OUR LADY OF FATIMA UNIVERISTY

LAGRO, QUEZON CITY

GRADUATE SCHOOL

MAN223
CLINICAL PRACTICE

Julius Rayos Dela Cruz

1ST SEMESTER, AY 2010
 TABLE OF CONTENT

I. Classroom Practice

II. Clinical Practice

III. Case Study: Common Case

IV. Case Study: Rare Case

V. Appendix

i. Communication Letters
 CLASSROOM PRACTICE

Area: SKILLS LABORATORY -MCN No. of Hours:_________________

Topic: Leopold’s Manuever Teaching Strategy Used: Lecture-Return Demonstration

Objectives: Content: Evaluation:

General:
Specific: Leopold's maneuvers

In obstetrics, Leopold's Maneuvers are a common and systematic

way to determine the position of a fetus inside the woman's uterus;
they are named after the gynecologist Christian Gerhard Leopold.
They are also used to estimate term fetal weight.

The maneuvers consist of four distinct actions, each helping to

determine the position of the fetus. The maneuvers are important
because they help determine the position and presentation of thefetus,
which in conjunction with correct assessment of the shape of
the maternal pelvis can indicate whether the delivery is going to be
complicated, or whether a Cesarean section is necessary.

The examiner's skill and practice in performing the maneuvers are the
primary factor in whether the fetal lie is correctly ascertained, and so
the maneuvers are not truly diagnostic. Actual position can only be
determined by ultrasound performed by a
competent technician or physician.

Performing the maneuvers

Leopold's Maneuvers are difficult to perform on obese women and

women who have hydramnios. The palpation can sometimes
beuncomfortable for the woman if care is not taken to ensure she is
relaxed and adequately positioned. To aid in this, the health care
providershould first ensure that the woman has recently emptied
her bladder. If she has not, she may need to have a straight
urinary catheter inserted to empty it if she is unable
to micturate herself. The woman should lie on her back with
her shoulders raised slightly on a pillow and herknees drawn up a little.
Her abdomen should be uncovered, and most women appreciate it if
the individual performing the maneuver warms their hands prior
to palpation.

First maneuver: Fundal Grip

While facing the woman, palpate the woman's upper abdomen with
both hands. A professional can often determine the size, consistency,
shape, and mobility of the form that is felt. The fetal head is hard, firm,
round, and moves independently of the trunk while the buttocks feel
softer, are symmetric, and the shoulders and limbs have small
bony processes; unlike the head, they move with the trunk.

Second maneuver

After the upper abdomen has been palpated and the form that is found
is identified, the individual performing the maneuver attempts to
determine the location of the fetal back. Still facing the woman, the
health care provider palpates the abdomen with gentle but also deep
pressure using the palms of the hands. First the right hand remains
steady on one side of the abdomen while the left hand explores the
right side of the woman's uterus. This is then repeated using the
opposite side and hands. The fetal back will feel firm and smooth while
fetalextremities (arms, legs, etc.) should feel like small irregularities
and protrusions. The fetal back, once determined, should connect with
the form found in the upper abdomen and also a mass in the maternal
inlet, lower abdomen.

Third maneuver: Pawlick's Grip

In the third maneuver the health care provider attempts to determine

what fetal part is lying above the inlet, or lower abdomen. The
individual performing the maneuver first grasps the lower portion of the
abdomen just above the symphysis pubis with
the thumb and fingers of the right hand. This maneuver should yield
the opposite information and validate the findings of the first
maneauver. If the woman enters labor, this is the part which will most
likely come first in a vaginal birth. If it is the head and is not actively
engaged in the birthing process, it may be gently pushed back and
forth. The Pawlick's Grip, although still used by some obstetricians, is
not recommended as it is more uncomfortable for the woman. Instead,
a two-handed approach is favored by placing the fingers of both hands
laterally on either side of the presenting part.

Fourth maneuver

The last maneuver requires that the health care provider face the
woman's feet, as he or she will attempt to locate the fetus' brow. The
fingers of both hands are moved gently down the sides of
the uterus toward the pubis. The side where there is the resistance to
the descent of the fingers toward the pubis is greatest is where
the brow is located. If the head of the fetus is well flexed, it should be
on the opposite side from the fetal back. If the fetal head is extended
though, the occiput is instead felt and is located on the same side as
the back .

Cautions

Leopold's maneuvers are intended to be performed by health care

professionals, as they have received training and instruction in how to
perform them. That said, as long as care is taken not to roughly or
excessively disturb the fetus, there is no real reason it cannot be
performed at home as an informational exercise. It is important to note
that all findings are not truly diagnostic, and as such ultrasound is
required to conclusively determine the fetal position. .

References

1. ^ Nahum GG (April 2002). "Predicting fetal weight.

Are Leopold's maneuvers still worth teaching to medical
students and house staff?". J Reprod Med 47 (4): 271–
8. PMID 12012878.
2. ^ "Pregnancy - antenatal checks of your baby - Better
Health Channel.".

External links

 Leopold's Maneuver Demo Video

 Maternal-Newborn Nursing & Women's Health Care, 7th
Edition
 CLINICAL PRACTICE

Area:__________________________________________________ No. of Hours:_________________

Topic:_________________________________________________ Teaching Strategy Used:_____________

Objectives: Content: Evaluation:

General:
Specific:
 CASE STUDY

Common Condition

NORMAL SPONTANEOUS VAGINAL DELIVERY

General Data:

PATIENTS NAME: Estrella Manatad

ADDRESS: Riles Basak, Mandaue City
AGE: 34
SEX: Female
OCCUPATION: Housewife
HUSBAND'S NAME: Crisroy Manatad
HUSBAND'S OCCUPATION: Construction Worker
CIVIL STATUS: Married
RELIGION: Roman Catholic
CITEZENSHIP: Filipino
HIGHEST EDUCATIONAL ATTAINMENT: High School Graduate

Chief Complaint:

History of Present Illness:

Client X doesnt experienced any illness. Furthermore, the latter only experience pain of labor
specifically, pain felt at the abdomen. Client was also experienced signs of true labor. According
to her, she experienced frequent uterine contractions, breast enlargement and some discharges.

Past Medical History:

Client had experienced fever. She had no past records in the hospital. Negative in allergies on
foods and drugs. For her childhood illness she had experienced colds, cough and fever.
Paracetamol are the usual drugs they used for treating fever. Client also didnt experienced any
injuries in the past. She had been able to had immuniation when she was a child.

Medication History:

Surgical History: N/A

OB History:

LMP: 11-16-08
EDC: 8-23-09
MENARCHE: 13 yrs.old
AOG: 38 weeks

History of Allergy: N/A

Blood Transfusion History: N/A

Physical Examinations:

Review of System:

CENTRAL NERVOUS SYSTEM

Client experienced headache after giving birth. She doesnt take any pain reliever because she
stated that it is manageable. She just take a rest to diminished the pain felt in the head.

EENT ( EYES, EARS, NOSE & THROAT)

Client does'nt complain any abnormalities and pain in her eyes, nose , ears, and throat. She
just felt itchy on her nose.

ENDOCRINE SYSTEM
Client does'nt had any complains . Hence, se does'nt had enlargement on her lymph nodes and
does not had graveyards disease.

GASTROINTESTINAL SYSTEM
The client experienced thirst and hungry after giving birth to his baby. She felt stomace ache if
she doesnt take her meals. She does not deficate after she give birth.

MUSCULOSKELETAL SYSTEM
Client just felt fatigue and pain felt at the lower extremities after a several minutes at lithotomy
position while the delivery is n going. She was taking mefenamic acid to minimized the pan she
felt.
GENITO-URINARY SYSTEM
Client had not urinating for an hour after she delivered. She started menstrating when she get 13
yrs. Old. And menstrate regularly without any dysmenorhea felt.

Admitting Diagnosis:

Laboratory and Ancillary Procedures:

Medication:

Final Diagnosis:

Nursing Care Plan:

 CASE STUDY

Rare Condition

NEONATAL SEPSIS

General Data:

Ms. Sepsis is 25 years old and is of Ilokano descent because her mother was
Ilokano. She was born on September 13, 1984 in Luna, La Union. She gave birth to
her first born but she is not yet married. She lives in an apartment located in San
Lorenzo Street, Sto. Domingo, Angeles City. She was admitted in a birthing home
last September 8, 2009 at 03:00 pm. Baby Boy S was born on the same date at Our
Lady of Good Birth Birthing Home near AMC via Cesarean Section I with an Apgar
score of 7 and 8at 11:20 pm. Two days after birth, September 10, 2009, the baby
was admitted at AMC Main ward because of reported continuous vomiting.

Ms. Sepsis works as a lady guard in Angeles City Jail wherein she inspects the
workers before entering the vicinity and she earns 13,000.00 per month. She
spends 2,500.00 for rental fee, water and electricity, 5,000.00 for food, and she
sends 4,000.00 to her parents in La Union, in a monthly basis. Then she has a
monthly mobile bill of 800.00 for Globe line and 80.00 for a smart line. She made a
loan to AFPMI in Manila for her giving birth; this was an agency which is readily
available for police officers and workers like them.

Ms. Sepsis finished tertiary education with commerce as her course. She got
the work in the City Jail through her cousin. It was offered to her when she was still
working as a clerk in an electronic company in Batangas. She decided to apply but
she did not pass the height requirement so she was not accepted. Two years after,
she applied again and got accepted. Now she has been working there for two years
as of September 4, 2009. But she worked for 2 years and 5 months for JMP in their
main headquarters.
 Ms. Sepsis and her family are under Iglesia Ni Cristo (INC). Being INC they
have several beliefs such as if there was someone who is sick like having colds, flu,
cough, their Jackono (officer) would pray over him because if it was severe would
they bring him/her to the hospital. The mother of Ms. Sepsis told her to not watch
television during her pregnancy and to not take cold bath after birth because they
will use steamed leaves for bathing. She also told Ms. Sepsis to use abdominal
binder while pregnant.

Chief Complaint:

History of Present Illness:

Ms. Sepsis had chicken pox; mumps at 6 years old which was treated with “tina”
and mefenamic acid, and measles wherein her mother told her to eat “balot” for
treatment. She had urinary tract infection before pregnancy which lasted for 5 days
and was treated with Cefalexin and at her 5th month during pregnancy which lasted
for about 1 week as well.

Past Medical History:

After birth, the baby was found to be having neonatal sepsis so he was admitted
at AMC Main Ward. He was breastfed few hours after birth then with water by the
mother and the nurse thereafter and he was still fine. Then he was fed with Bona,
formula milk, and then he vomited. The family thought it was fine and normal but it
became continuous so they notified her doctor and the baby was admitted after.

Medication History:

Surgical History: N/A

OB History:

Ms. Sepsis had her menarche at the age of 13 and lasted for a week. From then
on, she had regular menstrual period every month with 5 days to 1 week maximum
of delay. She gave birth to her first baby at the age of 25. She does not use OCP
rather she uses withdrawal method as their contraceptive method. She does not live
together with her partner because they are assigned in different areas.

Maternal-Obstetric Record

Ms. Sepsis is not married to her boyfriend yet and has no plan of getting
married as of the moment. She has an Obstetric record of Gravida 1, Para 1. She
has a TPAL record of 1-0-0-1. Her last menstrual period was last December 15,
2008. So her estimated date of delivery was supposedly on September 22, 2009.
She had given birth to her first baby, Baby Boy S last September 8, 2009 two weeks
ahead from her EDD. She was brought earlier than her estimated date of
confinement because she had an early contraction and abnormal fetal position and
attitude. She had given birth via Cesarean Section I in Our Lady of Good Birth
Birthing Home, which is a specialized clinic solely for giving birth.

Ante-partal/ Pre-natal Preparation

According to Ms. Sepsis she had a regular prenatal check-up on her doctor’s
clinic. She goes once a month during the first trimester, twice a month during the
second trimester, and every week during the third trimester. She received 1 dose
of tetanus toxoid vaccine from her doctor. She missed the second dose but her
doctor said it was fine.

Significant Trimestral Changes (1st – 3rd trimester)

On the first trimester of her first pregnancy, she did not experience much
change. She narrated that she once ate “bagoong with tomato” and vomited, since
then she had not have the appetite for it. On the second trimester of her
pregnancy, she noticed darkening of her neck, underarm and inguinal area. Third
trimester pregnancy, she noticed stretch marks and experienced slight itchiness.
Slight discomfort was felt all throughout the pregnancy period.

During her second trimester of pregnancy, Ms. Sepsis had urinary tract infection. It
was treated through oral antibiotics such as Cefalexin and by drinking lots of water

Last September 7, 2009 she felt contractions occurring at the interval of 5 minutes.
At September 8, 2009 she saw brown blood and then clear secretions of about two
spoonfuls. Then she was admitted at the same date at 03:00 pm.

She took vitamins during the course of her pregnancy like Ferrous sulfate for
the first trimester then Micron C for the second trimester then Terraferon for the
last trimester. She drank Anmum but stopped at the 8 th month as advised by her ob-
gyne because the baby was already 5.28 pounds.

History of Allergy: N/A

Blood Transfusion History:N/A

Physical Examinations:

September 10, 2009 (12:15 am)

P.A. of Baby Boy S

Upon admission (lifted from the Chart)

Vital signs:

T: 36.5°C

HR: 132 bpm

Wt: 2.9 kg

(-) Cleft lip and palate

• Clear breath sound; no rales
 • Normal respiratory rate and rhythm (NRRR)
• No murmur
• Normal Abdominal Bowel Sound (NABS)
• Soft full equal pulses

September 10, 2009 (04:00 pm)

Initial Interaction

P.A. of Baby Boy S

Vital signs:
HR: 165 bpm
Temp: 37.2 mmHg
RR: 53 bpm
Review of System:

CEPHALO-CAUDAL APPROACH

 SKIN
- Ruddy complexion
- With good skin turgor (negative tenting)
- Skin is warm to touch
 NAILS
- When palpated, the nail base is firm
- Tissue surrounding nails is intact
- Convex curve and pinkish nails
- Blanch test: prompt return of pink color less than 2 seconds
 HEAD
Hair and Scalp

- Hair is black
- Hair is evenly distributed
- Silky, resilient hair
- No dandruff or flaking
- Normal skull configuration, rounded, smooth skull contour
Skull and Face

- Smooth skull contour

- Absence of nodules or masses
- Symmetrical facial features and movements
 - Flat anterior fontanel
 EYES
- Eyebrows are evenly distributed and symmetrically aligned
- Equal movements of eyebrows
- Eyelashes are equally distributed, curled slightly outward
- lids are edematous
- transient strabismus
- Bulbar conjunctiva are clear
- Palpebral conjunctiva are shiny, smooth and pink
- No edema or tearing of lacrimal sac
- Anicteric sclerae
- Cornea are transparent, shiny and smooth
- Corneal reflex noted
- Pupil are equally round and receptive to light
- Iris is black in color

 EARS
- Auricles are symmetrical
- Auricles are firm, smooth, free from lesions and pain
- Tip of the ear is aligned with the outer canthus of eye
- Pinna recoils after it is folded
- intact startle reflex
 NOSE AND SINUSES
 - Symmetrical nares
- No flaring
- Nose is located symmetrically, midline of the face
- intact glabellar reflex
 MOUTH AND THROAT
- Lips and buccal mucosa are pink in color, moist and smooth texture
- Tongue pink in color, slightly moist; veins not prominent
- Sores and ulceration are not evident.
- intact rooting reflex
 NECK
- Presence of head lag
 BREAST AND AXILLAE
- Equal in size
- Areola is light brown in color
- No palpable lump
- Bilaterally the same
- No pain and tenderness upon palpation

 RESPIRATORY
- Symmetric with full chest expansion
- cylinder shaped
- slight sternal retractions
 CARDIOVASCULAR
 - Palpable arterial pulse
- Pulses are strong
 GASTROINTESTINAL
- Rounded
- With bowel sounds during auscultation
- No abnormal lumps and hardened areas in the abdominal area
 GENITAL
- Rugated scrotum
- Urinary meatus at tip of penis
 UPPER AND LOWER EXTREMITIES
- Symmetrical in shape
- Extremities are well flexed
- intact palmar grasp and babinski reflex

Admitting Diagnosis :T/C Neonatal Sepsis

Laboratory and Ancillary Procedures:

I. DIAGNOSTIC AND LABORATORY PROCEDURES

Diagnostic/Laboratory Date Indications Results Normal Analysis and
Procedures Ordered/ or Purposes Values Interpretation
Date
Results
Hematology
HCT (%) D.O. - To aid 63.0 40.0- The hematocrit
09/09/200 diagnosis of 54.0 is increased
9 abnormal
states of which is a sign
D.R. – hydration, of dehydration.
09/09/200 polycythemi
9 a and
anemia and
aids in
calculation
of
erythrocyte
indices

To evaluate
platelet
production
The platelet
140- count is in
Platelet 318 440
To normal amount.
determine
for
presence of
WBC is
for further
increased
tests such
which indicates
WBC ct (x18/1) as WBC 25.8 4.3- presence of
differential
10.0 infection.
infection
and also for
determinati
on count
Medication:

Generic Date Route of General Client’s response

Name Ordered/ administration Action
Date Taken Dosage and
Brand frequency and
Name Administration

Generic Sept. 9, IV 100mg q 12 Inhibits cell Client responded

Name: 2009 wall synthesis well and had no
during adverse reaction to
Ampicillin bacterial drug.
multiplication.

Brand
Name:

Ampicin

Generic Date Route of General Client’s response

Name Ordered/ administration Action
Date Taken Dosage and
Brand frequency and
Administration
 Name

Generic Sept. 9, 2009 IV 15mg q 12 Inhibits A reduction in

Name: protein neutrophils has been
synthesis by noted.
Amikacin binding
Sulfate directly to the
30S ribosomal
subunit;
Brand bactericidal.
Name:

Amikin

Final Diagnosis:Neonatal Sepsis-late onset

 NURSING CARE PLAN

Problem no.1 NUTRITIONAL IMBALANCE: LESS THAN BODY REQUIREMENTS

Assessment Nursing Scientific Objectives Nursing Rationale Expected

Diagnosis Explanation Interventions Outcome

S> Ø Imbalanced The patient’s After 3 hours of >Monitor and >To provide After 3 hours of
nutrition less intake of nursing record vital signs comparative nursing
O> Patient than body nutrients is interventions, the baseline interventions, the
requirement insufficient to SO will verbalize >Monitor weight SO will verbalize
may
related to meet the understanding of >To monitor understanding of
manifest: progression of
inability to body’s causative factors causative factors
ingest or metabolic when known and condition when known and
> vomiting
digest food demands. The necessary necessary
or nutrients body then interventions. >Assist in interventions.
> poor developing
reacts to the >To correct or
muscle tone low nutrient individualized control
synthesis regimen underlying
> body thus factors
weakness compensatory
mechanisms
>loss of are activated
such as
weight
decrease in
activity,
weight loss
Problem no. 2 HYPERTHERMIA

Assessment Nursing Scientific Goal/Expected Interventions Rationale Evaluation

Diagnosis Explanation Outcome

S> Ø Hyperthermia In sepsis, it After 1 hour of >Identify >To know what The patients’
implies the nursing underlying are the causes of SO had
presence of interventions, cause such condition. identified
an infection the underlying
of the blood cause and
O> WBC is caused by patient’s SO cotributing
will be able to >To be able to
increased, a rapidly identify if there is factors as
total of 25.8 multiplying identify > Monitor well as the
underlying dehydration and
wherein the microorganis sources of fluid excessive fluid importance of
normal is 4.3- ms or toxins cause/contribu loss the
ting factors loss
10.0 which can treatments.
result to and
hyperthermia importance of
as a defense the >To monitor the
>skin is treatments, as status of the client
mechanism
warm to touch well as signs
of the body.
and symptoms >Monitor
requiring laboratory
further studies.
intervention. >To protect the
cliet from any
>Identify factor which may
factors that the be hazardous to
SO can control the client
(if any)

>For the SO to
know the
importance of
preventing
dehydration to
>Discuss occur and the
importance of ways on how to
adequate fluid treat the client.
intake and
treatments.
Problem no. 3 INTERRUPTED BREAST FEEDING

Assessment Nursing Scientific Planning Intervention Rationale Expected

Diagnosis Explanation Outcome

S- Ø Interrupted Since the After 2hours of >Assess mother’s >To know The mother
breastfeeding neonate is nursing perception and what the was able to
related to diagnosed for intervention knowledge about mother identify
neonate’s having a and health breastfeeding and already knows and
present illness neonatal teachings the extent of and needed to demonstrat
O: as evidenced sepsis, the mother will instruction that know. e
by separation baby got identify and has been given. techniques
-The newborn of mother to separated demonstrate to sustain
is diagnosed infant from his techniques to lactation
with a certain mother and sustain and
disease >Give emotional
placed on a lactation until support to mother >To assist identify
(Sepsis) private room breastfeeding mother to techniques
and accept
separate from is initiated decision regarding maintain on how to
- The newborn
her mother. cessation/ breastfeeding provide the
was separated
Interrupted continuation of as desired. newborn
from his
breastfeeding breast feeding. with breast
mother
develops since milk.
- The mother the mother is
was unable to unable to
provide breast breast fed the >Demonstrate use >Aid in
milk to her baby of manual piston- feeding the
newborn continuously neonate with
due to their type breast pump. breast milk
separation. without the
mother
breastfeeding
the infant.

>To provide
optimal
nutrition and
>Review promote
techniques for continuation of
storage/use of breastfeeding
expressed breast process
milk
>So that
infant will be
hungry/ ready
to feed

>Determine if a
routine visiting
schedule or >To promote
advance warning successful
can be provided infant feeding

>Provide privacy,
calm surroundings >Reinforces
when mother that feeding
breast feeds. time is
pleasurable
and enhances
>Recommend for digestion.
infant sucking on a
regular basis
>To sustain
adequate milk
production and
breast feeding
process

>Encourage
mother to obtain
adequate rest,
maintain fluid and
nutritional intake,
and schedule
breast pumping
every 3 hours
while awake
 Problem no. 4 KNOWLEDGE DEFICIT

Cues Nursing Scientific Explanation Objective Nursing Rationale Evaluation

Diagnosis Interventions

S>“May Knowledge Neonatal sepsis is After 2 >Determine client’s >This may The patients’
kinalaman deficit caused by an infection hours of NPI most urgent need differ and SO
ba ang related to detected during or after the from both client’s require verbalized
laging pag- unfamiliari the delivery. In this case, patients’ SO and nurse’s adjustment in understandi
iyak sa ty with the the patient was will viewpoint. teaching plan. ng of the
kondisyon informatio identified to having verbalize disease
ng baby ko n neonatal sepsis after understandi process and
>Provide situation
ngayon?” resources. two days. Transplacental ng of the >Prevent was able to
relevant to the
infection or an condition, overload. clarify her
O> situation.
ascending infection from disease concern.
-frequently the cervix may be process and
ask caused by organisms treatment.
that colonize in the >Discuss client’s
questions.
mother's genitourinary perception of need
>In order for
tract, with acquisition of information related
the client to
the microbe by passage to client’s personal
feel competent
through a colonized birth desires, needs,
and respected.
canal at delivery. The values, and beliefs.
microorganisms most
commonly associated State objectives
with early-onset clearly in learner’s
infection include group B term.
Streptococcus (GBS),
Escherichia coli,
Haemophilus influenzae, >Begin with the
and Listeria information the
monocytogenes. client already knows
Whle the depression fetl and move to what >Can arouse
by the mother was the client does not interest/ limit
caused by hormonal know progressing to sense of being
changes during the simple to complex. overwhelmed.
pregnancy.
Problem no. 5 RISK FOR IMPAIRED PARENT/NEONATE ATTACHMENT

Assessment Nursing Scientific Planning Intervention Rationale Expected

Diagnosis Explanation Outcome

S- Ø Risk for Due to the After 3 hours >Interview >To know

Impaired newborn’s of nursing parents, noting what the
parent/ physical illness intervention their perception parents The parents
neonates and and health of situation and feelings will be able to
O: have a
Attachment hospitalization teachings the individual about the
-The newborn related to , the parents mother will concerns situation. mutually
is diagnosed neonates may have fear identify and satisfying
with a certain physical illness on how to demonstrate interactions
disease and handle their techniques to with their
>Educate >Helps newborn.
(Sepsis) hospitalization baby since the enhance parents clarify
. baby is on its behavioral regarding child realistic
- the newborn fragile state organization of
is hospitalized growth and expectations
and needed the neonate development,
extra care. addressing
- The newborn
And since he is parental
is separated
the 1st child . perceptions
from his
hospitalized in
parents
their family,
the parents
might still be > Involve
unsure on how parents in >Enhances
to take care of activities with self-concept
the baby. the newborn that
they can
accomplish
successfully

>Recognize and
provide positive
feedback for
nurturant and >Reinforces
protective continuation
parenting of desired
behaviors behaviors
Communication Letter