Pamantasan ng Lungsod ng Maynila – College of Nursing

(University of the City of Manila)

Intramuros, Manila

In Partial Fulfillment

in the requirement on

Maternal and Child Nursing I

Submitted by:

Domingo, Raven Khristine T,

BSN II-I

Submitted to

Prof. Ronie M. Tiamson RN, RM, MAN

June – October 2016

 Table of Contents

Introduction

Objectives

Demographic Data

History of Present Illness

Past Medical History

Psychosocial History

Familial History

Review of Systems

Physical Assessment

Anatomy and Physiology

Diagnostic Procedures and Lab Results with Analysis

Obstetrics

Drug Study

Nursing Care Plan

I. Introduction

Teenage pregnancy is one of the arising crisis in the Philippines regarding

the health due to certain factors that can trigger for teenagers to engage in early

coitus. It has a huge impact in the tradition and religion perception because we

are country tied to its religion.

Over the past few decades, teenage pregnancy has become a public

concern which has generated a great deal of attention in the locality. Increasing

awareness of the social and economic consequences of teenage pregnancy has

led to a consensus opinion among policy makers and the public that teenage

pregnancy and child bearing is a significant social problem. It has been linked to

an array of other social issues, such as welfare dependency, child health and

well-being, out of wedlock births, fatherhood responsibility, child abuse and

neglect, school drop-out and workforce development. (Torivillas, The Philippine

Star, 2013).

The frequency of teenage pregnancy among the youth is alarming and

has become more or less a fact of life in many nations of the world including

Philippines. This remains both culturally deleterious and personally destructive.

Teenage pregnancy has lots of effects on Educational Development of teenagers

who are victims of this phenomenon. The Philippine government and other

religious institutions are studying every angle to look for ways to reduce untimely

pregnancy among teenager. These are many factors which have been

recognized by researchers and authors as being responsible for teenage

pregnancy. It has been noted and well documented that today’s teenagers face

more sexual temptation than previous generations. They seem to be more aware

of sex and susceptible to the dangers of illicit sex. Today’s society is more

bombarded with sexually oriented materials in the environment.

II. Objective

General Objective

This case study aims to help two variables that is present; the patient,

to allow and detect discrepancies that can be thoroughly determined through

an assessment, in order to provide an efficient and liable nursing care

intervention helping the patient to achieve maximum health. The student

nurses, to be able to enhance their skills in communication, assessment and

application of nursing intervention during their stay in the area.

Specific Objective:

 To construct a firm foundation of rapport to the patient and

their relatives through effective and therapeutic

communication.

 To collect significant information from the patient that can

stand as the baseline data of my assessment.

 Implementation of an effective physical examination and

review of systems to the patient in order to determine and

prioritize the needs and problems of the patient.

 To determine the current medications being taken by the

patient and to have a thorough analysis on the effects and

significance of the drug to their health.

 To create a liable nursing care plan using the information

gathered.
III. Demographic Data

Name: Patient C

Age: 20 years old

Address: Paco, Manila

Gender: Female

Birthday: October 13, 1995

Birthplace: Manila

Occupation: None

Religion: Roman Catholic

Marital Status: Single

No. of Children: 1

Educational Level: 1st year college

Height: 142 cm Weight: 64 kg BMI: 31. 74

Date of Admission: September 20, 2016

IV. Chief Complaint

“nahihirapan ako makatulog kasi kumikirot yung pepe ko kasi yung

tahi” as verbalized by the patient.

Admitting Diagnosis:

G2 P1 (T1 P0 A0 L1) Pregnancy uterine 43 weeks age of gestation.

V. History of Present Illness

During the night before admission, prior to the confinement of the patient

there is positive (+) abdominal pains felt by the patient.

At 6 am of September 20, 2016, signs of positive (+) watery vaginal

discharge described as minerals is present, also positive (+) persistent

labor pains is determined.

VI. Past Medical History

The patient had acquired chickenpox and measles during childhood and

had experienced common illnesses such as fever, coughs and colds.

The patient has no history of any communicable disease and

cardiovascular diseases.

Also, the patient is not allergic to certain drugs, foods and animals.
VII. Psychosocial History

The female patient is 20 years old. She is the third child out of 4

siblings. The patient’s marital status is single and was accompanied by

her aunt during the antepartal stage of pregnancy. The usual sleeping

pattern of the patient is to have a 10 hour sleep with no feeling of distress

when waking up. The patient lies in bed during leisure however it all

changed during the onset of pregnancy.

OB History:

The last menstrual period of the patient is November 22, 2015. Therefore, the

estimated date of delivery is said to be August 29, 2016. According to the

patient’s chart, her age of gestation by the use of her LMP is 43 2/7 weeks, while

it is said to be 36 5/7 weeks by the ultrasound.

The OB score of the patient is G2 P1 (1001); gravida is 2, parity is 1, term is

1, 0 preterm, 0 abortion and 1 living child before delivery.

The age of menarche of the patient is at 12 years old with a regular menstrual

flow, use of 2-3 pads a day, and duration of 3-5 days maximum. The patient did

not experience a sensation of dysmenorrhea.

Maternal History:

The first pregnancy she had was delivered through a normal spontaneous

delivery with a labor period of almost 12-13 hours.

 Gordon’s 11 Functional Pattern

Gordon’s Before Admission During Admission Interpretation

Functional Pattern

How do you describe your health?

1. Pattern of “malusog naman ako” “feeling ko payat na ko, The patient’s view of

Health Perception as verbalized by the kasi nasanay akong her health changed due

and Health patient. may daladala sa tiyan to the onset of labor.

Management ko” as verbalized by the

patient.

How do you improve or maintain your health?

“matulog ng maaga” as “sinusunod ko yung The patient is well

verbalized by the sinasabi ng doctor” as aware and cooperative

patient. verbalized by the in the maintenance of a

patient. healthy lifestyle.

How do you link lifestyle choices and health?

“hindi ako naninigarilyo, “ngayon hindi na” as The patient maintains to

umiinom ako pero verbalized by the improve her health from

minsan lang” as patient. the time she stopped

verbalized by the drinking alcohols until

patient. the present day.

How big is the problem in financing health care for you?

“hindi naman gaano, “ganun pa din, nagipon The patient manages to

minsan kinakapos pero kami kasi prepare for the future

okay naman” as manganganak” as needs for health care

verbalized by the verbalized by the needs.

 patient. patient.

2. Nutritional What is your usual diet?

Metabolic Pattern
“wala kahit ano, hindi “sabi ng doctor ko mga The patient’s usual diet

naman ako mapili” as lugaw lang tsaka tubig” has been disturbed due

verbalized by the as verbalized by the to restrictions of food

patient. patient. related to her condition.

How’s your appetite?

“malakas ako kumain “medyo wala akong The patient’s nutritional

pero di ako tumataba” gana” as verbalized by pattern has been

as verbalized by the the patient. disturbed due to

patient. delivery.

Can you recall the highest weight you have?

“hindi ko na tanda eh” “hindi ko din alam eh” as The patient lacks the

as verbalized by the verbalized by the knowledge about her

patient. patient. physical statistics.

3. Pattern of Usual bowel pattern? Frequency? Color?

Elimination
“araw araw naman ako “ano…naiilang ako The patient’s bowel can

nakakatae, depende tumae dito sa hospital be changed because of

kung gaano kadami eh” as verbalized by the the uncomfortable

nakain ko” as verbalized patient. feeling that she have.

by the patient.

Do you experience any discomforts: pain, burning, and difficulty voiding? How

do you manage it?

 “wala naman, ayos “wala, okay pa din” as The patient does not

naman pagihi ko” as verbalized by the experience any difficulty

verbalized by the patient. in voiding or pain.

patient.

Do you experience any discomforts diarrhea, constipation, bleeding?

“nakaranas na ko dati “wala, masakit lang The patient has

ng diarrhea” as tiyan” as verbalized by experienced pain in her

verbalized by the the patient. abdomen and does not

patient. have any discomfort in

defecating.

Do you have any disease of the digestive system, urinary system or skin?

“wala naman” as “wala pa rin” as The patient condition

verbalized by the verbalized by the shows that there is no

patient. patient. disease related to the

genitourinary system.

Do you perspire heavily, in what occasions/ conditions?

“pinagpapawisan ako “grabe ako magpawis” The patient perspires

pero hindi ganoon as verbalized by the easily than she does

kagrabe” as verbalized patient. before even with low

by the patient. activities performed.

How do you describe your weekly pattern of activity and leisure, exercise and

recreation?
4. Pattern of
Activity and “wala, nakahilata lang “medyo naglalakad The patient’s pattern of

Exercise ako pag wala akong minsan” as verbalized activity increased on the

ginagawa” as verbalized by the patient. onset of pregnancy.

by the patient.

Do you have any disease that affects cardio-respiratory system or musculo-

skeletal system?

“wala, wala kaming lahi” “wala pa din naman” as The patient did not

as verbalized by the verbalized by the acquire any

patient. patient. cardiovascular disease,

etc.

Do you experience fatigue/weakness, pain after the activity?

“hindi, nakahilata lang “oo pero hindi naman The patient can

ako eh” as verbalized gaano” as verbalized by experience slight

by the patient. the patient. weakness after such

acitivities.

5. Cognitive – Do you have sensory deficits (sight, smell, auditory, taste and vision)? Are

Perceptual pattern they Corrected?

“wala. Malinaw pa “wala, maayos naman There is no any sensory

naman mata ko, wala lahat” as verbalized by deficits the patient have.

naman problema” as the patient.

verbalized by the

patient.

Do you experience pain? How do you manage it?

 “oo naman, pero wala “ganun pa rin” as The patient tolerates the

tiis tiis lang” as verbalized by the pain that she gets until it

verbalized by the patient. is gone.

patient.

6. Pattern of sleep Describe your sleep pattern?

and rest
“okay naman, “nahihirapan ako .The patient experience

nakakatulog naman ako matulog kasi may difficulty sleeping

ng 8 oras minsan” as sumasakit sakin” as because there is a pain

verbalized by the verbalized by the disturbing her.

patient. patient.

Do you feel tire upon waking up?

“hindi, fresh na fresh “oo, parang lutang” as The patient feels tired

yung feeling” as verbalized by the and events of spacing

verbalized by the patient. out when waking up.

patient.

Do you experience any problem falling asleep? What do you think caused it?

“hindi, masarap nga “oo, kasi may The patient is having

tulog ko eh” as nararamdaman nga difficulty sleeping

verbalized by the akong masakit” as because pain

patient. verbalized by the disturbance.

patient.

7.Pattern of self- Do you think that there is anything unusual about your appearance and self?

perception and self

“wala naman ata” as “wala ganun pa din eh” The patient doesn’t feel
concept
verbalized by the as verbalized by the any unusual about
 patient. patient. herself.

Are you comfortable with your appearance?

“oo naman” as “oo, kahit na madami na The patient is still

verbalized by the ko kamot” as verbalized comfortable even if

patient. by the patient. there is presence of

stretchmarks due to

pregnancy.

How are you feeling?

“okay lang naman” as “masaya kasi okay baby The patient is having an

verbalized by the ko” as verbalized by the improved emotional

patient. patient. status due to the baby’s

occurrence.

What are your traits that you’re proud of?

“mabait tsaka malakas “ayun pa din tapos The patient is proud for

loob” as verbalized by matiyaga” as, verbalized being a good and strong

the patient. by the patient. willed person.

8. Role- How do you describe various roles in life?

Relationship
“dapat marunong “ganun pa din, mas The patient is well-
pattern
lagging may oras sa dapat pahalagahan oriented on the roles of

pamilya” as verbalized yung mga taong nasa a person should have

by the patient. paligid mo” as when it comes to

verbalized by the significant people.

patient.

Which relationship is most important to you?

 “pagiging anak ” as “pati pagiging nanay The patient’s role have

verbalized by the kasama na” as been improved from

patient. verbalized by the being a daughter to

patient. being a mother.

9. Sexuality- Are you in a relationship? How many children do you wish/have?

Reproductive
“oo, pero di kami “di ko alam eh, basta The patient is uncertain
pattern
magkasama” as andyan na” verbalized with the decision that

verbalized by the by the patient. she have.

patient.

Can you say that you are sexually active?

“dati, oo” as verbalized “hindi na” as verbalized The patient was

by the patient. by the patient. sexually active before

pregnancy.

Do you use birth control method?

“hindi” as verbalized by “hindi pa din” as The patient do no use

the patient verbalized by the any birth control

patient. methods.

Age of menarche, cycle, duration, no. of pads, pregnant now, menopause,

vaginal mammogram, pap test.

“12 years old ako nung “hindi pa ulit, matagal pa Since the patient gave

unang beses ako ulit kasi kakapaanak ko birth to another baby,

niregla, regular naman pa lang” as verbalized her menstrual period

ako tas mga 3 pad sa by the patient. might come along in 3-4
 isang araw ganun” as months considering that

verbalized by the the patient’s baby is

patient. being breastfed.

10. Pattern of Have you experience any discomforts in life? What condition brought it?

coping and stress

“hindi ko matandaan, “oo, nung tinatahi ako. The patient experienced
tolerance
pero oo” as verbalized Wala naman ako disturbance due to pain

by the patient. magagawa tinitiis ko na of episiorraphy.

lang” as verbalized by the

patient.

How do you usually cope with problems?

“nagkwekwento ako “sa mama ko pa din tapos The patient seeks for

sa mama ko” as dinadasal ko na lang” as the comfort of her

verbalized by the verbalized by the patient. mother and also from

patient. God.

To whom would you go if you have problems?

“kay mama” as “sa kanya pa din” as The patient always

verbalized by the verbalized by the patient. seeks for help when in

patient. times of problem to her

mother.

11. Values-Belief What principle in life did you learn as a child? Do you think it’s important?

pattern
“dapat marunong “pamilya tsaka diyos lang The patient knows who

lumingon sa ang di magbabagoo, sila to hold on to when in

pinanggalingan, tsaka yung tatanggap sayo kahit times of suffering, and

papahalagahan ang anong mangyari” as is well aware of the

pamilya” as verbalized verbalized by the patient. lessons she learned

by the patient. when she was a child.

What support systems do you have?

“pamilya ko tsaka mga “sila pa din, pero si God The support systems

kaibigan ko” as pa din ang bahala” as that she have is her

verbalized by the verbalized by the patient. family and friends, and

patient. she still offers and

depend on God.
 VIII. Familial History

GENOGRAM

Maternal Side Paternal Side

LEGEND:

Patient C
Female

Deceased
Male

Hypertension Pulmonary
Tuberculosis
 Interpretation:

The patient has no diseases compared to the other members of her

family who have acquired a family disease. The patient’s grandparents at her

mother side are both hypertensive, while her grandparents at her father side is

both deceased and is said that Tuberculosis is the cause of death of his

grandfather. The mother of the patient is also hypertensive as well as 2 of her

siblings.

IX. Review of Systems

The patient appears to experience fatigue with no implications of

headaches or dizziness. The cooperation level of the patient is positive due to

understanding of health teachings being performed.

The skin has no presence of edema or skin lesions. The patient does not

also possess rash or events of itching.

There are no sensory deficiencies observed and assessed from the

patient, all sensory organs function properly with no difficulties. No visual loss,

negative hearing loss, no presence of nasal congestion or runny nose.

The patient does not experience any discomfort in breathing such as

dyspnea, coughing and wheezing. There is also no presence of chest pains.

The breast of the patient is palpated as engorged and positive with

tenderness related to lactation of milk because she is breastfeeding her baby.

The patient do not experience discomfort during urination and bowel

movement. There is no sensation of pain, burnings and distress.

The lower extremities of the patient suffer a sudden feeling of pain due to

fatigue and muscle sores as per the patient’s perception.

X. Physical Assessment

The patient appears to be weak and tired, however, patient is

cooperative, and answers all of our questions and understands all the

procedures that we need to be done to her.

The skin of the patient appears to be light brown in color without

appearance of any skin lesions and tenderness. The skin returns to its

previous state within 1-2 second if being pinched. There is also no detection

of edema.

The hair is evenly distributed and smooth in texture, no sightings of

lesions in the scalp, no lice and no dandruff.

The nails are symmetrically rounded, and appears to be pinkish white,

also has a good arterial circulation proved because blanch test result is, the

color comes back within 2 seconds after being pinched.

The head appears to be normocephalic and symmetric with frontal,

parietal and occipital prominences. There is no detection of masses or

nodules when palpated.

The eyes of the patient do not show signs of edema on the eyelids.

Both eyes of the patient continues to moved unison when tracking the 6

cardinal gazes.

The ears of the patient are parallel to the eyes and has the same color

as the facial skin, it is mobile and there is no palpation of tenderness

determined.

The neck can be moved simultaneously side by side and no feeling of

discomfort can be felt. There are no masses or nodules detected during

palpation.
 The patient does not experience difficulty in voiding and defecating,

there is no sensation of pain, burning or sweating.

The chest of the patient is symmetric and no signs of distress when

breathing. There is also no detection of tenderness when palpated.

The breast of the patient is symmetric, round in shape, engorged and

tender in assessment. The nipple is not distended and positive for

lactation.
 XI. Anatomy and Physiology

Female Reproductive System

The mons pubis is a thick, hair-covered, fatty and semi-rounded area

overlying the symphysis pubis. Symphysis is a type of strong and immovable joint

between bones. The two halves of the pubic bone are joined in the middle by the

pubic symphysis. The function of the fatty tissue in the mons pubis is to protect the

woman’s pubic area from bruising during the sex act.

The labia majora are two elongated, hair-covered, fatty skin folds that

enclose and protect the other organs of the external female genitalia.

The labia minora are two smaller tissue folds enclosed by the labia majora.

They protect the opening of the vagina and the urethra (the tube that carries urine

from the bladder to the urethral opening in the vulva). The labia minora normally have

an elastic nature, which enables them to distend and contract during sexual activity,

and labour and delivery.

The vestibule is the area between the labia minora, and consists of the

clitoris, urethral opening and the vaginal opening.

The clitoris is a short erectile organ at the top of the vestibule, which has a

very rich nerve supply and blood vessels. Its function is sexual excitation and it is

very sensitive to touch. Its anatomical position is similar to the position of the male

penis.

The vaginal opening is the entrance to the vagina. It is where you will begin

to see the ‘presenting part’ of the baby as it stretches wider open near the end of

labour.

The urethral opening is the mouth or opening of the urethra, which is a small

tubular structure that drains urine from the bladder.

 The skin-covered muscular area between the vaginal opening and the anus is

called the perineum. It has strong muscles and its own nerve supply, and it helps to

support the contents of the pelvic cavity.

The hymen is a fold of thin vaginal tissue which partially covers the vaginal

entrance in girls. It can be torn during strenuous exercise, as well as by the first

sexual penetration.

There are two fallopian tubes — one on each side of the uterus — and the

finger-like ends of each tube (called the fimbriae) are close to the ovary on the same

side, and open to the pelvic cavity. This means that if there is an infection in the

pelvic cavity, it can get into the uterus through the fallopian tubes. Similarly, if there is

an infection in the uterus, it can spread along the fallopian tubes and out into the

pelvic cavity, and from there all around the woman’s abdomen, affecting her other

organs.

The ovaries are paired female reproductive organs that produce the eggs

(ova). They lie in the pelvic cavity on either side of the uterus, just below the opening

of the fallopian tubes.

The uterus is a hollow, muscular organ in which a fertilised ovum becomes

embedded and develops into a fetus. Its major function is protecting and nourishing

the fetus until birth.

The cervix is the lower, narrow neck of the uterus, forming a tubular canal,

which leads into the top of the vagina. It is usually about 3 to 4 cm (centimetres) long.

The vagina is a muscular passage, 8 to10 cm in length, between the cervix

and the external genitalia. The secretions that lubricate the vagina come from glands

in the cervix.
XII. Diagnostic Procedures and Lab Results with Analysis

I was not able to back up the data of the Diagnostic Procedures and

Laboratories of the patient.

XIII. Obstetrics

Upon admission, the patient is under NPO for 8 hours and laboratories

requested are CBC, Urinalysis and Blood Typing.

Establishment of rapport to gather significant data is a must, I was able to

get her trust and comfortability that is why we had a thorough conversation

regarding the status of her health before admission and after delivery of birth.

The patient’s vital sign was being monitored during her stay in the

ward. The records of vital sign taken that day are BP: 110/80mmHg, Temp:

36.1 0C, RR: 20 cycles per minute, PR: 101 bpm.

 XIV. Drug Study

Drug Drug Route, Action Indication Contraindication Adverse Nursing

Class dosage Effect Responsibilities

and

Frequency

It elevates the Prevention and Occurrence of: Large doses .Assess the
Hemochromatosi may nutritional status
Ferrous Iron PO, BID serum iron treatment of iron s, hemolytic aggravate and dietary history
anemias. existing GI of the patient.
Sulfate Preparatio concentration deficiency Peptic ulcer, tract disease
(peptic ulcer, Monitor serum
n which helps to anemias. It is also regional enteritis, regional iron, total iron-
enteritis, binding capacity,
form high or a dietary ulcerative colitis ulcerative Hgb, ferritin.
colitis).
trapped in the supplement for with patients Severe iron Monitor daily
pattern of bowel
reticuloendoth iron. receiving frequent poisoning activity.

elial cells for blood transfusion. occurs most Expect color to

darken.
storage and often in
Do not take within
eventual children,
2 hours of other
conversion to a manifested
medication or
usable form of as vomiting,
iron that severe eggs, milk, tea,

prevents iron abdominal coffee, cereal.

deficieny. pain,

diarrhea,

dehydration,

followed by

hyperventilati

on, pallor,

cyanosis,

cardiovascul

ar collapse.
 XV. Nursing Care Plan

ASSESSMENT INFERENCE DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATION

S: Patient may be After 4 hours Independent: Within our

“Nahihirapan ako at a wrong Disturbed of nursing Provide a quite A quite environment management,
matulog kasi position that can Sleeping intervention environment promotes the patient
sumasakit yung sa cause pain to Pattern related the client will conducive for continuation of had improved
may pepe ko (tahi)” radiate more. to pain verbalize sleeping sleep without sleeping
as verbalized by secondary to understanding disturbance. pattern
the patient episiorraphy. on the cause through
of sleep Encourage the Voiding before verbalization
O: disturbance. patient to void bedtime may limit of:
(+) facial grimace before sleeping the sleep
disturbance brought “nakatulog
Irritable Patient may by urinary ako ng
experience frequency. maayos
extreme pain kagabi, may
Frequent yawning due to the Instruct the Performance of konting sakit
episiorraphy patient to always perineal care akong
noted. causing for her perform perineal prevents the risk for naramdaman
to experience care. infection especially pero hindi na
Vital Signs: difficulty in on mother’s who tulad ng dati”
sleeping. undergo
Temp: 37.6 0C. episiorrhapy.
.
RR: 16 cpm Teach the Elevation of the
patient to head promotes lung
BP: 110/70 mmHg elevate head by expansion, and
using pillows being in a side-lying
PR: 81 bpm during sleep or position decrease
have her on the pressure on the
side-lying chest wall and vena
position. cava by gravid
uterus.