A

CASE STUDY
ON
NORMAL SPONTANEOUS
DELIVERY
 I. Personal Profile

Name: Ms AS

Age: 22

Status: Single

Birth Date: October 27, 2000

Address: Purok Gueya Domang Dupax Del Sur

Birth Place: Purok Gueya Domang Dupax Del Sur

Religion: Iglesia ni Cristo

Educational Attainment: College level

Room: N/A

Ward: OB Ward

Chief Complaint: Lumbosacral Strain

Admitting Diagnosis: G1 P0 PU 406/7 weeks AOG by second trimester UTZ c/1

Past Health History

Patient A.S said that she has never had a medical history other than a frequent cough and cold,
which she manages with paracetamol and neozep. Occasionally, however, she forgoes
medication in favor of waiting for the symptoms to go away. According to the patient she said
that she had never been hospitalized before. The patient also stated that she has no allergies to
any kinds of foods, drinks or any medication.

Present Health History

Patient .AS stated that her last menstrual period was on January 9,2023 and tested out positive on
the pregnancy test on January 20, 2023. Her first prenatal checkup was on February 3,2023. Her
expected date of delivery is on October 16, 2023. She completed her prenatal check-ups on RHU
Dupax Del Sur and Dupax District Hosital.
On October 22,2023, the patient felt abdominal pain and back pain in the lumbar region. She was
admitted to the hospital in the morning at the LR (labor room) around 8:44 am. The nurse
monitored her womb for FHT (fetal heart tone) and progress of labor for Q1 (every 1hr) and
monitor her Vital Signs for Q4(every 4hrs). The doctor also ordered laboratory request of the
following; Hematology, Urinalysis, Blood Typing, HBsAG, Anti-treponema pallidum (VDRL).

On October 23, 2023 the patient felt an intolerable pain around 6 am in the morning. Her partner
rushed to the nurse station to get an assistance from them. The patient was move to the DR
(delivery room), the patient was 6cm cervical dilatation, while waiting her amniotic sac to broke
we were preparing the equipment to be needed by the nurse and doctor to use. We assisted her
until the baby comes out. After 5hrs of labor she was able to undergone a normal spontaneous
delivery to her firstborn baby boy.

Maternal and Prenatal History

Patient A.S stated that she had her first menstruation when she was 14 years old. It is regular
with 28 days cycle with a duration of 2-4 days each menstruation period. She stated that she
completed her prenatal checkups once a month 4-28 weeks, prenatal checkup for twice a month
during 28-36 weeks, and every week prenatal checkup from 37 weeks until the delivery. She had
her ultrasound at his Obstetrician clinic to confirm the gender and they found out it is a baby
boy. She also stated that she completed 2 tetanus vaccination and her prenatal medications
including Ferrous Sulfate, Vit. C, Folic acid, Iron, malungay capsule and Calcium.

Socio-economic History

Patient AS doesn’t have a work because she is still attending school but drop out due to her
pregnancy. Her boyfriend doesn’t have a work to because he is still attending school and he is a
Criminology student in the King’s College of The Philippines.

She stated that she is still living with her parents and still receiving support for her financial
status along with her boyfriend’s parents. She stated that their monthly expenses are ₱30,000
together with her boyfriend’s parents.

MONTHLY EXPENSES

FINANCIAL PIE GRAPH

 Finacial Pie Graph
10%

5%

15%
50%

20%

Savings Bills/house Foods Cloths Transportation

Environmental History

Patient A.S and her boyfriend stays in the family of the girl with their own room. They live at
Purok Gueya Monthly Percentage Domang Dupax
Del Sur. The Food 4,500 15% patient stated
that she likes to Bill/house 6,000 20% plant flowers in
the back and Transportation 3,000 10% front of their
house, she also Cloths 1,500 5% stated that they
have a little Savings 15,000 50% garden at the
back of their Total: = 30,000 100% house, where
she plants vegetables like
eggplant, tomatoes, okra, and flowers. Furthermore., their drinking water is mineral while they
use tap water for bath and washing clothes and lastly, she said that their garbage is being
segregated and collected 2-3 times a week but sometimes they burn their garbage.

Occupational History

Ms. AS currently stop studying because she is carrying her baby and her parent is working his
dad works at a construction and her mother is working on a salon.
 Lifestyle

According to the patient she learned a lot during her pregnancy, she learned how to become
independent. She said that it wasn’t easy to become a mother because she has to be careful in
every step that she makes and she said that she often sometime doe’s some chores except for
heavy duty because it is very dangerous for the baby’s health. After how many months of being
pregnant she always walks in the morning at 6:00 am to have an excise like doing squats and
walking because she believes that exercising can help her during her labor. She said that her
boyfriend sometime buys her food like Jollibee, Mcdo, Graham and Mangoes. She can perform
full self-care including bathing, grooming and cooking. She said that she has a good appetite and
drinks water from 6-8 glasses daily. She said that she used to drink alcohol but stopped when she
was pregnant.

Recreational History

She likes to spend her free time cleaning the house or doing the chores and sometimes with her
friends and boyfriend, they tend go outside to eat, buy clothes and they like to explore the town.
She also likes to watch Tiktok videos, Netflix and browsing her social media accounts. She also
like to walk around to their neighborhood with his boyfriend.

II. GORDON’S FUNCTIONAL HEALTH PATTERNS

PATTERN BEFORE HOSPITALIZATION

1. HEALTH Ms. AS can manage to take care of herself Wellness is state of well-being. Basic
PERCEPTION & by bathing, grooming and cooking. She aspect of wellness include self-
HEALTH often does some exercise like squatting and responsibility; an ultimate goal;
MANAGEMENT walking, she takes her vitamins and adynamic, growing process; daily
medications religiously. She goes to the decision-making in the areas of
hospital for her prenatal check ups to keep nutrition, stress management, physical
her baby safe and healthy. fitness, preventive healthcare, and
emotional health; and most
importantly, whole being of the
individual.
 Kozier & Erb’s Fundamentals of
nursing. Volume 1 Page 384.
2. NUTRITION Ms. AS drinks 6-8 glasses of water The body’s most basic nutrients is
AND everyday and she completes her 3 meals water. Because every cell requires a
METABOLISM daily. continuously supply of fuel, the most
important nutrition need, after water is
for nutrients that provide fuel, or
energy. The energy-providing nutrients
are carbohydrates, fats and protein.

Kozier & Erb’s Fundamentals of

nursing. Volume 1 Page 1187.
3. ELIMINATION She defecates once a day and urinate at Elimination of the waste products of
about 7-8 each day. digestion from the body is essential to
health. The excreted waste products are
referred to as feces or stool.An
individual’s urinary habits depends on
social culture, personal habits, and
physical abilities.

Kozier & Erb’s Fundamentals of

nursing. Volume 2 Page 1234 and
1271.
4. ACTIVITY & Ms. AS walks around their front house In general, regular exercise is essential
EXERCISE during morning as her exercise and doing for maintaining mental and physical
squats. She sometimes do some chores health.
when she is alone in their house.
Kozier & Erb’s Fundamentals of
nursing. Volume 2 Page 1117.
5. COGNITION & She doesn’t have any problem with her Often, someone other than the nurse
PERCEPTION eyesight. She can communicate properly measures the client’s vital sign. Prior ro
and doesn’t have any difficulties in hearing assigning this task to assistive
personnel, however, the nurse must
have assessed the client and determined
that the client is medically stable or in a
chronic condition and not fragile and
that the vital sign measurement is
considered routine for this client.

Kozier & Erb’s Fundamentals of

nursing. Volume 1 Page 533.
6. SLEEP & REST She usually sleep at 10 pm at night and Sleep is a basic human need; it is a
wake up 7 am in the morning. She often universal biological process common to
sleeps in the afternoon at 2hrs. all individuals. Humans spend about
one-third of their lives asleep.

Kozier & Erb’s Fundamentals of

nursing. Volume 2 Page 1165.
7. SELF- She has an optimistic outlook on becoming Self-concept is one’s mental image of
PERCEPTION a responsible partner and mother in the oneself. A positive self-concept
future. promotes an individuals with a positive
self-concept are better health.

Kozier & Erb’s Fundamentals of

nursing. Volume 2 Page 1012.
8. ROLE & She is very responsible and caring partner Universally, clients equate compassion
RELATIONSHIP she gives her best to be a mother for her with caring. The caring nurse is
child. She has a good relationship to her describe as warm and empathetic,
parents in-laws. compassionate and concerned.
Compassion involves participating in
the client’s experienced, with the
 willingness to share in his or here
experience.

Kozier & Erb’s Fundamentals of

nursing. Volume 1 Page 288.
9. SEXUALITY & She had her first menstruation at the age of Over a lifetime, sexual fantasies and
REPRODUCTION 14 and had a regular cycles since then. She single-partner sex are the most
enjoys her sexual relationship with her common sexual behaviors. Male-to-
partner. They want to have 3 kids in the female or female-to-female oral
near future. genitals sex is known technically as
cunnilingus.

Kozier & Erb’s Fundamentals of

nursing. Volume 2 Page 1032.
10. COPING & She stated the when they found out that she Coping may be describe as dealing
STRESS was pregnant her family didn’t complain with change successfully or
TOLERANCE they even supported her throughout her unsuccessfully. A coping strategy is
pregnancy as well as the family of her natural or learned way of responding to
partner. a changing environment or specific
problem or situation.

Kozier & Erb’s Fundamentals of

nursing. Volume 2 Page 1074
11. VALUES & She was an Iglesia ni Cristo before but she Many variables influence an
BELIEFS was removed because she was having her individuals health status, belief and
baby with a guy who is not the same in behavior or practices. These factors
religion. She stated that she wants to go may or may not be under conscious
back to the church as soon as the baby is control. Individuals can usually control
born as well as with her partner. their health behaviors and can choose
healthy or unhealthy activities. In,
contrast, individuals, have a little or no
 choice over their genetic makeup, age,
sex, culture and sometimes their
geographic environments.

Kozier & Erb’s Fundamentals of

nursing. Volume 1 Page 386.

III. Physical Assessment

Last October 23, 2023 at around 8;00 am, a Head-to-toe Physical examination to the client
C.N.L. was conducted General Assessment. The patient awake and conscious. She is attentive
and cooperative, and has good grooming. The patient’s vital signs are;

BP 120/80

RR 19 bpm

PR 93 bpm

TEMPERATURE 36.1oC

A. Skin, Scalp, Hair and nail

 brown skin is generally uniform in color except in areas exposed to the sun
 skin temperature uniform and within the normal range (37°C)
 when pinched, skin readily springs back to previous state
 moist skin folds
 nails with smooth texture
 nail beds pink
 prompt capillary refill time (2 seconds)
 bipedal non-pitting edema
B. Head, face and neck
 absence of nodules or masses
 symmetric facial features and movements
 symmetric nasolabial folds
 evenly distributed
C. Eyes
 eyebrows symmetrically aligned with equal movement
eyelashes equally distributed and curled slightly outward
 skin of eyelids intact with no discoloration
 lids close symmetrically
 bilateral blinking exhibited
 no discharge, edema or tearing
 white sclera
 pink palpebral conjunctiva
 iris black in color
 pupils equal in size with smooth borders  illuminated pupils constricts
 pupils converge when a near object is moved toward the nose
 when looking straight ahead, the client can see objects in the periphery
 both eyes coordinated, move in unison with parallel alignment
D. Ears
 color same as facial skin
 symmetrically aligned
 pinna immediately recoils after it is folded
 pinna is not tender
 no lesions or discoloration
 dry cerumen, grayish-tan color
 normal voice tones audible
 able to hear ticking of a watch in both ears
E. Nose
 symmetric and straight
  no discharge or flarin
 absence of lesions and tenderness
 nasal septum intact and in the midline
F. Mouth and throat
 outer lips uniform pink color with symmetric contour, soft and moist
 buccal mucosa is of uniform pink color
G. Thorax and Chest
 The client’s chest contour is symmetrically aligned. Chest walls are intact, no tenderness
and no masses noted.
H. Heart
 The patient has a normal heart rhythm when auscultated.
I. Abdomen
 striae present at hypogastric and iliac regions
 linea nigra present
 With tenderness
 light yellow urine

IV. Brief Description

Pregnancy is a state of having implanted products of conception located either in the uterus or
elsewhere in the body. It ends through either spontaneous or elective abortion or delivery. During
this time, the mothers body goes through immense changes involving all organ system to sustain
the growing fetus.

Pregnancy lasts for about 280 days or 40 weeks. A preterm or premature baby is delivered before
37 weeks of pregnancy. Extremely preterm infants are born through 23 weeks. Moderately
preterm infants are born between 29 and 33 weeks.

When women get into labor without the aid of any labor inducing drugs or methods, and is able
to deliver the baby without requiring a doctor’s aid through cesarean section, vacuum extraction,
or with forceps, this is known as a normal spontaneous vaginal delivery [NSVD].

A full-term newborn is one that been delivered between 27 and 42 weeks of gestation. It’s the
easiest way to give birth when compared to other techniques like cesarean section and artificial
 labor. A vaginal delivery occurs when the baby comes out of the mother naturally, without any
medical procedures or surgery involved. This happens following the labor that a pregnant lady
experiences.

V. Physiology [Parturition]

TRUE CONTRACTION

First Stage Second Stage Third Stage

(Latent) 3 P’s Uterus Contract

Early Stage  Power
 Passenger
 Passage
Placenta
Regular
Contraction

Active Phase Few Factors

 Fetal size
 Fetal attitude
 Fetal lie
 Fetal presentation
 Cardinal Movements
 Descent
 Engagement
 Flexion
 Internal Rotation
 Extension
 External Rotation
 Expulsion

VI. Anatomy and physiology

External genitalia

The external genitalia are the accessory structures of the female reproductive system that
are external to the vagina. They are also referred as the vulva or pudendum. The external
genitalia include the followings;

Mons pubis

A rounded mound of fatty tissue that covers the pubic bone. During the puberty, it
becomes covered with hair. The mons pubis contains oil-secreting [sebaceous] glands that
release substances that are involve in sexual attraction[pheromones].

 Source of cushioning during sexual intercourse.

 Protect the junction of pubic bone from trauma

Clitoris

The clitoris is a bulb-shaped sexual organ that’s part of the female reproductive system. It
is also known as the pleasure center of the female reproductive organ. The clitoris is found at the
top of the vulva at the point where the inner labia meet.

 Capable of erection under sexual stimulation.

Labia minora

A paired folds of smooth tissue underlying the labia majora. They range from light pink to
brownish black in color in different individuals. In a sexual stimulated condition, these tissue
covers the vaginal and urethral openings, but upon sexual arousal they become more open.

 Protect the vaginal and urethral openings from mechanical irritation, dryness and
infections.

Labia majora
 Are two thick folds of skin running from the mons pubis to the anus. The word labia
majora also defined as the ‘larger lip’. The anterior part of the labia majora folds comes together
to form the anterior labial commissure directly beneath the mons pubis. While the posterior part
of the labia majora comes together to form the posterior labial commissure. The labia majora
engorges with blood and appears edematous during sexual arousal.

 Enclose and protect the other external genital organs.

 It enclose the pudendal cleft into which the urethra and vagina open.

Urethral opening

The female urethra is embedded within the vaginal wall, and its opening is situated
between the labia. The female urethra is shorter than the male, being only 4cm long it begins at
the bladder neck and opens to the outside just after passing through the urethral sphincter.

 Excretion of urine.
 Transport tube that leads from the bladder to discharge urine outside the body.

Anus

Anus is the external opening of the rectum, located inside the intergluteal cleft and
separated from the genitals by the perineum. Anus is also the end of the digestive tract where
below contents leave the body.

 It is where the feces leave the body.

Internal genitalia

The vagina

The vagina is a muscular, ridged sheath connecting the external genitals to the uterus,
where the embryo grows into a fetus during pregnancy. In the reproductive process, the vaginal
function as a two-street, accepting the penis and sperm during intercourse and roughly nine
months later, serving as the avenue of the birth through which the new baby enters the world.

 It’s the route in which menstrual blood leaves the body during periods.
 It’s the pathway or the birth canal through which a baby leaves a woman’s body during
childbirth.
 Where the penis is inserted during intercourse.

The cervix

Female cervix is a muscular, tunnel-like organ. It’s the lower part of the uterus, and it
connects the uterus to the vagina. Sometimes called ‘neck of the uterus.’
  Allowing fluids to pass between the uterus and vagina.
 Producing cervical mucus during the most fertile phase of the menstrual cycle, which
helps the sperm travel from the vagina to the uterus.
 Opening during labor to allow the baby to pass through the birth canal.
The uterus

Uterus is a pear-shaped organ in the reproductive system of people assigned female at birth
[AFAB]. It’s where a fertilized egg implants during pregnancy and where your baby develops
until birth.

 Pregnancy; female uterus stretches to grow the baby during pregnancy. It also contracts
to help push your baby out of the vagina.
 Fertility; uterus is where a fertilized egg implants during conception and where the baby
grows
 Menstrual cycle; uterine lining is where blood and tissue come from during menstruation.

The fallopian tubes

The fallopian tube or oviducts are two very fine tubes leading from the ovaries of female
into the uterus.

On maturity of an ovum, the follicle and the ovaries wall rapture, allowing the ovum to
escape and enter the fallopian tube. There it travels toward the uterus, pushed along by
movements of cilia on the inner lining of the tubes. This trip takes hours or days. If the ovum is
fertilized while in the fallopian tube, then it normally implants in the endometrium when it
reaches the uterus, which signals the beginning of pregnancy.

The ovaries

The ovaries are the place inside the female body where ova or eggs are produced. The
process by which the ovum is released is called ovulation. The speed of ovulation is periodic and
impacts directly to the length of a menstrual cycle.

After ovulation, the is captured by the oviduct, where it travelled down the oviduct to the
uterus, occasionally being fertilized on its way by an incoming sperm leading to pregnancy and
the eventual birth of a new human being.
 The fallopian tube is often called the oviducts and they have small hairs [cilia] to help the
egg travel.

VII. Laboratory Procedures

URINALYSIS RESULT

Color; Yellow; Pus cell; 3-5/HPF; Cast:

Transparency: Slightly Turbid Red blood cell: 0-2/HPF Crystal:
Reaction: Acidic Epithelial cell: Many Yeast cells:
Glucose: Negative Amorphous Few Pregnancy
Urates: Test:
Protien: Negative Amorphous Others:
Phosphates:
pH: 5.0 Mucus Thread: Rare REMARKS:
Specific 1.020 Bacteria: Moderate
Gravity:
HEMATOLOGY

RESULT NORMAL RESULT NORMAL

VALUES VALUES
WBC 8.17 4.0-10x109/L MCV 93.5 80-100 fL
RBC 4.52 3.8-5.4x1012 MCH 31.8 27.0-34.0 pg
HGB 144 110-160g/L MCHC 340 320-360 g/L
HCT 42,.2 37.0-54.0% RDW 11.9 11.0-16.0%
PLT 190 150-400x109 MPV 10.6 6.5-12.0 fL
DIFF.CT.
%NEU 70.6 50.0-70.0% #NEU 5.77 2.0-
7.0x109/L
%LYM 23.3 20.0-40.0% #LYM 1.9 0.80-
4.00x109/L
%MON 5.4 3.0-12.0% #MON 0.44 0.12-
1.20x109/L
%EOS 0.6 0.5-5.0% #EOS 0.05 0.02-
 0.50x109/L
%BAS 0.1 0.0-1.0% #BAS 0.01 0.00-
0.10x109/L

VIII. Drug Analysis

Drug Generic Brand Route Frequen Mode of Side Adverse Nursing

Classificatio Name Name cy Action Effect Effect Consider
n ation
Antispasmod Hyoscine- Buscopan Intrave Every Used for Dizzines Hypotensio Raise side
ic/ N- nous 1hr abdominal s, n and rails as
anticholinerg butylbrom pain and blurred anaphylaxis precautio
ic ide spasm in vision, ns.
organs tachycar Reorient
contain dia patient as
smooth- needed.
muscle Do not
fiber. It administe
binds to r hnbb if
muscarinic patient is
receptors, has
blocking abnormal
them and muscle
thereby weakness.
rendering
them
inaccessibl
e to Ach.
Antibiotics, Co- Augmentin Oral Twice The Diarrhea Anaphylaxis *Report
Aminope- amoxiclav a day clavulanic Nausea Seizures Haematu-
nicillins Acid stops ria or
beta- bacteria oliguria
lactamase from as high
inhibitors breaking doses can
down be
amoxicillin nephrotox
allowing ic.
the *Observe
antibiotic for
to work anaphia-
better. xis.
*Assess
respirator
y status.

Iron Ferus Ferosol Oral Twice a Elevates Nausea, Gastrointest Observe

supplements sulfate day the serum stomach inal for sign
iron discomf disturbance for
concentrati ort. [erosion of adverse
on, and gastric effect or
then mucosa, toxicity.
converted dark stool] Keep in
to hbg or Hypotensio mind
trapped in n. gastro-
the intestinal
reticuloend upset may
othelial be dose
cells for related.
storage
and
eventual
conversion
 to a usable
form of
iron.
Ascorbic Cenolate Oral Once a Function Heartbu Fatigue and Caution
Acid and day as a co- rn, faintness should be
Vitamin C factor, nausea, exercise
enzyme headach when
compleme e and ascorbic
nt co- stomach acid is
substrate cramps administe
and a or red to a
powerful bloating nursing
antioxidant . woman.
in various *consult a
reactions doctor if
and patient is
metabolic breastfeed
processes. ing.
Oxytocics, Oxytocin Piticon intrama As Causes Tachyca Postpartum Monitor
exogenous scular needed potent and rdia, hemorrhage, fluid
hormones selective nausea, seizure, intake
stimulation and neonatal and
of uterine increase jaundice output
and uterine and infant Monitor
mammary motility brain and
gland damage record
smooth uterine
muscle. contractio
n, HR,
BP,
intrauteri
 ne
pressure,
FHR.
Anthranilic Mefenami Ponstan oral 3x a day Binds the Headach Peripheral Asses for
acid c acid prostaglan e, edema history
derivative din dizzines anaphylacto for
class of synthetase s and id reaction NSADs
NSAIDs receptors insomni to allergies
COX-1 a anaphylactic before
and COX- shock. giving
2, mefenami
inhibiting c acid to
the action the
of patient.
prostaglan Orient the
din patient to
synthetase. not chew
or crush.
Monitor
for
adverse
effect.
Antifibrinoly Tranexami Cyklokapro intrave As Tranexami Nausea Anaphylaxis Assess
tics c acid n nous needed c acid diarrhea or eye for other
competitiv abdomin problem complicat
ely and al pain ions
reversibly and Advice
inhibits the fatigue patient to
activation take
of medicatio
plasminog n exactly
 en via as
binding at directed.
several
distinct
sites,
including
4/5 low
affinity
sites and
one high
affinity
sites.
Nonsteroidal ketorolac Toradol intrave As It works Headach Pallor, Asses
anti- nous needed by e, dry sweating, accurately
inflammatory blocking mouth and record
drugs the and drowsiness. maternal
production diarrhea vital
of signs.
prostaglan Assess
dins, clients
compound history of
that cause allergy to
pain, fever the drug
and to avoid
inflammati complicat
on. ions.
Benzodaizepi Midazola Dormicum intrave As May Decreas Nausea Have
nes m nous needed potentiate ed Vomiting oxygen
the effects respirato Headache and
of GABA, ry rate. Coughing resuscitati
depress the Tendern on
 CNS, and ess at iv equipmen
suppress site t
the spread injection available
od seizure . incase of
activity. Oxygen severe
desatura respirator
tion y
depressio
n.
Monitor
and
record
patient
response
to
medicatio
n and
level of
sedation.

IX. Course in the Ward

Date & Time Physicians Order

10/22/2023  Admit to LR
8:44 am  Secure consent for admission and management
 DAT
 DX: CBC, BT
 HBSAG
VDRL
VA
 TX: IVF: D5 LRS 1L + Oxytocin 10V x 10gtts/min
  HNBB 20MG IV Q1(every 1 hour) x 3 doses
 Proper perineal care
 Proper FHT and progress of labor Q1(every 1 hour)
 MVS Q4(every 4 hours)
 refer

 7pm  IVF rate to 10gtts/min

 IE:6cms  Refer
 St -1, ceph

10/23/23  IVF TF: D5 CRS 1L + Oxytocin 10V x 15gtts/min
6 am  Wait monitoring
 refer

IE: 8CM
11:03 AM  S/P NSD
 Oxytocin 10 V IM Now
 IVF to consume
BP: 120/80  Start co-amoxiclav 625mg/tab 1tab BID
 FeSOy + FA TAB 1tab BID
 Ascorbic acid tab, 1tab DD
 Keep uterus contracted
 WOF for profuse bleeding her vagina
 refer
4:15 PM  Start Mefenamic Acid 500mg/cup. 1cup TID
 refer
4:40 pm  Change IVF to PLRS 1L, FD nov
 IVF FF: PLRS 1L x 2cycles
 Bleeding  Tranexamic Acid 1mg IV now
BP: 90/60  Give Ketorolac 20mg IV now
 Midazolam 5mg IV now
 For evaluation of retired fragments and blood clots
 Refer
10/24/23  MGH
6:30 AM  Home Meds
 Co-amoxiclav 625mg

X. Nursing Care Plan

Assessment Diagnosis Planning Intervention Evaluation

Subjective: Lumbosacral After 8 hours of INDEPENDENT After 8 hours of
‘Biglang sumakit strain related to nursing -Assessed pain, intervention the
ang likod ko’ as acute lower intervention, the character, patient was able to
verbalized by the back pain as patient will be location, severity participate in
patient. manifested by able to and duration. decision making for
childbearing. experience -Monitor vital pain management
Objective: gradual signs every 4 plan and engage in
BP- 130/90 reduction. hours. nonpharmacologic
PR- 93 -Provide/ measures to reduce
T- 36.1 encourage use of discomfort/pain.
comfort
measures, back
leg rubs, and
sacral pressure.
DEPENDENT
-Administer
medications
particularly
analgesic as
 prescribed by the
doctor.

Assessment Diagnosis Planning Intervention Evaluation

Subjective; Acute pain After 4hrs of Encourage the After 8hrs of
‘sumasakit paren related to intervention uses of relaxation intervention patient
yung sugat lalo na episiotomy patient will techniques for will report reduced
pag gumagalaw- repair as experience pain reduction. discomfort and can
galaw ako’ as evidence by pain within demonstrate
verbalized by the positioning to tolerate pain. -encourage early appropriate comfort
patient. ease pain ambulation as measure to help
-patient will no tolerated. alleviate pain.
Objective; longer
-facial grimace demonstrate -encourage the
-discomfort grimace upon patient to eat
movement. high-fiber foods.

XI. Discharge Planning

Date of discharge: October 24, 2023
Time of discharge: 3:06 pm
Medication ;
* Co-amoxiclav
* Feso4 + FA
* Ascorbic acid
* Mefenamic acid
Environment/Exercise:
* Instruct client to balance activities with adequate rest periods.
* Educate diet on proper body mechanics to prevent muscle strain and enable client to relax.
* Encourage client to ambulate and assume normal
* Encourage deep breathing exercise
Treatment
* Discussing the purpose of treatments to be done and continued at home and continue
monitoring blood pressure.
* Tell patient to continue submitting self to diagnostic examination to make sure that she is not
having any complications.
* Tell patient to follow advice of physician or any other health care provider
*Tell the patient not to use hot water when cleaning episiotomy
Health Teaching
Breastfeeding
* Wash breast daily at bath or shower time
* Wear supportive bra
* Wash hands before and after every breastfeeding
Family Planning (Contraception choices immediately after birth)
* A contraceptive implant
* Male condoms
* The progesterone-only pill