOSIS
PLANNING
INTERVENTION
RATIONALE
EVALUATION
S> Hindi ako

makatulog ng
maayos kapag
gabi,
as
verbalized by
the client.
SHORT
TERM
GOALS:
After 1 day of nursing
intervention
the
patient will able to
identify
individually
appropriate
interventions
to
promote sleep
>verbalize
understanding
to
sleep disorders
>report improvement
in sleep/rest pattern
1. Identify the patient

and establish rapport.
2.
Explain
the
procedure
to
the
client.
3. Decrease intake of
caffeinated
substances (e.g., tea,
colas, coffee).
4. Evaluate sedative
effects of medications
and
schedule
administration
to
diminish
daytime
sedation and promote
sleep at night.
- To gain the trust

and cooperation
of the client.
- To gain clients
cooperation.
Caffeine
stimulates CNS
and may interfere
with
patients
ability to rest and
sleep.
This
discourages
sleeping during
day
and
promotes restful
night sleep.
Goal met: After 2 days of

nursing intervention the
patient will be able to
prolonged the hours of
sleep without suspension
by any uncomfortable
sleep environment
O> v/s taken

and recorded
as ff:
Bp-120/80
mmHg
T- 36.5 C
P- 80 bpm
R- 20 cpm
> restlessness
> yawning
BACKGROUND
KNOWLEDGE
Sleep
>
Sleep
Disturbance
disturbance:
related
to Sleeping difficulty,
excessive
called insomnia,
stimulation and can
involve
other generated difficulty
falling
awakening.
asleep when you
first go to bed at
night, waking up
too early in the
morning,
and
waking up often
during the night.
LONG TERM GOAL:

After 2 days of nursing
intervention
the
patient will be able to
prolonged the hours of
sleep
without
suspension by any
uncomfortable sleep
environment
54
IV. DISCHARGE PLANNING

A. General condition of the client upon Discharge
The client condition upon discharge is well, she had a good elimination as she defecates once a day and urinates 5 times a day without discomfort.
She had a good appetite as she eat nutritious food and no discomfort while eating, there are minimal vaginal bleeding and hse had a good
appearance as she fix her hair and good body hygiene.
B. METHODS
MEDICATIONS
The medications should take on time and every after meal except ferrous sulfate which intake before meal..
Cefalexin 500mg 1 cap TID X 7 days
Mefenamic Acid 500mg TID
prior to pain
Methylergonovine maleate 1 tab TID x 3 days
Ferrous Sulfate 1 tab OD
EXERCISE
The client may walk inside their house as her exercise for her to gain energy and strength
TREATMENT
Instruct the client to clean the cord of the newborn using 7o% alcohol once a day. Also instruct the client to clean her episiotomy
if its not already heal to protect her from infection and contamination sung a feminine wash or betadine with flushing of water.
55
HEALTH TEACHING
Instruct the client to always clean her body, take a bath, brush her teeth and always wash her hands. To avoid infection and have
a clean body as she always hold her newborn. Instruct client not to lift heavy objects for one month, she must always remind to breastfeed her child
as it help her newborn to have a strong immunity and far from illnesses and it also give mother and child relationships. The mother should drink her
medicines on time, and go to the doctor for their scheduled check-up.
OUT PATIENT
Out patient appointment:
Date to comeback: September 5, 2009
Time: 2pm
Place: OPD-OB section Ospital ng Guiguinto
DIET
Give mother the instruction that she must eat healthy foods like green leafy vegetables like malunggay that good for her
to have more milk, camote tops, Pechay, potatoes, cabbage, etc. fruits like apple, banana, orange, grapes, moderate meat like chicken, cows meat
fish and egg.
SPIRITUALITY/SLEEPING PATTERN
Instruct the client that spiritual believe may help them to cope to their new life and situation. The mother must have a rest
or a complete sleep as she gain energy to take care her newborn. And do some activity in their house.
56
VII. CONCLUSIONS
The case of Mrs RN of ONG whos delivered her son in NSD gave us more knowledge and skills in Maternal And Child Nursing. As we study
her case we gain more knowledge about Normal Spontaneous Delivery. Normal Spontaneous Delivery is birth of an infant without any aid from an
attendant or vaginal birth occurring without the mechanical assistance of obstetric forceps or vacuum aspirator. This is the common delivery of the
fetus if the mother doesnt have any complication in their pregnancy. This is the required delivery because it must be safe for the mother and the
baby. There is another delivery like caesarean section or birth accomplished through an abdominal into the uterus, is one of the oldest types of
surgical procedures known. The mother must be give birth in the hospital to secure her safety, and her baby.
In this case we learn how to gather data from the client by asking her Health History, we also got her name, address, age and condition during
her hospitalization. We able to get Genogram and Daily Intake for us to know if the client is im healthy condition. We determined
Her functional pattern prior and during her hospitalization, along to it we determined her growth and development together with her child by using the
theories of some theorist of that aspect.
We enable to study and learn the anatomy and physiology of the female reproductive system, we study on how this system help a women to
get pregnant, its process and condition upon it. We learned that each part of this system from external to internal had its all unique function that help
and support each other. We learned that in a mother that with a Normal Spontaneous Delivery each of this system give contribution so that the baby
will be delivered. As added we study the conception where the fertilization and implantation of the embryo in the mothers uterus perform so after
that the mother will be get pregnant after her menstruation if she is fertile. In this case we apply the Physiology of NSD where the changes, signs and
symptoms are indicated both mother and her child.
We enable to get the Physical Assessment through assessing her for us to know if there are some abnormalities in her condition and if there
are review each system and enable to determine why there are deviations. We cant be able to get the laboratory of the mother because when we
get her medical record it was not indicated that there are laboratory test done for her. As we analyzed her record we notice that there are elevation of
57
blood pressure thats why there are some medication given to her. We create a nursing care plan on a NSD patient with diagnosis and intervention
that we implement on the client. The nursing care plan was prioritize from life threatening and need immediate action from less life threatening and
dont need immediate action. Along each NCP we make a health teaching plan for the mother and we ask her to demonstrate it to us for us to know if
she really understands the health teaching. Upon discharge we create reminders using METHODS.
And all above knowledge and skills this case give us experience in the profession that we choose.
VIII. BIBLIOGRAPHY
References:
http://www.medicinenet.com/female_reproductive_system/page2.htm
http://images.search.yahoo.com/search/images;_ylt=A0oGklO0oLlKqNMAVpZXNyoA?ei=UTF-8&p=anatomy%20of%20female
%20reproductive%20system&SpellState=n-3698714451_q-xB0%2FQ7kOMEvhuc7CvMfxIAAAAA%40%40&fr2=tab-web&fr=sfp
http://images.search.yahoo.com/search/images;_ylt=A9G_bF_poblKzz8Ah7KJzbkF?p=menstrual+cycle&fr=sfp&ei=utf-8&x=wrt
http://www.theholisticcare.com/cure%20diseases/Images/Menstrual%20Cycle.jpg
BOOKS:
Pilliterri Adelle Maternal and child health Nursing: Care of the Childbearing and Childrearing Family: copyright Lippincott Wiliams and Wilkins;
5th edition
Malan Pres, Inc, PPDs Nursing Drug Guide; Copyright 2008; 2 nd edition
Dorling Kindersley limited, Human body; Copyright 2001
Nowak, Thomson J; Hanford Gordon A; Pathophysiology: Concepts and application for heath care professionals; 3 rd edition
Alice C. Murr; Nurse Pocket Guide; Diagnosis, Prioritized Interventions and Rationales; 11th edition
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I.

1. Massage her face to help release stress and relax her.

REASON FOR CHOOSING SUCH CASE STUDY

II. NURSING ASSESSMENT

Date of Assessment: September 01, 20009

B. CHIEF COMPLAINT OR REASON FOR VISIT

See the familys genogram on the next page

DECEASED BECAUSE OF LUNG

GORDONS 11 FUNCTIONAL PATTERN

1. HEALTH PERCEPTION/HEALTH MANAGEMENT PATTERN

2. NUTRITIONAL METABOLIC PATTERN

As what we observed during the interview, Mrs. Nicholass skin is

DAYS DIETARY CALL

August 29, 2009

August 30, 2009

September 01, 2009

The patient urinated on August 29, 2009 around 6am to 6pm at

The client sleeps at 10 to 11 pm in the evening and wake up at 9 am in

6. COGNITIVE PERCEPTUAL PATTERN

9. SEXUALITY REPRODUCTIVE PATTERN

Her menarche is at the age of 13. She had no menstrual problem at

10. COPING STRESS TOLERANCE

The patient was able to cope up during times of problems

The patient was a Roman catholic; she was able to attend

GROWTH AND DEVELOPMENT

Identity vs. Role Confusion

Formal Operational Period

Harry Stack Sullivan

The adolescent is newly

Includes everything that we

Characterized by hypotheticodeductive reasoning (Inhelder

The sense of identity and

Sullivan called his approach

The methods the ego uses to

be known is through the

area has special significance

The newborn have to pass the

Cognitive development refers

The client has a strong

Sullivan called his approach

adolescence stage where the

expelling feces provide

(stimuli) must exist before

autonomous monads who

sex peers. Last stage is the

III. ANATOMY AND PHYSIOLOGY

Female External Reproductive System

Female Internal Reproductive Parts

What Parts Make-up the Female Anatomy?

The internal reproductive organs in the female include:

What Happens During the Menstrual Cycle?

IV THE PATIENT AND HIS ILLNESS

NON MODIFIABLE FACTORS

Uterine contractions occurring at regular intervals and increase

Cervical dilation and effacement

Pain in the back that radiates at the abdomen

First stage of Labor (latent, active, transition)

Second stage- Stage of expulsion

Woman reaction during labor:

Newborn baby via vaginal delivery

Convex curvature: smooth

E. HEAD AND FACE