University of Baguio

Baguio City
School of Nursing

A CASE STUDY ON NORMAL SPONTANEOUS

VAGINAL DELIVERY

In Partial Fulfilment
Of the Requirements for the
NCENH01 subject

Herreria, Olivia Fe T.
Pelingen, Shaye Alyxen J.
Ramilo, Sheena Patricia M.
Sato, Edenmae D.
Tabije, Arvie

February 28, 2018

Jennifer Boleyley
Clinical Instructor
 APPROVAL SHEET

This case study entitled “A CASE STUDY ON NORMAL SPONTANEOUS VAGINAL DELIVERY” is prepared
and submitted by: Herreria, Olivia Fe T., Pelingen, Shaye Alyxen J., Ramilo, Sheena Patricia M., Sato, Edenmae D.,
Tabije, Arvie in partial fulfilment of the requirements for the NCENH01 subject.

PANNEL OF EXAMINERS

Helen D. Alalag RN, MAN

Chairman

Jennifer Boleyley RN, MAN Diana Marie Amwao RN,MAN

Accepted and approved in partial fulfilment of the requirements for the subject NCEN01
 ACKNOWLEDGEMENT

The materialization of this case study wouldn’t be possible without the aid of the following folks:

To the Almighty Father for the strength and knowledge given to us to complete our case study; to our
beloved parents who have always been supportive all throughout the start of the duty until the end; to our dear
colleagues who have been helping us during rough times; and to my group mates for the overwhelming support and
help, for being cooperative, that helped us boost our learning and somehow sharpened our skills.

To our ever lenient but strict clinical instructor, Mrs. Jennifer Boleyley, for simplifying what used to be
incomprehensible, tricky and complicated concepts, for assisting us in the various procedures we have performed,
and for being kind to us despite our immaturity.
 TABLE OF CONTENTS

I. INTRODUCTION
II. PATIENT PROFILE
III. PHYSICAL ASSESSMENT
IV. ANATOMY & PHYSIOLOGY
V. PATHOPHYSIOLOGY
A. SCHEMATIC
B. NARRATIVE
VI. LABORATORY & DIAGNOSTICS
VII. MEDICAL & NURSING MANAGEMENT
A. NURSING
B. MEDICAL
VIII. SUMMARY OF CARE
A. NURSING
B. MEDICAL
IX. RECOMMENDATIONS
X. REFERENCES
XI. APPENDICES
XII. LEARNING INSIGHTS
XIII. CONSENT
XIV. SOME TABLES
 CHAPTER I
INTRODUCTION

Pregnancy, also known as gestation, is the time during which one or more offspring develops inside a
woman. It can be determined through OTC urine pregnancy test or laboratory blood pregnancy test, ultrasound,
detection of fetal heartbeat, or an X-ray. Pregnancy lasts for nine months, measured from the last menstrual period
(LMP) of the woman. Pregnancy is typically divided into three trimesters, each has 3 months long.

After nine months of gestation, it goes through the process called delivery, where the fetus is expelled out
from the mother’s womb. There are two options of delivery: Cesarean section and NSVD or normal spontaneous
vaginal delivery. A c-section, or cesarean section, is the delivery of a baby through a surgical incision in the
mother's abdomen and uterus. In some circumstances, a c-section is scheduled in advance. In others, the surgery is
needed due to an unforeseen complication and a spontaneous vaginal delivery is defined as the delivery of a baby
through the vagina.

Normal labor is a physiologic process during which the fetus, membranes, umbilical cord, and placenta are
expelled from the uterus. Undergoing the process of labor is not that easy that is why Obstetrics has divided the
process into three.

First stage of labor

Begins with regular uterine contractions and ends with complete cervical dilatation at 10 cm. It is
divided into a latent phase and an active phase. The latent phase begins with mild, irregular uterine
contractions that soften and shorten the cervix, contractions become progressively more rhythmic and
stronger and the active phase usually begins at about 3-4 cm of cervical dilation and is characterized by
rapid cervical dilation and descent of the presenting fetal part.

Second stage of labor

Begins with complete cervical dilatation and ends with the delivery of the fetus. In nulliparous
women, the second stage should be considered prolonged if it exceeds 3 hours if regional anesthesia is
administered or 2 hours in the absence of regional anesthesia and in multiparous women, the second stage
should be considered prolonged if it exceeds 2 hours with regional anesthesia or 1 hour without it.

Third stage of labor

This stage is the period between the delivery of the fetus and the delivery of the placenta and fetal
membranes. The delivery of the placenta often takes less than 10 minutes, but the third stage may last as
long as 30 minutes. The expectant management involves spontaneous delivery of the placenta. The third
stage of labor is considered prolonged after 30 minutes, and active intervention is commonly considered
and active management often involves prophylactic administration of oxytocin or other uterotonics
(prostaglandins or ergot alkaloids), cord clamping/cutting, and controlled traction of the umbilical cord.

Labor and delivery of the fetus entails physiological effects on both the mother and the fetus. The mother’s
cardiac output increases because of the increase in the needed amount of blood in the uterine area. Blood pressure
may also rise due to the effort exerted by the mother in order expel the fetus. There could also be a development of
leukocytes or a sharp increase in the number of circulating white blood cells possibly as a result of stress and heavy
exertion. Increased respiratory may also occur. This happens as a response to the increase in blood supply in order to
increase also the oxygen intake.

Braxton Hicks contractions are intermittent uterine contractions that start in early pregnancy, although you
probably won't notice them until sometime after mid pregnancy. True labor is felt in the upper and mid abdomen
and leads to the cervical changes that define true labor.

During delivery, the mother is placed in supine position with her knees bent (lithotomy position).
Sometimes your doctor may need to use different procedures to help deliver the baby. Forceps delivery or vacuum
extraction is used to assist a vaginal delivery. This may be needed when labor is stalled at the pushing stage or when
the baby shows signs of distress at the pushing stage and needs to be delivered quickly. A surgical cut made at the
opening of the vagina during delivery (epistiotomy) can be done to widen the perineum. This is sometimes used to
deliver the baby's head more quickly, when there are signs of distress.

Labor and birth process is accompanied with pain that is why health care providers give several pain
relievers to control or ease the pain. It may be given intravenously or intramuscularly. Analgesics lessen pain
without loss of feeling or muscle movement. Anaesthetics relieve pain by blocking most feeling, including pain.
 CHAPTER II

PATIENT’S PROFILE

Nursing health history are data collected about a patient's level of wellness, changes in life patterns,
sociocultural role, and mental and emotional reactions to illness. It is one of the most significant aspects in case
studies. The gathered data are used as basis for making nursing diagnosis and interventions.

In keeping the private life of our patient and in maintaining confidentiality we will call our client Patient X.

I. GENERAL DATA

HOSPITAL: Baguio General Hospital-Medical Center

PATIENTS NAME: Flora Mamaril

ADDRESS: Holyghost Extension Baguio City,Benguet

AGE: 23

SEX: Female

OCCUPATION: Housewife

HUSBAND'S NAME: Not Married

HUSBAND'S OCCUPATION: N/A

CIVIL STATUS: Single

RELIGION: Roman Catholic

CITIZENSHIP: Filipino

LMP: 05-18-17

EDC: February 15 to 19 2018

MENARCHE: 13 years old

AOG: 38 to 39 weeks

HIGHEST EDUCATIONAL ATTAINMENT: High School Graduate

II.HISTORY OF PRESENT ILLNESS

Patient X doesn’t experience any illness. Furthermore, the latter only experience pain of labor specifically,
pain felt at the abdomen. Patient X was also experienced signs of true labor. According to her, she experienced
frequent uterine contractions, breast enlargement and some discharges.

III. PAST HEALTH HISTORY

Patient X had experienced fever. She had no past records in the hospital. She has negative in allergies on
foods and drugs. For her childhood illness she had experienced colds, cough and fever. They usually use
paracetamol to treat fever. Client also didn’t experience any injuries in the past. She had been able to had
immunization when she was a child.

IV. HEREDOFAMILIALHISTORY

They have no common family

 CHAPTER III

PHYSICAL ASSESSMENT

I. Social Status

Mrs. X is 23 yrs. Old, born on January 17, 1995. She resides at Holyghost Extension Baguio City Benguet
together with her husband. Her husband is an elevator attendant. They have one daughter that was recently
delivered. Mrs. X’s medical expenses and other financial needs are supported by her husband. She is a Roman
Catholic and she goes to church if she have time and she also stated that she do not smoke and drink alcohol.

II. Mental Status and Emotional Status

Mrs. X is oriented to time, place and person. She can identify things or names being asked. She can recall
recent and remote memories she experienced. She is able to read and write and can speak in English, Tagalog and
Ilocano. She is responsive and answers to the questions being asked. Mrs. X is cooperative and relaxed while
performing the interview.

III. Environmental Status

Mrs. X has an appropriate state of mobility to her age and aware of the potential danger hazard. She has no
sensory deficit. Patient and family members has no any history of any infectious disease. She always practices
proper hygiene to maintain good health. She is near the comfort room and also near from the nurse’s station. Her
lighting and ventilation is accommodated well and the noise is minimal.

IV. Sensory Perception

Mrs. X has 20/20 vision. Her hearing ability is normal using whisper test with distance of two feet. Her
sense of smell is normal and she can distinguish foul and fresh odor. Her lips are pinkish in color. Her tongue is
slightly pink and she can taste whatever food she eats. She has the ability to perceive dull and sharp objects.

V. Motor Status

Mrs. X’s gait is slight staggering with weakness on legs but she doesn’t need support when standing up
and walking. She is comfortable with her condition. She finds walking, sitting, or changing positions tolerable. Mrs.
X tries to perform things alone if she can but admitted that she needs the help or assistance of another person often.

VI. Nutritional Status

Prior to admission Mrs. X meal intake is two to three times a day. The food served is usually vegetables,
fish, and sometimes meat. She always eats fruit. After delivery, her doctor ordered that she is allowed to eat
anything. She consumed 100% of hospital food served and she has no problem swallowing her food. She doesn’t
feel pain on her abdomen and she doesn’t feel nauseated or vomiting.

VII. Elimination Status

Mrs. X usually defacates one to two times daily and urinate two to three daily depending on her fluid
intake.

VIII. Fluid and Electrolyte Status

Mrs. X has a good skin turgor. She was able to consume one litter of water and urinated two times within
the shift.

IX. Circulatory status

The pulse rate during the shift is 85 beats per minute which is in the normal range. The pulse was strong
with regular rhythm. With regards to emotional stress and physical activity, the pulse rate increases. The patient’s
blood pressure is 110/60. This was taken while the patient is lying down in the bed.

X. Respiratory status

Her respiratory rate is 19 breaths per minute with no use of accessory muscles. There is no abnormal breath
sounds heard. The patient’s lip’s color is pinkish but slightly dry along with her nails.

XI. Temperature Status

Patient’s axillary temperature is 36.9 degree Celsius. There is no sign of profuse sweating or even irritated.
The environmental temperature is cold and the humidity is high and the patient is comfortable with it.

XII. Integumentary Status

 Skin color is brownish and has a good skin turgor at 1- 2 sec/s. There are no wounds noted or reported by
the patient. The dressing is dry and intact and sometimes felt pain. Nails and hair are well kept by the patient. There
are no odorous secretions or oily secretions.

XIII. Comfort and Rest Status

The patient claims that normally she sleeps 7-8 hours in a day. Her sleep was now only 6-7 hours during
hospitalization. She claims that she is very comfortable with her sleep even if she is in the ward but sometimes being
disturbed when nurses have to get her vital signs or give medications.
 CHAPTER IV
ANATOMY AND PHYSIOLOGY OF THE SYSTEM INVOVLED:
FEMALE REPRODUCTIVE SYSTEM

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 arecomparable 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 2inches wide. They lie just
inside the labia majora, and surround the openings to the vagina (thecanal that joins the lower part of the uterus to
the outside of the body) and urethra (the tube thatcarries 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.

Clitoris:
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.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.

Mammary Glands
Mammary glands, which are part of the breasts, are very high modified sudoriferous (sweat) glands, which
appear in mostly all vertebrates, but are developed in their own ways. The glands are also somewhat different from
species to different animals. Each mammal may secrete milk in different ways. When they produce it’ll of these
organs are major and critical parts of the female reproductive system. They are housed internally within the body.
These organs work together to help the ovaries release the egg follicle which is then either implanted in the uterus or
is sloughed out. Humans are the only mammal to have enlarged breasts when they are not lactating. This is due to
the large content of fat (adipose tissue) contained in a breast surrounding the mammary gland.
 CHAPTER V

PATHOPHYSIOLOGY

HOST AGENT
ENVIRONMENT

Female
23 years old

Fertilization Therapeutic Environment

(Union of sperm and ovum)

Zygote-Unicellular
Intermingling of haploid paternal 23 X or Y and maternal X chromosomes

Series of Mitotic Cell Division-Cleavage

(In 24 hours become two cell organism)

In 72 hours become 15 cell called Morula

Morula enters the uterus on the 3rd day through peristaltic movement

Separate into two parts by fluid from the uterus on the 4th day

The outer layer gave rise to the placenta The inner layer gave rise to the embryo
(trophoblast) (embryoblast)

blastocytes attaches to endometrium on the 6th day

implantation

Embryonic development begins during second week continues through

The eight week

Fetal Development from ninth week to birth

Newborn baby via Vaginal Delivery

3 stages
 1st stage- increase in cell number and with elaboration
Cell products
 2nd stage-morphogenesis/includes mass cell movement
 3rd stage-differentation or maturation of physiologic processes

Fertilization happens when the sperm and egg unite in one of your fallopian tubes to form a one-celled
entity called a zygote. If more than one egg is released and fertilized, you may have multiple zygotes. The
zygote has 46 chromosomes— 23 from you and 23 from your partner. These chromosomes will help
determine your baby's sex, traits such as eye and hair color, and, to some extent, personality and
intelligence. Soon after fertilization, the zygote travels down the fallopian tube toward the uterus. At the
same time, it will begin dividing rapidly to form a cluster of cells resembling a tiny raspberry. The inner
group of cells will become the embryo. The outer group of cells will become the membranes that nourish
and protect it. Implantation by the time it reaches the uterus, the rapidly dividing ball of cells — now
known as a blastocyst— has separated into two sections. The inner group of cells will become the embryo.
The outer group of cells will become the membranes that nourish and protect it. On contact, it will burrow
into the uterine wall for nourishment. This process is called implantation. The placenta, which will nourish
your baby throughout the pregnancy, also begins to form. The embryonic period begins. The fifth week of
pregnancy, or the third week after conception, marks the beginning of the embryonic period. This is when
the baby's brain, spinal cord, heart and other organs begin to form. The embryo is now made of three layers.
The top layer— the ectoderm — will give rise to your baby's outermost layer of skin, central and peripheral
nervous systems, eyes, inner ear, and many connective tissues. The cells of the embryo now multiply and
begin to take on specific functions. This process is called differentiation. It leads to the various cell types
that make up a human being (such as blood cells, kidney cells, and nerve cells).There is rapid growth, and
the baby's main external features begin to take form. It is during this critical period (most of the first
trimester) that the growing baby is most susceptible to damage. The following can interfere with the baby's
development:

 Alcohol, certain prescription and recreational drugs, and other substances that cause birth
defects
  Infection (such as rubella or cytomegalovirus)

 Nutritional deficiencies

Monitor X-rays or radiation therapy week by week changes. The period of time between conception and
birth during which the fetus grows and develops inside the mother's womb is called gestation. In humans,
the length of pregnancy, or gestational age, is the time measured from the first day of the woman's last
menstrual cycle to the current date. It is measured in weeks. Gestational age may also be called menstrual
age. Fetal development is from ninth week to birth. Pain during labor is caused by contractions of the
muscles of the uterus and by pressure on the cervix. This pain may be felt as strong cramping in the
abdomen, groin, and back, as well as an achy feeling. Some women experience pain in their sides or thighs
as well. Other causes of pain during labor include pressure on the bladder and bowels by the baby's head
and the stretching of the birth canal and vagina.
 CHAPTER VI
Laboratory and Diagnostics

RESULT FORM
TEST ACTUAL NORMAL INTERPRETATIO NURSING
VALUES VALUES N RESPONSIBILITIES
COMPLETE BLOOD COUNT
DATE: O2/18/2018 1. Explain test procedure.
Hemoglobin 120 120-160 g/L NORMAL Explain that slight discomfort
Hematocrit 0.37 0.37-0.47L/L NORMAL may be felt when the skin is
WBC Count 12.08 5.0-10.0 Indication of punctured.
infection 2. Encourage to avoid stress if
Differential Count possible because altered
Neutrophils 71 50-70% Indication of
infection
Lymphocytes 18 20-40% NORMAL
Monocytes 10 0-10% NORMAL
Eosinophil 1 0-7% NORMAL
Basophils 0 0-1% NORMAL
Total 100
RBC Count 4.44 4.04-5.48 10 NORMAL
^12/L
Platelet Count 326 150-400 10^9/L NORMAL
MCH 27 27-31 pg NORMAL
MCHC 325 310-360 g/L NORMAL
RDW-CV 13.20 11-16% NORMAL
RDW-SD 39.40 35-56 fL NORMAL
URINALYSIS
Color Light yellow Amber NORMAL 1. Instruct the patient to void
Appearance Turbid Clear Cloudy or milky directly into a clean, dry
urine is a sign of a container.
urinary tract 2. Cover all specimens tightly,
infection label properly and send
pH 7 4.6-8 NORMAL immediately to the laboratory.
Specific Gravity 1.015 1.002-1.030 NORMAL 3. Observe standard
Glucose Negative Negative NORMAL precautions when handling
Protein Negative Negative NORMAL urine specimens.
 CHAPTER VII

MEDICAL AND NURSING MANAGEMENT

A. NURSING

LIST OF IDENTIFIED PROBLEM:

1. Acute pain related to surgical incision.
2. Ineffective breastfeeding
3. Risk for infection related to traumatized skin
tissue secondary to episiotomy

PRIORITIZATION WITH JUSTIFICATION:

DATE SUBJECT NURSING INTERVENTION JUSTIFICATION

IDENTIFIED CUES DIAGNOSIS
February 19, 2018 “Masakit Acute pain According to Maslow of hierarchy of
yung sugat related to needs physiological needs must prioritize
ko sa surgical first. Acute pain is a physical health
pwerta” incision. problem thus belongs to physiological
stage. Absence of pain may indicate that
the client’s health status is getting better.
February 19, 2018 Nakapag- Ineffective Provided health Breastfeeding is considered the safest,
breastfeed breastfeeding teachings about simplest, and least expensive way to
na ako related to breastfeeding like the provide complete neonate nourishment.
pero di ko knowledge proper positioning of It’s both an advantage for the baby and
pa alam deficit the baby. Advised to the mother. For them mother it helps in
kung breastfeed every 2-3 the uterine contraction, protection from
paano hours, 8-10 times breast cancer, and empowerment. For the
yung daily. Demonstrated baby, it gives passive immunity during
tamang how to get the baby the first months of life, increase brain
paraan.Una into a good development and it is full of nutrients.
ng anak ko attachment making There are some factors that can affect the
pa lang sure baby sucks the breastfeeding process which eventually
kasi ito.” areola, not just the can bring bad effects and unsatisfying
nipple. Instructed feeding process for both the baby and the
client to clean breasts mother.
only with water and
cotton and should not
use soap or lotion.
Supported baby’s
head, neck and back
while breastfeeding.

February 19, 2018 “May tahi Risk for Noted risk factors for Contamination of a wound surface with
ako tapos infection related occurrence of microorganism thus this colonization has
medyo to traumatized infection in the a complete new cells for oxygen and
mainit sa skin tissue incision. Make health nutrition and because their by-products
baba” secondary to teachings especially can interfere with a healthy surface
episiotomy in identification of condition that leads to infection.
environmental risk
factors that could add
up on infection.
Administered
antibiotics as ordered
by the physician.
NURSING CAPE PLAN

ASSESSMEN EXPLANATIO GOAL/OBJECTIV IMPEMENTATIO RATIONAL EVALUATIO

T N OF THE E N E N
PROBLEM
S: “Nakapag- Knowledge STO: Provided health For effective After 8hours of
breastfeed na Deficit After 1-2 hours of teachings about breastfeeding nursing
ako pero di ko nursing breastfeeding like intervention:
pa alam kung intervention, the the proper
paano yung Cannot position client will be able to positioning of the The mother
tamang the baby verbalize/ baby. was able to
paraan.Unang properly demonstrate gain knowledge
anak ko pa understanding of Advised to about the
lang the proper breastfeed every 2- proper way to
kasi ito.” The baby cannot breastfeeding 3 hours, 8-10 times hold her baby,
latch on the daily. breastfeed her
O:Doesn’t nipples of the baby and clean
know how to mother properly Demonstrated how her breasts.
breastfeed to get the baby into
completely, a good attachment
doesn’t know Ineffective LTO: After 2-3 making sure baby
how to position breastfeeding days of nursing sucks the areola,
the baby intervention the not just the nipple.
client will be able to Soap will
breastfeed properly Instructed client to remove the
NURSING without any help clean breasts only natural oils
DIAGNOSIS: from health care with water and that are
Ineffective provider cotton and should present on
breastfeeding not use soap or your breasts
related to lotion. and nipples
knowledge and will
deficit contribute to
drying and
cracking

To be able to
Supported baby’s breastfeed
head, neck and back properly and
while breastfeeding. for the safety
of the baby

ASSESSMENT EXPLANATI GOAL/OBJECTIVE IMPLEMENTATION RATIONALE EVALUATI

ON OF THE ON
PROBLEM
S: -After 8 hours of Noted risk factors for To help the After 8
“May tahi ako Acute wound nursing intervention, occurrence of infection patient hours of
tapos medyo the patient will: in the incision. identify the nursing
mainit sa baba” Microorganis present risk intervention,
ms Short term: Make health teachings factors that the patient
Identify the risk especially in may add up to was able to
0: Inflammation factors that are identification of the infection meet the
present environmental risk goals with
factors that could add To help the an evidence
Infection Have partial up on infection. client of the
understanding about modify/change absence of
infection control Administered /avoid some of the sign sand
antibiotics as ordered the symptoms
NURSING Long term: by the physician. environmental related to
DIAGNOSIS: factors present infection.
Client’s full which could
Risk for knowledge in reduce the
infection related identifying the risk incidence of
to post factors of the infection
Operative infection
incision. Antibiotics
Be free from any will help kill
signs and symptoms and stop the
of related to proliferation
infection. and growth of
the bacteria
which could
 cause
infection.

ASSESSMENT EXPLANATI GOAL/OBJECTIVE IMPLEMENTATION RATIONALE EVALUA

ON OF THE TION
PROBLEM
S:“Masakit -After 8 hours of Assessed pain Assessment of Goal met.
yung sugat ko Surgery nursing intervention, characteristics pain
sa pwerta” the patient will be experience is After 8
Wound able to report pain the first step in hours of
reduced/ controlled. planning pain nursing
Post surgical management interventio
O: Patient seen incision strategies. n, the
lying on bed, Specifically, the patient
conscious, Local patient will able to: Observed and Some people was able
weak eye bags effect:PAIN monitored signs and deny the to report a
noted on both 1.Verbalizes adequate symptoms associated experience of decreased
eyes, with relief of pain or with pain pain when it is pain
grimace face, ability to cope with present. sensation
with imited completely relieved Attention to from pain
movements, pain. associated scale of 6
with a pain signs may help to 3 and
scale of 6/10. 2.Demonstrates use the nurse in displayed
of relaxation skills or evaluating a relaxed
divertional activities pain facial
as indicated for his expression
condition. .
NURSING Assessed patients for Some patients
DIAGNOSIS: 3.Display relax facial the range of pain, relief may be
Acute pain expression and strategies available unaware of the
related to and evaluate patients tension and
episiotomy response to pain irritability.

B. Medical

Drug Action Adverse effect Contraindication Nursing

consideration
Generic name: By direct action on CV: -Hypersensitive to - Continuously
oxytocin myofibrils produces -Hypertension drug when vaginal monitor
Brand name: phasic contractions -Increased heart rate delivery is advised contractions, fetal
Pitocin characteristics of -Systemic venous return -Cephalopelvic and maternal heart
syntocinon normal delivery. - Cardiac output disproportion is rate, and maternal
therapeutic Promotes milk GI: present blood pressure
classification: ejection (let down -Nausea -When delivery -Discontinue
uterine active reflex in nursing -Vomiting requires conversion infusion if uterine
agent mother thereby RESPIRATORY: as in transverse 1 hyperactivity occurs
increasing flow (not -Anoxia -Monitor patient
Dosage: volume) of milk; also -Asphyxia extremely closely
10 units/ml in 1 facilitates flow of OTHERS: during first and
ml ampule milk during period of Low APGAR second stages of
breast engorgement. Score at 5 mins labor because of risk
Route: Uterine sensitivity to of cervical
IV oxytocin increases laceration, uterine
during gestation rupture and maternal
Frequency: period and peaks and fetal hearth
Prn sharply before death
parturition. Not used -Assess fluid intake
for elective induction and output. Watch
of labor. for signs and
symptoms of water
intoxication

Drug Action Adverse Effect Contraindication Nursing

Consideration
Generic Name: Anthranillic acid CNS: Drowsiness, Hypersensitivity to Assess patients who
Mefenamic acid derivative. Like insomnia, dizziness, drug: GI develop severe
Brand Name: ibuprofen inhibits nervousness, inflammation, or diarrhea and
Ponstan, Ponstel prostaglandins confusion, headache. ulceration. Safety in vomiting for
Therapeutic synthesis and affects GI: Severe diarrhea, children, during dehydration and
Classification: platelet function, No ulceration, bleeding, pregnancy or electrolyte
Analgesic evidence that it is nausea, vomiting, lactation is not imbalance.
superior to aspirin. abdominal cramps, established. Lab tests: With long-
flatus, constipation, term therapy obtain
Dosage: 250 mg hepatic toxicity. periodic complete
Frequency: q6h prn HEMATOLOGIC: blood counts, Hct
Route: Oral Prolonged and Hgb, and kidney
prothrombin time, functiontests.
severe autoimmune Discontinue drug
hemolytic anemia, promptly if
leukopenia, diarrheam dark
eosinophilia stools, hematemesis,
ecchymoses,
epistaxis, or rash
occur and do not use
again. Contact
physician.

Drug Action Adverse effects Contraindications Nursing

Consideration
Generic name: It blocks the Constipation Myasthenia gravies, Assess for the eye
Hyoscine-N- muscarinic receptors Decreased sweating Megacolon, pain; discontinue use
butylbromide found on the smooth Mouth, Skin, eye hypersensitivity to Monitor intake and
Brand Name: muscle walls which dryness drug contents, output ratio;
Buscopan means it blocks the Blurred feeling narrow angle retention commonly
Classification: action of acetyl Bloating glaucoma, prostate causes decreased
Antispasmodics choline on the Dysuria hypertrophy with urinary output.
Route: Po receptors found Nausea or vomiting urinary retention, Assess for
Dosage:500mg within the smooth Light headedness mechanical stenosis parkinsonism, extra
Frequency: TID muscle of the Headache in the GI tract, pyramidal symptoms
gastrointestinal and Weakness tachycardia Assess for urinary
urinary tract and hesitancy, retention,
thus reduces the palpate bladder if
spasm and the retention occurs
contractions. This Assess for
relaxes the muscle constipation
and thus reduce the Assess for tolerance
pain from the over long term
cramps and spasms therapy
Assess mental status
 CHAPTER VIII
SUMMARY OF CARE
A. Nursing
1. Acute pain related to surgical incision
 Promotive/Preventive
 Assessed pain characteristics
 Observed and monitored signs and symptoms associated with pain
 Assessed patients for the range of pain, relief and strategies available
 Evaluated patients response to pain
 6/10 pain scale
 Curative
 Administered mefenamic acid, buscopan to relieve pain
 Rehabilitative
 Advised client to move slowly.
 Encouraged adequate rest periods to prevent fatigue.
 Instructed client to change in position.
2. Ineffective breastfeeding related to knowledge deficit
 Promotive/Preventive
 Assessed clients ability to breastfeed
 Rehabilitative
 Provided health teachings about breastfeeding like the proper positioning of the
baby.
 Advised to breastfeed every 2-3 hours, 8-10 times daily.
 Demonstrated how to get the baby into a good attachment making sure baby sucks
the areola, not just the nipple.
 Instructed client to clean breasts only with water and cotton and should not use soap
or lotion.
 Supported baby’s head, neck and back while breastfeeding.

3. Risk for infection related to post-operative incision.

 Promotive/Preventive
 Noted risk factors for occurrence of infection in the incision.
 Curative
 Administered antibiotics as ordered by the physician
 Rehabilitative
 Make health teachings especially in identification of environmental risk factors that
could add up on infection.

EFFECTIVENESS OF CARE RENDERED TO CLIENT

The goals of the following problems are fully met:

 Acute pain related to surgical incision

After 8 hours of nursing intervention the patient was able to report of decreased pain
sensation from pain scale of 6/10 to 2/10 and displayed a relaxed facial expression.
 Ineffective breastfeeding related to knowledge deficit
After 8 of nursing intervention the mother was able to gain knowledge about the
proper way to hold her baby, breastfeed her baby and clean her breasts.
 Risk for infection related to post-operative incision.
After 8 hours of nursing intervention, the patient was able to meet the goals with an
evidence of the absence of the sign and symptoms related to infection.

B. Medical

Patient X was admitted on February 18, 2018. During her delivery at 12:30 am she was given 10 units of oxytocin to
produces phasic contractions characteristics of normal delivery and promotes milk ejection via IM. During 3-11 shift
at 10 and 11pm HNBB was administered via oral to reduce the spasm and the contractions at 12:24 am of February
19, 2018. At 3:10 am amoxicillin 500 mg which was an antibiotic was administered. Amoxicillin is to be given
thrice a day. Mefenamic acid 500mg was ordered by the physician to relieve pain and should be given thrice a day.
Cefuroxime 500mg was given by 7-3 and 3-11 shift.
 CHAPTER IX
RECOMMENDATON
There were problems and weaknesses that were encountered by the researcher during the course of data completion
for the said case study. The researcher only handled the patient for just a day and time coverage in handling and
dealing with the patient was also limited due to the condition of the patient. As a result, the researcher was able to
identify recommendations that would assist the future researchers in doing their future case studies. The researcher
recommends that future researchers should spend more time in assessing and visiting their patient in order to obtain
a more accurate data for future utilization. Researcher also recommends that the future researchers should have
sufficient time in gathering information about their future patient so that they would come up with more appropriate
nursing problems.
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