Liceo de Cagayan University Pelaez Blvd.

RN,Carmen, Cagayan de Oro City

COLLEGE OF NURSING

IN PARTIAL FULFILLMENT OF THE REQUIREMENTS IN NCM501201 RELATED LEARNING EXPERIENCE

Submitted to: Mrs. Florabelle Uliarte, RN Clinical Instructor

Submitted by: Alcordo, Vincent Julius Bacan, Marjorie Jane Balabaran, Sandra Balagot, Julie Mae Brown, Jackilou Cahatol, Ma. Lourdes Cordero, Claire Dela, Maria Laarnie Dimaporo, Maha Gaid, Karl Alexander

I. INTRODUCTION
The greatest embarking journey the woman will ever take in their life is pregnancy. Pregnancy is one of the miracles of life. It is so amazing how a person emerges from another person, quite similar in genetic make-up but a totally different individual with a unique personality and a distinct characteristic. A mother undergoes pain in giving life to another person which only shows that each of them is created with the great love felt for one another. Truly, the Creator made this life perfect, a bit of pain and suffering, but with a basket full of love. Childbearing is a no easy task. It is one of the complex processes that all women who want to have a child should undergo and it encompasses a lot of problems and complications. It has different stages, phases, and periods, each of which has a whole new experience to offer to each conceiving mother. The pregnancy is divided into 3 periods Anterpartum, Intrapartum, and Postpartum period. Antepartum is the period of time from the fertilization up to the time the labor begins. Intrapartum, the period of actual birthing process is divided into 4 stages. The 1st stage (Dilatation), 2nd stage (Delivery), 3rd stage (Placental and 4th stage (Recovery). Postpartum period refers to the 6-week period after childbirth. The students are required to provide nursing interventions to their assigned patients and compare those interventions to what they learned in school and in textbooks in order for them to understand real situations and able to compare the positive and negative corners of these type of actual situations.

Objectives of the Study: The study centers in promoting Maternal and Child Nursing Care which include the organized series of steps of the nursing process to ensure quality and consistency. Thus, the study aims to: Assess thoroughly the patient to formulate the proper nursing diagnoses Plan appropriate nursing care Implement interventions as to the continual of care after delivery Impart health teachings to the mother well as to other members of the family.

Scope and Limitation of the study As far as the study was conducted, the above objectives have been puts into application. Nevertheless, the study has set its own limitation that will particularly apply within our 1 hour care and stay at patients house. This involves the following: Conducting an interview during the early stage of labor( Latent Phase) Monitoring patients condition as to the progress of true labor contractions Assist patient during stages of labor Implementing possible nursing actions to the mother and the neonate during post partum stage.

II. PATIENTS PROFILE

Name: Age: Gender: Status: Address: Nationality: Religion: Place of Birth: Date of Birth: Last Menstrual Period Name of Husband: Occupation: Income: Temperature: Pulse Rate: Respiratory: Blood Pressure: Height: Weight: Baby Boy Weight: Head circumference: Chest circumference: Abdominal circumference: Length: Temperature: 2.8 kgs. 34 cm 32 cm 30 cm 55 cm 36.7 C Alma Tomloan 28 yrs. old Female Married V.castro Street, Carmen, Cdo Filipino Born again Malaybalay, Bukidnon November 23, 1978 December 6, 2007 Joseph Tomloan Tricycle driver Php 1400/week 36.0C 95 bpm 27 cpm 90/60 mmHg 49 54 kg

III. STAGES OF LABOR / PHYSIOLOGY OF LABOR

A. First Stage of Labor (Stage of Cervical Dilation)

Begins with the first true labor contractions and ends with complete The first stage of labor averages about 13.3 hours for a nulli Para and

effacement and dilation of the cervix (10 cm dilation).

about 7.5 hours for a multipara. 1. Latent phase (early):

Dilates from 0 to 4 cm.

Contractions are usually every 5 to 20 minuteslasting 20 to 40 seconds, and of mild intensity.

The contractions progress to about every 5 minutes and establish a regular pattern. 1. Active phase: Dilates from 4 to 7 cm. Contractions are usually every 2 to 5 minutes; lasting 30 to 50 seconds and of mild to moderate intensity. After reaching the active phase, dilation averages 1.2 cm per hour in the nullipara and 1.5 cm per hour in the multipara. 2. Transitional phase: Dilates from 8 to 10 cm. Contractions are every 2 to 3 minutes, lasting 50 to 60 seconds and of moderate to strong intensity. Some contractions may last up to 90 seconds. B. Second Stage of labor (Stage of Expulsion). Begins with complete dilation and ends with birth of the baby. The second stage may last from 1 to 1 hours in the nullipara and from 20 to 45 minutes in the multipara. C. Third stage of labor, (Placental Stage)

Begins with delivery of the baby and ends with separation and delivery of

the placenta.

The third stage may last from a few minutes up to 30 minutes.

D. Fourth Stage Last from delivery of the placenta until the postpartum condition of the woman has become stabilized (usually 1 hour after delivery). THEORIES OF LABOR

Uterine stretch theory uterus becomes stretched and pressure increase, causing physiologic change initiating labor. Oxytocin effect theory as pregnancy progresses, there is a gradual rise in the amount of circulating Oxytocin. Progesterone depletion theory as pregnancy advances, progesterone is less effective in controlling rhythmic uterine contractions that occur. Production of Prostaglandins increased production of prostaglandin by fetal membranes and uterine deciduas as pregnancy progresses. Fetal production of Cortisol in later pregnancy, the fetus produces increased level of cortisol that inhibits progesterone from the placenta.

MECHANISMS OF LABOR The mechanism of labor refers to the sequencing of events related to posturing and positioning that allows the baby to find the easiest way out. For the most part the fetus is a passive respondent in the process of labor, while the mother provides the uterine forces and structural configuration of the passageway through which the passenger must travel. For a normal mechanism of labor to occur, both the fetal an maternal factors must be harmonious. An understanding of these factors is essential for the obstetrician to appropriately intervene if the mechanism deviates from the normal. The following definitions must be mastered to be able to discuss and understand the mechanism of labor.

Attitude this refers to the posturing of the joints and relation of fetal parts to one another. The normal fetal attitude when labor begins is with all joints in flexion.

Lie this refers to the longitudinal axis of the fetus in relation to the mothers longitudinal axis; i.e., transverse, oblique, or longitudinal. Presentation this describes that part on the fetus lying over the inlet of the pelvis or at the cervical os. Position this describes the relation of the point of reference to one of the eight octanes of the pelvic inlet (e.g., LOT: the occiput is transverse and to the left). Engagement this occurs when the biparietal diameter is at or below the inlet of the true pelvis. Station this reference of the presenting part to the level of the ischial spines measured in plus or minus centimeters.

The single most important determinant to the mechanism of labor is probably pelvic configuration. Their classification of the pelvis into four major types (gynecoid, android, anthropoid, and platypelloid) helps the student understand the possible difficulties that may arise in a laboring patient. A quote that should be remembered is No two pelvises are exactly the same, just as no two faces are the same. The narrowest part of the fetus attempts to align itself with the narrowest pelvic dimension which means the occiput generally tends to rotate to the most ample portion of the pelvis. The mechanical steps the baby undergoes can be arbitrarily divided, and clinically they are usually broken down into six or eight steps for ease of discussion. The following six divisions of labor are easy to use:

Flexion and engagement this occurs at various times before the forces of labor begin Descent this occurs as a result of active forces of labor. Internal rotation this occurs as a result of impingement of the presenting part on the bony and soft tissues of the pelvis. Extension this is the mechanism by which the head normally negotiates the pelvic curve.

External rotation this is the spontaneous realignment of the head with the shoulders. Expulsion this is anterior and then posterior shoulders, followed by trunk and lower extremities in rapid succession.

The above mechanisms of labor should become second nature to the practitioner and indeed does become such by careful observation. Those patients who have undeliverable or uncorrectable problems should be unhesitatingly delivered by the abdominal route because inappropriate operative vaginal intervention may lead to damage to both mother and fetus. Some of the undeliverable situations include persistent mentum posterior, persistent brow presentation, some types of breech presentations, and shoulder presentation

Differentiation between True and False Labor Contractions

True Contractions

False Contractions

Begin irregular but become regular and predictable.

Begin and remain irregular Fell first remain abdominally and confined to the

Felt first from lower back groin to abdomen in a wave

abdomen and groin Often disappear with

Continue no mailer what

ambulation and sleep. the womans activity Increase in duration, Do not increase in duration, frequency, or intensity Do not achieve cervical dilatation

frequency and intensity Achieve cervical dilatation

First Trimester During the first trimester, the pregnant can expect a host of pregnancy symptoms including breast changes, tiredness, nausea and vomiting, frequent urination and many more. At the end of the first trimester, the uterus will have grown into the size of a grapefruit, while the baby inside is the size of a cherry. The baby will grow from being a mass of cells to having a heartbeat, reflexes and the ability to move its tiny limbs. Now is the time to start prenatal care and a nutritious, healthy diet. Regular exercise will keep the baby safe and ready for a healthier birth. Second Trimester Throughout the second trimester, the body will grow more scatterbrained and the belly will start to show the baby growing inside the body. The body will experience

pregnancy discomforts such as sleeping problems and notice Braxton Hicks contractions. During the second trimester, the baby will grow hair all over its body and the senses will begin to develop. At the end of the second trimester, the baby will measure about 10 inches (25 cm) and will frequently practice their kicking movements. Third Trimester The third trimester brings many changes to the body; the pregnant will need to urinate frequently and the body belly looks like its ready to explode. Now is the time to start taking childbirth and breastfeeding classes. The finishing touches are being placed on the baby, and the partner is looking forward to delivery day! Dont forget to include the patients partner and prepare him for the responsibility of fatherhood.

IV. PHYSIOLOGY OF LABOR

MATURED FETUS

UTERINE MUSCLE CONTRACTIONS

Stimulates Posterior Pituitary GLAND to secrete Oxytocin

Release of PROSTAGLANDIN stored in the uterine Decidua, umbilical cord and amnion

Increase level of OXYTOCIN raise uterine muscle Calcium levels

Stimulates BIOCHEMICAL CHANGES in the uterine wall

Through this MYOMETRIUM is capable of contraction

Stimulates UTERINE CONTRACTION

LIGHTENING -10 to 14 days before labor begins - Uterus becomes lower and more OF ACTIVITY INCREASE LEVEL anterior -abdominal release initiated by an increase - due to an increase of epinephrine pressure increases in progesterone produced by the placenta -increase vaginal discharge -urinary frequency from pressure in the bladder

BRAXTON HICKS CONTRACTIONS - strong contractions

RIPENING OF THE CERVIX - butter-soft and softer - internal announcement that labor is close at hand.

SHOW - mucus plug is expelled

RUPTURE OF THE MEMBRANES - sudden gush or scanty - slow seeping of clear fluid from the vagina

BLOODY SHOW

CERVICAL EFFACEMENT - thinning and shortening or obliteration of the cervix that occur before dilatation begins.

DESCENT - full descent occurs when the fetal extrudes beyond the dilated cervix and touches the posterior vaginal floor

FLEXION - pressure from the pelvic floor causes the fetal head to bend forward onto the chest

INTERNAL ROTATION -the head flexes as it touches the pelvic floor and the occiput rotates until it is superior, or just below the symphisis pubis, bringing the head into the best diameter for the of the pelvis.

EXTENSION - as the occiput is born, the back of the neck stops beneath the pubic arch and acts as a pivot for the rest of the head. The head thus extends, and the foremost parts of the head, the face and the chin are born.

EXTERNAL ROTATION - The head rotates back to the diagonal or transverse position of the early part of labor almost immediately after the head of the infant is born. The after coming shoulders are thus brought into an anteroposterior position, which is best for entering the outlet. The anterior shoulder is born first, a assisted perhaps by downward flexion of the infants head.

EXPULSION -immediately after external rotation, the anterior shoulder appears under the symphisis pubis and the perineum soon becomes distended by the posterior shoulder, gentle but firm pressure downward traction of the head is done to deliver the anterior shoulder then the head is raised to deliver the posterior shoulder, then the body follows without difficulty.

V. Nursing Assessment (System Review and Nursing Assessment) Name: Alma Tomloan BP: 90/60 mmHg Weight: 54 kg
EENT: [ ] Impaired vision [ ] blind [ ] pain redden [ ] drainage [ ] gums [] hard of hearing [ ] deaf [ ] burning [ ] edema [ ] lesion teeth [ ] assess eyes ears nose [ ] throat for abnormality [x] no problem RESP: [ ] Asymmetric [ ] tachypnea [ ] barrel chest [ ] apnea [ ] rales [ ] cough [ ] bradypnea [ ] shallow [ ] rhonchi [ ] sputum [ ] diminished [ ] dyspnea [ ] orthopnea [ ] labored [ ] wheezing [ ] pain [ ] cyanotic [ ] assess resp. rate, rhythm, pulse blood [ ] breath sounds, comfort [ x] no problem CARDIOVASCULAR: [ ] arrhythmia [ ] tachycardia [ ] numbness [ ] diminished pulses [ x] edema [ ] fatigue [ ] irregular [ ] bradycardia [ ] mur mur [ ] tingling [ ] absent pulses [ ] pain Assess heart sounds, rate rhythm, pulse, blood Pressure, circ., fluid retention, comfort [ ] no problem GASTROINTESTINAL TRACT: [ ] obese [ ] distention [ ] mass [ ] dysphagia [ ] rigidity [ ] pain [ ] assess abdomen, bowel habits, swallowing [ ] bowel sounds, comfort [x] no problem GENITO URINARY AND GYNE [ ] pain [ ] urine [ ] color [ ] vaginal bleeding [ ] hematuria [ ] discharge [ ] nocturia [ ] assess urine frequency, control, color, odor, comfort [ ] gyne bleeding [ ] discharge [ x] no problem NEURO: [ ] paralysis [ ] stuporous [ ] unsteady [ ] seizure [ ] lethargic [ ] comatose [ ] vertigo [ ] tremors [ ] confused [ ] vision [ ] grip [ ] assess motor, function, sensation, LOC, strength [ ] grip, gait, coordination, speech [x ] no problem MUSCULOSKELETAL and SKIN: [ ] appliance [ ] stiffness [ ] itching [ ] petechiae [ ] hot [ ] drainage [ ] prosthesis [ x ] swelling [ ] lesion [ ] poor turgor [ ] cool [ ] flushed [ ] atrophy [x ] pain [ ] ecchymosis [ ] diaphoretic moist [ ] assess mobility, motion gait, alignment, joint function [ ] skin color, texture, turgor, integrity [ ] no problem

Temperature: Height:

36.O C 49 cm

PR: 95 bpm

RR: 27 cpm

No problem

No problem

Ankle edema

Back pain

No problem

SUBJECTIVE COMMUNICATION Comments

[ ]Hearing Loss [ ]Visual changes [x]Denied Wala man ko problem sa ako panan-an as verbalized by the patient.

OBJECTIVE
[ ] glasses [ ] contact lens R 3-4mm Pupil size: 3-4mm Reaction: PERRLA [ ] languages [ ] hearing aide L 3-4mm [ ]speech difficulties

OXYGINATION

Comments wala man ko problema sa akong paginhawa. As verbalized by the patient

[ ]Dyspnea [ ]Smoking History ________________ [ ]Cough [ ]Sputum [ x]Denied

Respiratory: [x] Regular []irregular Description: RR is within normal range R: right lung is symmetric to the left lung L: left lung is symmetric to the right lung

CIRCULATION

Comments sakit akong likod inig hapon as verbalized by the patient

[x]Back Pain [ ]Leg Pain [ ]Numbness of the Extremities [ ]Denied

Heart Rhythm: [x] regular [] irregular Ankle Edema present in both foot Pulse Car Rad DP Fem R + + + + N.O L + + + + N.O Comments: All pulse sites are palpable

NUTRITION

Comments wala man ko problema sa akong pagkaon as verbalized by the patient.

Diet: DAT [ ]N [ ]V Character [ ]Recent change in Weight, appetite [ ]Swallowing Difficulty [x ] denied

[x]dentures Upper Lower Full [] []

[]none partial [x] [x] with patient [] []

ELIMINATION

Usual bowel pattern frequency Once adays day [ ]Constipation Remedy Date of last BM: Setember 7, 2010 [ ]diarrhea Character

[ ]urinary 2 3 times a [ ]urgency [ ]dysuria [ ]hematuria [ ]incontinence [ ]polyuria [ ]foly in place [ ]denied

Comments: the bowel sound Is in normal sound Distension

Bowel sounds: Abdominal

Present []yes[x]no Urine (color, consistency odor) yellowish in color

MGT. OF HEALTH & ILLNESS

[ ]alcohol [x ]denied Dili ko gainom ug makahubog nga ilimnon [x]SBE Last Pap Smear: NONE LMP: December 17, 2009

Briefly describe the patients ability to follow treatments (diet, meds., etc.) for chroni9c health problems ( if present) The patient did not experience any chronic problem.

Skin integrity
[ [ [ [ ]Dry ]itching ]other ]denied

Comments wala man ko problema sa akong panit as verbalized by the patient

[ ]dry [ ]flushed [ ]moist

[ ]cold [ ]pale [ ]warm [ ] cyanotic

Rashes, ulcers, decubitus (describe size, location, drainage) No found any impaired skin integrity. [ ] LOC and orientation: patient is well oriented with time and date. Gait: [ ]Walker [ ]cane [ ]other [ ]steady [ ]unsteady_______ [ ]sensory and motor losses in face or extremities: NONE [ ] ROM limitations

Activity/safety

Comments [ ]convulsion wala ko problema sa [ ]dizziness [ ]limited motion of joints paglihok2xas verbalized by the patient [ ]ambulate [ ]Bathe self [ ]Other [x]denied

Comfort/sleep/awake:
[x ] pain (location, frequency remedies) [ ] nocturia [ ]sleep difficulties [ ]denied

Comments Sakit akong likod padulong sa akong tiyanas verbalized by the patient

[ [ [ [

]facial grimace ]guarding ]other signs of pain ]side rail release form signed (60+ tears)

Coping:

Occupation: housewife Members of household: 5 Most supportive person: husband

Observed non-verbal behavior: the patient was conscious and coherent The person and her phone number that can be reached any time: none

VI. IDEAL NURSING MANAGEMENT

Nursing Diagnosis: Antepartum period

Health-seeking behaviors related to guidelines for nutrition and activity during pregnancy. Imbalanced nutrition, less than body requirements, related to inadequate intake of calories. Fatigue related to increased physiologic demands of pregnancy and inadequate nutritional intake.

Intrapartum period

Powerlessness related to duration of labor. Anxiety related to stress of labor. Pain related to labor contractions.

Postpartum period Risk for infection (uterine) related to lochia. Risk for impaired urinary elimination or constipation related to loss of bladder and bowel sensation after childbirth. Fluid volume deficit related to vaginal bleeding and lack of oral intake.

Newborn Ineffective airway clearance related to mucus in airway. Ineffective thermoregulation related to heat loss from exposure in birthing room. Imbalanced nutrition, less than body requirements, related to sucking reflex.

INTERVENTION

Antepartum period

Perform initial assessment, including vital signs, height and weight measurement, history and physical examination. Assess clients knowledge about guidelines for healthy pregnancy and antepartal care. Explain with the client the increased nutritional needs during pregnancy. Provide information about a well-balanced diet, including food selections, such as fresh fruits and vegetables, calcium sources, and high protein foods, fluid intake, and prenatal vitamin supplementation. Monitor weight at every visit and compare with the baseline data.

Intrapartum period Provide clear liquids and ice chips as allowed.

Evaluate urine for ketones and glucose

Administer IV fluids as indicated. Inform the woman/ couple of maternal status and fetal status and labor progress.

Explain all procedures and equipment used during labor. Monitor maternal vital signs. Remember the individual patient condition is used to determine frequency of vital signs and FHR assessment.

Encourage ambulation as tolerated regardless of membrane status as long as presenting part is engaged.

Encourage diversional activities, such as reading, talking, watching TV, playing cards, and listening to music.

Effleurage, light massage over abdomen with fingertips; can be used with slow chest and modified-paced breathing; start at pubic bone and move hands slowly upsides of abdomen in wide circular sweep; during exhaling, move fingertips down center of abdomen.

 Encourage a warm shower. Laboring woman can sit in the chair in the shower with the water running continuously over her lower back. Encourage relaxation techniques Provide comfort measures: Give back rubs. Assist woman to change position. Walking, squatting, semi-sitting, kneeling, standing, side-lying, or sitting on the toilet are positions that help to accommodate the descending fetus and relieve pain of uterine contractions.

Reposition external monitors as needed.

Postpartum period Monitoring for Hypotension and Bleeding Monitor vital signs every 4 hours during the first 24 hours. Increased respiratory rate greater than 24 breaths per minutes may be caused by increase blood loss, pulmonary edema or pulmonary embolus. Increased pulse greater than 100 beats per minute may be present with increase blood loss, fever, or pain. Decrease in blood pressure 15-20mmHg below baseline pressures may indicate decrease fluid volume or increase blood loss. Assess the woman for light-headedness and dizziness when sitting upright or before ambulating. Evaluate orthostatic blood pressures. Have the woman lie in bed if symptoms exist.

Assess vaginal discharge for clots and amount. Encourage food and drink as tolerated. Encouraging Bladder Emptying Observe for the womans first void within 6-8 hours after delivery.

Palpate the abdomen for bladder distension if the woman cannot void or if she complains of fullness after voiding.

Uterine displacement from the midline suggests bladder distension Frequent voiding of small amounts of urine suggests urinary retention with overflow.

Promoting Proper Bowel Function Teach the woman that bowel activity is sluggish because of decreased abdominal muscle tone, decreased solid food intake during labor, and prelabor diarrhea. Review the womans dietary intake. Encourage daily, adequate amounts of fresh fruit, vegetables, fiber, and at least 8 glasses of water. Encourage frequent ambulation. Administer stool softeners as indicated. Preventing Infection Observe for elevated temperature above 38 degree Celsius (100.4 F). Evaluate perineum for redness, ecchymosis, edema, discharge (color, amount, odor) and approximation of the skin Assess for pain, burning, and frequency on urination. Reducing fatigue Provide a quiet and minimally disturbed environment. Organize nursing care to keep interruptions to a minimum. Encourage the woman to sleep while the baby is sleeping, specifically to nap or lie down and get off her feet at least 30 minutes per day. Minimizing Pain

Instruct the woman to apply ice packs to the perineal area for the first 24 hours for perineal trauma or edema.

Instruct the woman to contract her buttocks before sitting to reduce perinea discomfort.

 Assist the woman in the use of positioning cushions and pillow while sitting or lying. Check breasts for any signs of engorgement Promoting Postpartum Health Maintenance
Teach

the woman to perform perinea care to promote comfort,

cleanliness, and healing. Assess the condition of the womans breast and nipples. Teach woman to wash her breast with warm water without soap, which prevents the removal of protective skin oils Instruct breast-feeding woman to add between 500 and 750 additional calories daily for milk production.
Instruct

the woman in postpartum exercises for the immediate and later

postpartum period. Newborn Care Immediate Care Promoting Airway Clearance and Transitioning of the newborn Assess the infants weight and height. Assess the infants vital signs (eg. Temperature per rectum, respiration) Drying and wrapping the infant prevents from heat loss (evaporation, convection and radiation) Premature Infant Notice physical characteristic of the premature infant: hair, ear cartilage, skin, and subcutaneous fat, sole of foot, breast buds, testes/labia majora, scrotum, fingernails, abdomen, thorax, head, and muscle tone. Obtain accurate body measurements: head circumference, abdominal girth, heel, shoulder to umbilicus, weight.

Assess gestational age using a tool as the Ballard scoring system. Monitor closely for respiratory or cardiac complications. Position infant to allow easy ventilation, paying careful attention to maintaining positioning. body alignment and facilitating hand-to-mouth

Protect the infant from infection by following scrupulous hand washing policy, minimizing infants contact with unsterile equipment, and minimizing the number of people who come in contact with the infant.

Post mature Infant Be alert for the physical appearance of a postmature infant. Determine the gestational age by physical examination. Measure weight, length, and head circumference. Determine blood sugar. Assess for aphyxia neonatorum by Apgar score and blood gas analysis. Be alert for meconium aspiration. Provide supportive treatment for meconium aspiration. Provide psychological support to the parents

VII.

ACTUAL NURSING INTERVENTION

FIRST VISIT Date: Sept 6 ,2010 During our first visit, we were shocked of what we saw because we did not expect the type of environment we would encounter. We introduced ourselves so that the patient will feel comfortable and to promote cooperation. We gathered the necessary data in order to complete our patients profile. At this time, AOG was already 35 weeks; vital signs were as follows; Temperature: 35.8 Celsius Pulse: 95 bpm Respiration: 21 cpm Blood Pressure: 90/60 mmHg. Fetal heartbeat: 143 bpm and was audible at the left lower quadrant And health teachings were imparted, such as doing antepartal excercises and eating foods which are low in sodium to prevent or reduce edema. SECOND VISIT September 17, 2010 The second time we visited our patient; she was more cooperative and answered our questions promptly. We did our routine assessment the data gathered were as follows; Temperature: 36 Celsius Pulse rate: 76 bpm Respiration rate: 23 cpm Blood pressure: 100/70 mmHg Fetal heartbeat: 135 bpm and audible at the right lower quadrant We also brought fruits and gave the vitamin supplements to provide the nutrients that the patient and her child needs.

THIRD VISIT September 25, 2010 On our third visit, the patient still had not give birth despite it was already past the EDC (expected date if confinement) which was due on the 24th of September. We obtained her vital signs and readings are as follows: Temperature: 36.5 Celsius Pulse rate: 70 bpm Respiration rate: 18 cpm Blood pressure: 100/70 mmHg Fetal heart beat: 142 bpm and audible at the right lower quadrant We also brought her fruits and vitamins also FOURTH VISIT September 29, 2010 In our fourth visit, the patient was already gave birth, last September 28, 2010.She delivered a healthy baby boy. As part of the health care team, we rendered health teachings about nutritional foods and demonstrated the postpartum exercises. We offered foods like fresh fruits and gave iron supplement. Also, we do our assessment to our patient and as well as the newborn. We then took the vital signs and readings are as follow: Temperature: 36.9 Celsius Pulse rate: 80 bpm Respiration: 20cpm Blood pressure: 100/90 mmHg

VIII.SUMMARY
For the entire visits of our client, we were able to monitor our clients pregnancy stage. During each visits, our client has met the expected events such as the different psychological and physiological changes of her pregnancy. And based on the data that we gathered we found out that our clients adaptation to pregnancy are normal based on the different psychological and physiological changes of pregnancy, as well as, the growth and development of the fetus inside her womb. The results of the assessment of Alma also show a healthy and positive remark of each stage. Comparing it with what we gathered from the stages of fetal development and changes of pregnancy, it shows that the need of our client was met. She showed a positive resolution to us because we approach our client fairly well and we have handled her with care. She showed us positive characteristics in dealing with the changes that she undergone. Her nutritional needs are not provided fairly well because of poverty. And that all those factors mention above are helping our client a lot in dealing with the changes that is happening rapidly in her life during pregnancy stage.

IX. DOCUMENTATIONS

X. HEALTH TEACHINGS

Medication

Advice patient to continue taking ferrous sulfate, for iron supplement, 500mg 1 tab/day.

Environment

Instructed patient to stay in calm, quiet environment Home environment must be free from slipping or accident

Treatment

hazards Informed patient to visit ob-gyne if possible for further check-up and to facilitate her fast recovery and to secure the wellness of the infant Instructed patient to promote breastfeeding and frequent cleaning of breast using clean water and avoid using of bath soap and alcohol, to avoid irritation of breast Instructed patient to avoid lifting heavy objects for 1-2 weeks

Health teachings

Diet

Encouraged client to increase intake of fiber to avoid constipation Instructed to increase fluid intake Instructed to increase intake of nutritious foods such as fruits and vegetables

XI. BIBLIOGRAPHY

Pillitteri, Adele: Maternal and Child Health Nursing. Cesarean Birth Vol.1.4th edition. Pg 540-542, 557-560 Lippincot Williams and Collins, 2003 Nursing 2005 Drug Handbook 6th edition. Lippincott Williams and Wilkins 2006 Doenges, Marilyn E. et.al: Nurses Pocket Guide: Diagnoses, Interventions, and Rationales. 9th edition pp. 278-279, 472-477, 576-578 F.A. Davis Company Philadelphia, 2004 Adele Pilitteri: Maternal and Child Health Nursing. Volume 1.3rd edition, pp. 524-530, 533-539. Lippincott Williams and Wilkins , Inc.

TABLE OF CONTENTS I. Introduction II. Patient Profile III. Stages of Labor/Physiology of Labor IV. Ideal Nursing Care Plan Antepartal Period Intrapatal Period Postpartum Period V. Actual Nursing Care Plan Antepartal period Postpartum Period New born Care VI. Health Teachings (REFERRALS) VII. Summary VIII. Documentations XI. Drug Study X. Bibliography