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TABLE OF C O N T E N T S

A. ABSTARCT..............................................................................1

B. INTRODUCTION.....................................................................1

C. PATIENT HISTORY.................................................................2

D. ASSESSMENT...........................................................................3

E. NURSING CARE PLAN..........................................................5

F. DRUG STUDY.................................................................................6

G. CONCLUSION...............................................................................7

H. HEALTH TEACHING..................................................................7
A. ABSTRACT

Pregnancy, the state of carrying a developing embryo or fetus with in a female body.
This condition can be indicated by positive results on an over-the-counter uterine test, and
confirmed through a blood test and ultrasound, detection of fetal heartbeat, or an Xray.
Pregnancy last for about nine months, measured from thedate of the woma’s last menstrual
period (LMP). It is conventionally divided into three trimesters, each roughly three months
long.

B. INTRODUCTION

The postpartum period is the time immediately after a woman delivers her baby. It is the
time when the mother's body is changing back to the non-pregnant state. It lasts approximately
can expect a variety of symptoms ranging from physical discomfort to emotional upsets.
Feeling overwhelmed with the responsibility of caring for an infant is a normal
postpartum symptom. Other emotions may include sadness, feeling helpless, and a "let down"
feeling. Discomfort in the perineum (area between the rectum and vagina) is expected and may
cause difficulty with sitting or walking. It is common for the breasts to be swollen and painful.
The new mother may feel tired, experience hot flashes and sweating, and may be constipated. A
woman may also have a reduced interest in sex for up to 6 months after childbirth. All these
symptoms are normal, a temporary reaction to childbirth.
There are symptoms that are not normal and may be considered postpartum
complications. Contact your healthcare provider immediately if one of more of these symptoms
develop:
 temperature of 100.4 degrees Fahrenheit (38 degrees Centigrade) or greater
 chills
 nausea or vomiting
 moderate to strong abdominal or back pain that is more than just an ache
 increased pain, swelling, redness, or drainage from the episiotomy or C-section incision
 bleeding through more than one pad per hour
 blood clots the size of a plum
 a foul smelling vaginal discharge
 chest pains
 increasing tenderness in the lower abdomen
 red, warm to the touch, painful breasts
 burning when urinating or blood in the urine
 a severe headache in the forehead and behind the eyes, accompanied by extreme pain
while sitting or standing
 feeling depressed or blue for more than 3 days
 severe weakness
 extreme paleness or
 a rapid, racing pulse
Treatment for complications varies depending on the source of the problem. Infection
usually responds to antibiotic treatment. Other special medications and procedures are available
for treating postpartum problems.
A new mother who experiences one or more of these symptoms should contact her
provider immediately.

C. PATIENT HISTORY
GENERAL DATA

HOSPITAL: Zamboanga del Sur Medical Center


PATIENTS NAME:
ADDRESS: Purok Rang-ay, Labangan, Zamboanga del Sur
AGE: 39
SEX: Female
OCCUPATION: Housewife
HUSBAND'S NAME:
HUSBAND'S OCCUPATION: Constraction Worker
CIVIL STATUS: Married
RELIGION: Roman Catholic
CITEZENSHIP: Filipino
LMP: 02/10/2018
EDC: 09/17/2018
MENARCHE: 13 yrs.old
AOG: 38 weeks
HIGHEST EDUCATIONAL ATTAINMENT: High School Graduate

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 HEALTH 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.
D. ASSESSMENT

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 on 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.

FAMILY,PRSONAL, SOCIAL AND ENVIRONMENTAL HISTORY

MEMBERS OF IMEDIATE FAMILY

NAME SEX AGE GEN. HEALTH POSITION IN EDUCATIONAL


STATUS THE FAMILY BACKGROUND
CRISROY MALE 17 YRS. HEALTHY ELDEST SON HIGH SCHOOL
OLD GRADUATE
CHRISTIAN MALE 10 HEALTHY 2ND SON GRADE SCHOOL
YRS.OLD
MARK JAY MALE 5 YRS.OLD HEALTHY 3RD SON KINDER
JOHN MALE 2 YRS.OLD HEALTHY 4TH SON NOT YET IN
CLIFFORD SCHOOL
BABBY GIRL FEMALE 2DAYS HEALTHY YOUNGEST NOT YET IN
OLD DOUGHTER SCHOOL

PERSONAL AND SOCIAL HISTORY

Client x is a married, 39 yrs.old and married. She was just a high school graduate and
did not able to proceed in college. During his pregnancy, she was able to continue his usual
activities and continue to met her friends and neighboor. She also send his eldest son to school
and get her child from school. She oually get to sleep after she watched televesion and
preparetheir foods. Before she get sleep she make sure that she is clean and maintain proper
hygiene. She knows how to speak tagalog and speak mostly on cebuano and a little
comprehension on english dialect
ENVIRONMENTAL HISTORY
Client house is located at Rang-ay, Labangan, Zamboanga del Sur. The place is near the
Fatima Parish. As the table shown above, she had 5 children. Their family lie in a semi-concrete
house and not fully furnished, located near the highwa and about 3minutes walk going to the
church. Regularly, they dispose their waste in the garbage can and collected by the bargy.
Workers every week.

HEREDO-FAMILIAL HISTORY
Their common family illness is asthma. Her father had asthma until now.

E. NURSING CARE PLAN

F. DRUG STUDY
GENERIC NAME: CEPHALEXIN
CLASSIFICATION: Anti-Infectives
ACTION: Inhibits DNA synthesis by inhibiting DNA gyrase in susceptible gram negative gram
positive organism.
INDICATION: Infectious diarrhea, respiratory tract infection, infection on the skin structures,
bones and joints
CONTRAINDICATIONS: Hypersensitivity to drug or other flouroquinolones.
ADVERSE REACTIONS:
 CNS: Headache
 CV: Orthostatic Hypotension
 EENT: Blurred Vision
 GI: Nausea and Vomiting, diarrhea, constipation
 OTHER: Taste
INTERACTION: oral anticoagulants. Increase anti-coagulant effects
NURSING CONSIDERATION:
 Advice patient not to take drugs with dairy or caffeinated products
 Inform physician if allergies or rashes abruptly develop

GENERIC NAME: Mefenamic Acid


CLASSIFICATION: Anti-Inflamatory, analgesics
ACTION: Inhibits reuptake of serotonin noreipeniphrine CNS
INDICATION: Moderate to moderately severe pain
CONTRAINDICATIONS: Hypersensitivity to drug, acute intoxication with alcohol, physical
opioid dependene.
ADVERSE REACTIONS:
 CNS: Dizziness
 CV: Vasodilation
 EENT: Visual disturbances
 GI: Nausea and Vomiting
 GU: Urinary Retention
 SKIN: Pruritus
NURSING CONSIDERATION:
 Tell patient that drug works best when taken before pain becomes severe
 Recommended abstinence from alcohol when taking medication
 Caution patient that drug can cause dependence

ADMINISTERING ORAL MEDICATION


Medication is given to the client as ordered by the physician. As to the setting, normally
the midwife give medication that are independent , such as mefenamic acid, Cephalexin. Each
drugs has its own specific effects on the clients body.

H. CONCLUSION

In this study, it really proof that knowledge is a power for it really help individual to
make appropriate actions and interventions that can be applied to each specific objectives with a
specific rationale so that people whom gonna read this work will be able to comprehend and
understand what im talking about especially caring this kind of client so that others will be
guided on what to do and what would be the priority action to be done. May this work of mine
can help us health care providers on what is the proper and exact ways on ealing our clients
problem so that it is easy for us to make specific action for them.
I. HEALTH TEACHING
Client was able to learned proper breastfeeding technique. She was also taught on the
pros and cons of the latter. She was also reminded on proper hygiene to her and to the child so
that she can assure to be healthy for as long as she implemented what we taught to her. I also
include to have regular consultation to the nearest health center to monitor the recovery and the
come back of her normal vital signs.

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