OB CASE STUDY GRAND PRESENTATION

PATIENTS PROFILE:Mrs. Rowena Salas

• Age: 30 years of age• Address: Cala-cala,

Macasandig CDO• Last Menstrual Period: December 22, 2008• Height: 4’9’’ ft• Weight: 53 kg.• Civil Status: Married• Educational Attainment: High School Level• Religion: Roman Catholic• Citizenship: Filipino• Occupation: Housewife• Expected Date of Confinement: September 29, 2009• Name of Husband: Marcelo Salas Sr.• Occupation: Laborer• Number of Children: Three (3)

Fourth Pregnancy:• LMP: December 22, 2008• EDC: September 29, 2009• Number of fetus: One (1)• Presentation: Cephalic• FHB: 128 beat per minute• Prenatal Visits: Monthly at their clinic at

Tibasak, Macasandig CDO• Medication: Ferrous Sulfate• Date of Delivery: September 16, 2009• Manner of Delivery: Normal Spontaneous Vaginal

Delivery• Delivery History: G4P4T3P0A0L3• Tetanus Toxoid 1, 2,& 3: During the previous pregnancies• Tetanus Toxoid 4: 2009• Tetanus Toxoid 5: September 16, 2010

ASSESSMENT:First visit (July 24, 2009) Second visit (August 3, 2009)

• Age of Gestation: 33 weeks Age of Gestation: 36 weeks

• FHT: no chance to conduct yet FHT: 145bpm (LLQ)• Respiration: 17cpm Respiration: 20 cpm• Pulse Rate: 108 bpm Pulse Rate: 99 bpm• Temperature: 36.4*c Temperature: 36.9*c• Blood pressure: 100/60mmHg Blood Pressure:

90/60mmHg

Third Visit (September 7, 2009) Fourth visit (September 27,2009)• Age of Gestation: 38 weeks Respiration: 18 cpm• FHT: 130bpm (left lower quadrant) Pulse Rate: 90 bpm• Respiration: 23 cpm Temperature: 36.8 C• Pulse Rate: 95 bpm Blood Pressure: 100/70 mmHg• Temperature: 36.6 C• Blood Pressure: 100/80 mmHg

Baby Marcelo

• Respiration: 48 cpm

• Pulse Rate: 125 bpm

• Temperature: 36. 9 C

• Blood Pressure: N/A

Vaccine 1st Dose 2nd Dose 3rd Dose

BCG 9-16-09 --- ---

DPT --- --- ---

OPV --- --- ---

Hepatitis B --- --- ---

HEALTH HISTORYMrs. Rowena Salas had never gone any

surgery during her pregnancy. She hasn’t experienced abortion or death of the infant during delivery, and she hasn’t attempted to abort the child.

She has not received any blood transfusion. She experienced constipation during her second pregnancy, her 4th months of pregnancy and she haven’t take any medicines during that time, but she has able to manage constipation by eating fruits that would facilitate easy and normal bowel movement. She is neither drinking alcohol nor smoking. She eats any kind of foods, especially nutritional foods, foods that is known to have rich in iron such as “kalamunggay” which is very readily accessible around the community.

This is good and recommended for her knowing that she has low blood pressure and red blood cell count during her past pregnancies and also now. She is also not allergic to any kinds of drug.

Our patient claims that they have no common diseases within their family, or the so called the heridofamilial disease. So we asked the most common disease that the family has acquired. As claimed, the most common disease in their family was Tuberculosis.

During her first trimester of pregnancy she had experienced nausea and vomiting.

PHYSIOLOGY OF LABORMechanism of labor

• Descent – Is the downward movement of the biparietal diameter of the fetal head to within the pelvic inlet. Full descent occurs when the fetal head extrudes beyond the dilated cervix and touches the posterior vaginal floor.

• Engagement – The settling of the presenting part of a fetus far enough into the pelvis to be at the level of the ischial spines, a midpoint of the pelvis

 

• Flexion – As descent occurs and the fetal head reaches the pelvic floor, the head bends forward onto the chest making the smallest anteroposterior diameter, (the suboccipitobregmatic diameter) the one presented to the birth canal.

• 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 relationship to the outlet of the pelvis. This movement brings the shoulders, coming next, into the optimal position to enter the inlet, putting the widest diameter of the shoulders in line with the wide transverse diameter of the inlet.

• 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 extends and the foremost parts of the head, and the face and chin, are born.

• External Rotation – In external rotation, almost immediately after the head of the infant is born, the head rotates back to the diagonal back to the diagonal or transverse position of the early part of labor. This brings the after coming shoulders into an anteroposterior position, which is best for entering the outlet. The anterior shoulder is born first, assisted perhaps by downward flexion of the infant’s head.

• Expulsion – One of the shoulders are born, the rest of the baby is born easily and smoothly because of its smaller size. This is the end of the pelvic division of labor.

Theories of the stages of Labor

A. Hormonal factors

• Estrogen theory

• Progesterone withdrawal theory

• Prostaglandins theory

• Oxytocin theory

• Fetal cortisol theory

B. Mechanical factors

• Uterine distension theory

• Uterine Stretch Theory

• Theory of Aging Placenta

• STAGES OF LABOR

The First Stage:

»Latent Phase»Active Phase»Transition Phase

The Second Stage:

» Fetal Expulsion

The Third Stage:

» Placental separation

The Fourth stage:

» Recovery

SIGNS OF LABORPRELIMINARY SIGNS OF LABOR

»LIGHTENING

»Increase in Level of Activity

»Braxton Hicks Contractions

»Ripening of the Cervix

SIGNS OF TRUE LABOR

UTERINE CONTRACTIONS• The surest sign that labor has begun is productive uterine

contractions. Because contractions are involuntary and come without warning, their intensity can be frightening in early labor. Helping a woman appreciate that she can predict her pattern and therefore can control the degree of discomfort she feels by using breathing exercises offer her a sense of control.

SHOW• As the cervix softens and ripens, the mucus plug that filled

the cervical canal during pregnancy (operculum) is expelled. The exposed cervical capillaries seep blood as a result of pressure exerted by the fetus. The blood, mixed with mucus, takes on a pink tinge and is referred to as “show”. Women need to be aware of this event so that they do not think they are bleeding abnormally.

RUPTURE OF THE MEMBRANES• Labor may begin with rupture of the membranes,

experienced either as a sudden gush or as scanty, slow seeping of clear fluid from the vagina. Some women may worry if their labor begins with rupture of the membranes, because they have heard that labor will then be “dry” and that this will cause to be difficult and long. Actually, amniotic fluid continues to be produced until delivery of the membranes after the birth of a fetus, so no labor is very”dry”. Early rupture of the membranes c an be advantageous if it causes a fetal head to settle snugly into the pelvis; this can actually shorten labor.

DIFFERENTATION BETWEEN TRUE AND FALSE LABOR CONTRACTION

FALSE CONTRACTION TRUE CONTRACTIONBegin and remain irregular. Begin irregularly but become

regular and predictable.

Felt first abdominally and remain Felt first in lower back and sweep confined to the abdomen and groin. around to the abdomen in a wave.

Often disappear with ambulation Continue no matter what the and sleep. woman’s level of activity.

Do not increase in duration, frequency Increase in duration, frequency,or intensity. and intensity.

COMPONENTS OF LABOR

A. Passage

B. Power of Labora. Uterine Contraction

b.Cervical Changes» Effacement» Dilatation

c. Psyche

d. Passenger»Structure of the fetal Skull»Diameters of the fetal skull

FETAL PRESSENTATION AND POSITIONTwo other factors play a part in whether a fetus is

lined up in the best position to be born; fetal presentation and position.

»Attitude»Engagement»Fetal station»Fetal lie

TYPES OF FETAL PRESENTATION

Fetal presentation denotes the body part that will first contact the cervix or be born first. This is determined by a combination of fetal lie and the degree of fetal flexion.

Cephalic (head-first) presentation:

Cephalic presentation is considered normal and occurs in about 97% of deliveries.

Breech presentation

Shoulder presentation

TYPES OF FETAL POSITION

Type of Fetal PresentationPosition is the relationship of the presenting part to a

specific quadrant of a woman’s pelvis. For convenience, the maternal pelvis is divided into four quadrants according to mother’s right and left: (1) right anterior, (2) left anterior, (3) right posterior, and (4) left posterior. Four parts of a fetus have been chosen as landmarks to describe the relationship of the presenting part to one of the pelvic quadrants. In a vertex presentation, the occiput is the chosen point; in a face presentation, it is the chin (mentum), in a breech presentation, it is the sacrum; in a shoulder presentation, it is the scapula or the Acromion process. Position is indicated by an abbreviation of three letters. The middle letter denotes the fetal landmark (O for occiput, M for mentum, Sa for sacrum, and A for Acromion process). The first letter defines whether the landmark is pointing to the mother’s right (R) or left (L). The last letter defines whether the landmark points anteriorly (A), posteriorly (P), or transversely (T).

IDEAL NURSING INTERVENTIONA. Antepartum1.)Fatigue• Nursing Diagnosis: fatigue related to physiologic

demands of pregnancy and labor• Note clients belief about what is causing the fatigue

and what relieves it to give a sense of respect. • Advice client to increase amount of rest and sleep

to relieve fatigue• Instruct methods to conserve like sitting instead of

standing to conserve energy.• Advice client to sleep in side lying position to allow

good circulation in lower extremities.• Provide environment conducive to relief of fatigue

since high temperature are known to affect exhaustion.

2.)Breast Tenderness• Nursing Diagnosis: disturbed body image related to breast tenderness

secondary to pregnancy.• Advice patient to dress warmly to avoid cold drafts.• Encourage patient to wear a bra with a wide shoulder strap for

support.• Sleeping Pattern• Nursing Diagnosis: Altered sleep pattern disturbance due to change

body image related to pregnancy• Create quite environment conducive to sleep; for example, close

curtains, adjust lighting, and close doors. These measures promote rest and sleep.

• Ask patient to describe and specific terms each morning the quality of sleep during the previous night. These help detect sleep related behavioral symptoms.

• Educate patient in such relaxation techniques as guided imagery. Purposeful relaxation effort usually help promotes sleep

• Administer medication that promotes normal sleep patterns as ordered. Hypnotic agent induced sleep; tranquillizers reduces anxiety

• Allow patient to discuss any concern that maybe preventing sleep. Active listening help you to determine causes of difficulty with sleep

B. Intrapartum1.)Fear• Nursing Diagnosis: Fear related to stressful situation secondary to labor

and delivery.•

– Sense of abandonment can exacerbate fear.– Encourage and assist client to develop exercise program.– Explain procedures within level of clients ability– Provide a healthy outlet for energy generated by feeling and promotes

relaxation.– Stay with the client of make arrangements to have someone else be there.

2.)Powerlessness• Nursing diagnosis: powerlessness related to change in labor pattern and

increase in contraction in pregnancy.• Reassure as appropriate, the labor is proceeding without problems.• Slowly and clearly explain the events and changes occurring with the

active stage of labor. Inform the couple of things that can and cannot be controlled.

• Emphasize positive aspects of situation and what can be controlled.• Assess couple for contributing factors related to feeling of control.

3.)Risk of Infection• Nursing diagnosis: risk for infection related to

rupture of amniotic membrane.• Maintain sterile technique for invasive

procedures.• Monitor visitors/caregivers to prevent exposure

of client.• Maintain adequate hydration.• Stress proper hand washing techniques by all

caregivers between therapies/clients. It is a first line of defense against nasocomial infections or cross contamination.

• Stand or sit to void and catheterize if necessary to avoid bladder distention.

C. Postpartum1.)Sleep Pattern• Nursing Diagnosis: Disturbed sleep pattern related to exhaustion from

and excitement of birth• Ask patient what environmental factors make sleep difficult. Sleeping and

strange or new environment tends to influence both REM and non-REM sleep

• Ask patient what changes would promote sleep. This allows patient to take an active role in treatment.

• Make whatever immediate changes are possible to accommodate patient; for example, reduce noise, change lighting, and close door. These measure promote rest and sleep.

• Plan medication administration schedule to allow for maximum rest. If patient requires diuretics in the evening, give far enough in advance. To allow peak effect before bedtime.

• Instruct patient to eliminate caffeine from diet, limit alcohol intake, and avoid foods that interfere with sleep (for example, spicy foods). Foods and beverages containing caffeine consumed fewer than 4 hours before bedtime may interfere with sleep.

D. Newborn Care1. Ineffective thermoregulation• Nursing Diagnosis: Risk for ineffective thermoregulation

related to newborn’s transition to extra uterine environment.• Gently rub a newborn dry to allow little body heat lost by

evaporation.• Swaddle the newborn loosely with a blanket to prevent

compromising respiration.• encourage the patient to place the child on the parent’s arms

to conserve heat and encourages bonding • perform extensive procedures, such as resuscitation, under

the radiant heat source to reduce heat loss• encourage the mother to start breast-feeding immediately

after birth to reduce heat loss

2. Injury• Nursing Diagnosis: Risk for injury related to

newly clamped umbilical cord.• perform cord care properly to prevent

infection• put the permanent cord clamp to the infant

cord to prevent further complications such as infection

• inspect the cord to be certain it is securely clamped to prevent hemorrhage

• encourage the parents to continue providing cord care to keep the cord dry until it falls off after they return home

2.)Fear

• Nursing Diagnosis: Fear related to uncertainty of pregnancy outcome.

• Encourage patient to identify of fear. Patient’s perceptions maybe erroneously based.

• Explain all treatments and procedures, answering any questions patient might have. Present information at patient’s level of understanding or acceptance to reduce patient’s anxiety and enhance cooperation.

• Orient patients to surroundings. This enhances patient’s ability to orient to time, place, person and events.

• Assign the same nurse to care for patient whenever possible. Provide consistency of care, enhance trust, and reduce threat commonly associated with multiple caregivers

• Spend time with patient each shift to allow time for expression of feelings. Provide emotional outlet, and promote feeling of acceptance.

Discomfort Solution

Ankle Edema Rest with your feet elevated, avoid standing too long, avoid restricted garments in the lower half of your body.

Backache Apply local heat, avoid long period of standing, Stoop to pick up object.

Constipation Increase fiber in your diet. Drink additional fluids, Have a regular time for bowel movement.

Difficulty in Sleeping

Drink warm water, caffeine free drink before bed, practice relaxation technique.

Fatigue Schedule rest daily, Have a regular bedtime routine, have extra pillow for comfort.

Faintness Move slowly, avoid crowds, lie on your left side when at rest.

Leg Cramps Avoid pointing your toes, straighten your legs and dorsiflex your ankle.

Nausea Eat a piece of dry toast or some crackers before getting to bed. Eat six small meals rather than 3

Shortness of Breath Use proper posture, use pillow behind head, shoulder at night.

Urinary Frequency

Void as necessary at least every 2 hrs., Increase Fluid intake, avoid caffeine, practice Kegel’s exercise.

Varicose Veins Walk regularly, rest with feet elevated, avoid long period of standing, Avoid knee-high stockings

Heart Burn Eat small frequent meals, avoid over eating as well as spicy, fatty, and fried food

ACTUAL NURSING INTERVENTION

• Antepartum• Reducing Anxiety and Providing Knowledge in

Preparation for Labor, Delivery, and Parenthood:• Encourage the women and couple to discuss

their knowledge, perception, and expectations of the labor and delivery process.

• Provide information on childbirth education classes and encourage participation.

• Discuss coping and pain control techniques for labor and birth

• Encourage the women and couple to discuss their perception and expectations of parenthood and their “ idealized child ”

• Discuss physical preparations for infant, such as a sleeping space, clothing, feeding, changing and bathing equipments.

• Encourage discussion of feelings and concerns regarding the new role of mother and father

• Teaching the women and couple that there are no contraindications to sexual activity provided the woman’s membranes are intact, there is no vaginal bleeding, and she has no current problems or history of premature labor

• Promoting Exercise and Mobility:• Explain that exercise during pregnancy should in keeping

with the woman’s pregnancy pattern and type of exercise.• Identify activities or sports that have a risk of bodily harm.• Explain the endurance of during exercise may be

decreased.• Recommended exercise classes for pregnant woman that

concentrate and toning and stretching to enhance physical condition, increase self-esteem, and provide socialization.

• Avoiding Constipation• Instruct the woman to increase her fluid intake to at least 8

glasses of water a day; 1-2 liter of fluid per day is desirable.• Teach in food high in fiber.• Encourage regular patterns of elimination.• Encourage daily exercise such as walking.• Discourage the use of over -the-counter laxatives; bulk

forming agents that may prescribe if indicated.

• Minimizing Fatigue• Advised 8 hours rest at night.• Advised the woman that, in the later months of pregnancy, sleeping on the side under the pillow may enhance comfort.• Encourage frequent 15-30 min. rest period during the to

• avoid over fatigue. • Suggest the woman work while sitting with legs elevated whenever possible.• Discourage standing prolonged periods, especially during third trimester.• To promote placental perfusion, discourage the woman from lying on the back-the left lateral position provides the best placental perfusion.

Intrapartum – Strengthening Coping

• Providing comfort measure measures, which may include back and leg rubs; a cool cloth to face, neck, abdomen, or back; ice chips to moisten mouth; clean pads and linens as needed; and quite environment; and repositioning- either side preferable –with the pillow and blanket.

• Encourage the women to deal with one contraction at a time and to alter her breathing techniques to maintain control. Provide reassurance method encouragement during each contraction.

• Encourage resting between contraction.• Postpartum

-Reducing Fatigue • Provide a quite and minimally disturbing environment.• Organizing nursing care to keep interruption to a minimum.• Encourage the women to minimize visitors and phone calls.• Encourage the women to sleep while the baby is sleeping.•

Promoting Breast-feeding • Have the mother wash her hands before feeding to help prevent

infection.• Encourage the mother to assume a comfortable position, such as sitting

upright, tailor sitting, or lying on her sides.• Have the women hold the baby so he or she is facing the mother “cradle

hold,” with the baby’s head and body are supported against mother’s arm with buttocks resting in her hand; the “football hold” supports the baby’s legs under the mother’s arm while his or head is at the breast resting in her standing; lying on the side with the baby lying on his or her side facing the mother.

• Have the women place her nipple against the baby’s mouth, and, when the mouth opens, guide the nipple and the areola into mouth.

• Encourage the women to alternate the breast she begins feeding with at each feeding to ensure emptying of both breast and stimulation for maintaining milk supply.

• Teach the mother to provide for adequate rest and to avoid tension, fatigue and a stressful environment, which can inhibit the letdown reflex and make breast milk less available at feeding.

• Advise the women to avoid taking medications and drugs because many substance pass into the breast milk and may affect milk production or the infant

Promoting Health Maintenance• Teach the woman to carry out perineal care.• Teach the woman to apply perineal pads by touching the outside

only.• Inform the woman that intercourse may be resumed when

perineal and uterine wounds have healed.• Counsel the woman to provide quiet times for herself at home and

help her establish realistic goals for resuming her own interests and activities.

• Teaching the Postpartum Exercise• Instruct the woman in exercises for the immediate postpartum

period (can be performed in bed)• Toe stretch (tightens calf muscles): while lying on back, keep legs

straight and point toes away from body, and then pull legs toward body and point toes toward chest. Repeat 10 times.

• Pelvic floor exercise (tightens perineal muscles): contract buttocks, press thighs together for a count of 7, and relax. Contract buttocks, press thighs together, and draw in anus for a count of 10 and relax.

• Bicycle (tightens thighs, stomach, and waist): lie on back on the floor, arms at sides, palms down. Begin rotating legs as if riding a bicycle, bringing the knees all the way in toward the chest and stretching the legs out as long and straight as possible. Breathe deeply and evenly. Do the exercises at a moderate speed and do not tire your self.

• Buttocks exercise (tightens buttocks): lie on abdomen and keep legs straight. Raise left leg in the air, and then repeat with right leg to feel the contraction in buttocks. Keep hips on the floor. Repeat 10 times.

• Twist (tightens waist): stand with legs wide apart. Hold arms at sides, shoulder level, palms down. Twist body from side to front and back again to feel the twist in waist.

Newborn Care Bathing the Neonate • Make sure bath water is 98 degree to 100 degree Fahrenheit (37

degree to 38 degree Celsius), and use neutral soap or plain water (if skin is dry).

• Use cotton balls or soft disposable wash cloths to wipe eyes (from inside corner outward), face, and outer ears.

• Wash head using circular motions, tilt head back to expose skin folds to cleanse neck.

• Bathe torso and extremities quickly to prevent unnecessary exposure and chilling.

• Clean genital area of male. Retract foreskin gently to clean underneath, and replace quickly to prevent edema.

• Clean genital area of female. Gently separate folds of the labia and remove secretions. Wipe vaginal area with cotton balls, using one stroke from front to back.

• Bathe buttocks using a gentle, patting motion. Keep anal area clean and dry to prevent diaper rash. If rash does occur, apply protective ointment, such as zinc oxide or A&D, or expose buttocks to air or heat lamp.

Providing Umbilical Care• Inspect the umbilical cord stump for bleeding

or foul odor, which may indicate infection.• Apply a drying agent such as 70% alcohol or

merthiolate to cord stump where it exits abdominal wall, using gauze or cotton swabs, 3 to 4 x a day.

• Leave open to air; do not cover with diaper or use a dressing.

• Teach care to family, and tell them to expect stump to dry up and fall off within 7 to 10 days.

• First VisitIt was July 29, 2009, when we did our first

visit. First we did, we approach her regarding to our intention of visiting her and get her approval. After getting patient’s approval, we interviewed about the patients profile and any discomfort she had been experienced. Then we tackled about the importance of nutrition related to pregnancy such by explaining the benefit you could get by following the food pyramid, we emphasized the food which is high in iron because we have observed that our patient has a low blood pressure, in addition, we brought some fruits and vegetables that are rich in vitamins and minerals such as green leafy vegetables that are highly acceptable to improve heath status.

• We also did help teaching about the importance of immunization specifically the tetanus toxoid which may help in avoiding complications during pregnancy. We did ask some any complaint about her condition, and she told us that she has constipated. She said that “galisud kug kalibang ning niaging adlaw pa”. Second is she complaining about her urination that she told us that “sige kug ihi ihi”.. Prior to the patient complaint we did some health teaching that this discomfort is normally to occur during pregnancy. Then we ask for the frequency of urination and voiding to confirm for there is any abnormalities. After gaining the important cues, we did some nursing intervention that would help the patient regarding on her problem. We did intervention that where based on the availability of source, competency, and time factor. Because our group agreed that nursing intervention will be more just likely effective if we meet these factors.

• Second VisitDuring the second visit, last August 3,

2009, we were able to assess and observe about the discomfort experienced by our patient. We did some physical assessment and taking of vital signs in order to determine patients subsequent condition if she has abnormalities that she can hardly to determine. Then we asked if our nursing intervention is effective in improving on her condition. We questioned her also that if she had new discomfort that she can already determine or recognized. She told us that she had problem regarding on lower back pain, she said that “sakit ang akoang likod “and we observed also non-pitting edema is present. Regarding on complains we did some health teachings that could help patients discomfort

• Health teaching imparted was antepartal exercise, major discomfort during pregnancy. We also had performed the Leopold’s maneuver, we found out that the baby is in cephalic presentation, the fetal heart rate heard at left lower quadrant with estimated age of gestation of 36 weeks. By that information that we obtain, we securely said to the mother that her baby is in good condition by means of this factor.

• Third VisitSeptember 7, 2009 Monday, we had our third visit

on our clients’ house, we perform urinalysis. This is to know if there are abnormalities on our patients’ urine. As far as we’ve noticed the results are all negative, and we are all glad for the result. Since we have the same problems during our second and third visit, we monitored the patients’ status and there is a continuity of care and nursing interventions regarding the noted problems specifically the non-pitting edema of the lower extremities and back ache. After that we have imparted health teachings to our client. These are the following; encourage ambulation, this is to stretch properly the clients muscle specifically the vaginal muscles and also this is helpful to deliver the baby easily, encourage patient to increase fluid intakes for about 8-10 glasses of water/day to include milk, encourage patient for breastfeeding to protect the baby from any diseases and infection.

• Fourth VisitSeptember 27, 2009 Tuesday at around 10:00 in the

morning, our group decided to visit our postpartum client. We took the clients vital signs first. Having these results; BP=100/70 mmHg, pulse=90bpm, respiration=18cpm, temperature=36.8*C, we also include baby Marcelo’s vital signs; Respiration=48cpm, pulse=125 bpm, temperature=36.9*C. After taking vital signs, we did the physical assessment, the baby’s physical appearance is normal but we have noticed that he has skin rashes. After the assessment, we did the health teaching, we taught the client on how to perform the postpartum exercise and the reason behind each exercise. Since the client already has 4 offspring which has a short on gap, we advised her to apply some of the family planning method; we introduced IUD which has a long term effect, withdrawal, and cervical mucus method. Since our client prioritize their family’s basic needs rather than buying contraceptives we introduced to her the methods that are non-expensive and have no cost.

• We also tackled about the importance and benefit of breastfeeding for her as one of the effective family planning methods, explaining to her that if she plans to use this method, she must exclusively breastfeed baby Marcelo and her menstruation must be regular. For baby Marcelo, breastfeeding is important because almost all the nutrients are there that would protect him for any diseases and infections. We also emphasized to her breast care as one of the important doings before she will breastfeed the baby. After the health teaching, we ended the discussion by giving some offerings that would help to improve the clients’ health status, and thanked them for their cooperation and promised to go back after few weeks.

CUES NURSING Dx OBJECTIVES INTERVENTION RATIONALE EVALUATION

Subjective:

“Sigeg kog ihi ihi, ika daghan sa isa ka adlaw”

Objective:

9 times to urinate within a day

Urinary retention related to urethral blockage.

At the end of 24 hours, the patient will able to decrease stress incontinence.

Independent:

Monitor frequency and consistency of urine.

Perform Kegels maneuver

Increase fluid intake

Void as necessary

Avoid Caffeine

-to evaluate volume losses

-TO increases bladder pressure and this may stimulate relaxation of sphincter to allow voiding.

-to avoid urine distention.

Caffeine can stimulate pain in urination

At the end of 24hrs, the patient was able to decrease stress incontinence.

CUES NURSING Dx OBJECTIVES INTERVENTION RATIONALE EVALUATION

Subjective:

“ nanghupong lagi akong tiil”

Objective:

Non-pitting edema observed at both ankles.

Ineffective tissue perfusion related to electrolyte imbalance.

At the end of 24hrs, the atient will be able to maintain tissue perfusion on both ankle

Rest with your feet elevated

Encourage the patient the to turn in bed frequently or ambulate.

Instruct the patient to correct body mechanics

Provides foods low in sodium to minimize edema and provide foods high in potassium such as bananas

Promotes arterial blood circulation

To reduce pressure on bony prominences and areas of edema.

To avoid pain or injury during activities,

To maintain electrolyte balance.

At the end of 4hrs, the patient was able to maintain tissue perfusion on both ankle.

CUES NURSING Dx OBJECTIVES INTERVENTION RATIONALE EVALUATION

Subjective:

“kasagara gasakit ako likod jud”

Objective:

Relief or destruction behavior( like seeking other peoples attention)

Guarding Behavior or protecting body part.

Acute pain at the lower back, related to the increasing weight of the gravid uterus.

At the end of 3mins, the patient will verbalized adequate relief of pain or ability to cope with incompletely relieved pain

Advised the client, partner or significant others to anticipate the need for pain relief

Provide rest periods to facilitate comfort, sleep and relaxation.

Instruct the client to verbalized pain in scale from 1-10

Provide comfort measure such as massage at the site of pain

Dependent:

Give analgesic as ordered, evaluating effectiveness and observing for any signs and symptoms for untoward effects.

Early intervention may decrease the total amount of analgesic required.

The patient experiences of pain may become exaggerated as the result of fatigue.

To be able to determine the type or level of care to be given.

To relief or reduce pain into tolerable scale

Pain medication are absorbed and metabolized differently by pt’s, so their effectiveness must be evaluated from pt. to pt.

At the end of 30mins, of independent and independent nursing intervention the pt, has verbalized relief of pain.

CUES NURSING Dx OBJECTIVES INTERVENTION RATIONALE EVALUATION

Subjective:

“naay gamay na burot2x na pula sa panit niya”

Objective:

Rashes that provide discomfort to the baby.

Impaired skin integrity related to poor sanitation.

At the end of 15mins,the mother would be able to apply the health teaching that we taught to her, to minimized the skin rashes of the baby.

Instruct the mother to bath the baby with lukewarm water and mild soap.

Encourage the mother to avoid vigorous rubbing and scratching and to pat skin dry instead of rubbing.

Turn/ reposition frequently

Inforn the parents that all linens and clothing used by the child should be washed with detergent in hot water separately from those of other household members

Allow lesions to dry by air exposure.

To maintain cleanliness without irritating the skin.

Help prevent skin friction to sensitive tissue

Promotes circulation and prevent undue pressure on skin/tissues.

To prevent further complications of the skin

To facilitate wound healing

After 15mins of our conversation with the mother, she was able to know the nursing intervention that could minimize the skin rashes of her baby.

CUES NURSING Dx OBJECTIVES INTERVENTION RATIONALE EVALUATION

Subjective:

“galisod ko ug kalibang ning niaging adlaw pa”, as verbalized by the patient.

Objectives:

Abdominal pain, urgency and cramping

Altered bowel sounds

Constipation related to decreased dietary intake.

At the end of 24 hours, the patient will able to defecate normally as possible as once in a day.

Independent:

Determine stool color, consistency, frequency and amount

Auscultate bowel sounds

Encourage fluid intake of 2500-3000 ml/day within cardiac tolerance

Recommended avoiding gas forming foods

Encourage to eat high-fiber rich foods

-assist in identifying causative or contributing factors and appropriate interventions

-bowel sounds generally decreased in constipation

-assist in improving stool consistency

-decrease gastric distress and abdominal distention

At the end of 24 hours of nursing intervention, the patient defecated normally.

-to enhance easy defecation

At the end of 24 hours of nursing intervention, the patient defecated normally.

Referral and Summary Since our client settled in lowland area of Macasandig

us advice our patients to continue visit the Macasandig Health Center for the continuation of immunization of her child and for consultation, if there are manifestation of sickness that they should be guided properly by person who is working in any of the sector of health care. We advised the parents to be guided properly with the family planning method for greater good of their living. We give emphasis also on the sanitation and proper hygiene to avoid risk for sickness and diseases. We promote breast care and breast feeding in nourishing the newborn. We give also the mother some protective measures for the newborn since accident do happen no matter what.

We thanks to this experience of interacting with our patient that we learn a lot not just for our future job as a nurse but also as a person for developing us as a better person that is thankful for the gift of life and love.

ORGANIZATION AND BIBLIOGRAHY I was able to come up with this care study

with the help primarily of my awesome God. Next would be the cooperation and accommodation of our client. These are our source:

• Lippincott, Williams, and Wilkins. Manual of Nursing Practice Hanbook...3rd edition page.981-1024

• Adele Piliteri, ed. Maternal and Child Health Nursing.5th edition , C and E Publishing, Inc. San Juan Metro Manila, Philippines

• Doenges, Moorhouse, Geissler-Murr.8th edition. Nurse’s Pocket Guide …452-457

• www.wikipedia.com • www.google.com