A CARE STUDY ON NORMAL SPONTANEOUS VAGINAL DELIVERY

In Partial Fulfillment Of the Requirements of the Subject: NCM102 Care of Mother, Child, Family and Population Group at-Risk

Submitted by: Charlene M. Letrero BSN Level II-A

February 20, 2012

TABLE OF CONTENTS CONTENTS I.INTRODUCTION_________________________________________ II.GENERAL DATA________________________________________ III. HEALTH ASSESSMENT A. HEALTH HISTORY A.1. Biological data------------------------------------------------------A.2. Reason for seeking consultation---------------------------------A.3. Current Health Status---------------------------------------------A.4. Past Health History------------------------------------------------A.5. Family History------------------------------------------------------A.5.1. Members of the Immediate Family A.5.2. Genogram /Heredo-familial History A.6. Review of System (Gordons Funtional Health Pattern)--A.7. Psychosocial Profile-----------------------------------------------A.8. Developmental Data-----------------------------------------------B. PHYSICAL EXAMINATION-----------------------------------------IV. ANATOMY AND PHYSIOLOGY__________________________ V. CONCEPTUAL FRAMEWORK OF THE PHYSIOLOGY (FOR NORMAL CONDITION) OR CONCEPTUAL FRAMEWORK OF THE PATHOPHYSIOLOGY (FOR ABNORMAL CONDITION)_____________________________ VI. EXPLANATION OF THE PHYSIOLOGY OR THE PATHOPHYSIOLOGY OF THE DISEASE CONDITION/ SYMPATHOMATOLOGY__________ VII. CLINICAL MANAGEMENT A. MEDICAL MANAGEMENT A.1. LABORATORY AND DIAGNOSTIC EXAMINATIONS---------A.2. TREATMENT AND PRUCEDURES------------------------------------A.3. MEDICATIONS USE AND ALL THE MEDICATIONS GIVEN BY THE PATIENT AND DATE ORDERED--------------------------------------A.4. DIET---------------------------------------------------------------------------B. NURSING MANAGEMENT B.1. NURSING CARE PLAN-----------------------------------------------------B.2. DISCHARGE PLAN----------------------------------------------------------ACTUAL CARE GIVEN----------------------------------------------------PAGE

PROBLEMS ENCOUNTERED DURING THE CARE---------------HEALTH TEACHINGS-----------------------------------------------------IX.CONCLUSIONAND RECOMMENDATION____________________________ X. IMPLICATIONS OF THE STUDY TO: A. NURSING EDUCATION----------------------------------------------------------------B. NURSING PRACTICE-------------------------------------------------------------------C. NURSING RESEARCH----------------------------------------------------------------APPENDICES: APPENDIX A: APPENDIX B: APPENDIX C: APPENDIX D: APPENDIX E: PERMIT LETTER GENOGRAM NURSING CARE PLAN DISCHARGE PLAN DRUG STUDY

BIBLIOGRAPHY:

INTRODUCTION

A pregnancy occurs when reproductive cells from a man and a woman's body become combined inside a woman's uterus. The normal way that this occurs is through sexual intercourse, where the man's penis enters the woman's vagina and ejaculates sperm (the male reproductive cells) into the vagina during the process of orgasm or sexual climax. Microscopic though they are, the sperm are able to move around within the vagina, and make their way through the cervix and into the uterus where, if the timing is just right, a female ovum or egg (the female reproductive cell) is waiting. Sexually mature adult females ovulate (produce eggs) once each month as a part of their normal menstrual cycle. The sperm compete to penetrate the outer membrane or covering of the egg which seals off permanently once a single sperm makes its way inside. The new sperm and egg combination next exchange genetic material to form a unique blueprint for a new human being, producing a fertilized egg that will later attach itself to the wall of the uterus and start growing into a new human being if all goes well. Conception is said to occur at the moment the egg and sperm combine.

GENERAL DATA

Name of Patient Age Sex Race Place of birth Marital Status Occupation Religion Date of Admission Room/Bed No. Hospital No. Diagnosis Diet Referring Physician Chief Complaints

: Mrs. Rachel Rosalita Baclaan : 31 years old : Female : Filipino : Naga Cebu : Married : None : Roman Catholic : January 13, 2012 : Aboitiz Ward, Bed no.10 : : Full Term Normal Spontanous Vaginal Delivery : Full Diet : Dr. Milan : Labor Pains

I. HEALTH ASSESSMENT

A. HEALTH HISTORY

A.1 Biological Data Name of Patient: Mrs. R.R.B. Age: 31 Sex: Female Race: Filipino Place of birth: Naga Cebu Marital Status: Married Occupation: None Religion: Roman Catholic

A.2 Reason for seeking consultation Five days prior to admission, patient experienced ruptured bag of water. She was not expecting of her labor because as she knew, she will deliver her first baby on the 2nd week of February. She was admitted at Vicente Sotto Medical Center (VSMMC) .Since her baby did not reached the gestational week, the baby died after delivery. The patient claimed after she was out in the delivery room, She was not able to see her baby. She was trying to cope up, to recover past and discharge as soon as possible.

Gynecological History Patient had her menarche at the age of 13. Patient is sexually active, she has one partner, she had her first sexual contact at the age of 28. Patient hasnt used yet a Family Planning Method for the reason it is their 1st born baby. Patient states that she had an regular menstruation lasting for 5 or 6 days and consumes 2 to 3 pads a day without dysmenorrhea.

Obstetrical History OB score is G-1 T-1 P-0 A-0 L-1 M-0. Patient hasnt yet use Family Planning Method. Patient has been faithful to her husband. She had her first sexual contact at the age of 28.Last menstruation period was on April 6, 2011. The expected date of confinement is on January 13,2012. Patient delivered a preterm stillbirth through Normal Spontaneous Vaginal Delivery. And Age of Gestation is 34 5/7. A.3 Current Health Status Patient usually sleeps 8 hours per night, go to bed at around 10 PM & wakes up at 5 AM. On her admission patient merely sleep and take rest due to an uncomfortable environment. A.4 Past Health History Patient is conscious, coherent and oriented to time and place. Patient was calm, cooperative and responds appropriately. During childhood years, patient experienced mumps & chicken pox at the age of 7 & 9 year 1997&1999 with no other known illnesses. Patient stated that she received complete immunizations like BCG, OPV, DPT, Hep. B & measles. Her adult illnesses is only fever & headaches. Patient had good psychiatric condition and never experienced any problems with it. No previous minor or major surgery involved. She has no allergic reaction. Patient usually sleeps 8 hours per night, go to bed at around 10 PM & wakes up at 5 AM. Her habits include reading books, cooking & watching television.

A.5 Family History GENOGRAM

aged
79

aged
78 81

74 81

A&w 69

A&W 68

A& W 66 53

A&W 63

HTN 59

DM 57

A&W

52

HTN 50

TB 47

HTN 46

A&W

35

A&W 31

A&W

28

A&W 26

A&W 24

A&W

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Legend: Living Male Living Female Deceased Male Deceased Female Points to patient HTN - Hypertension DM Diabetes Mellitus TB-- Tuberculosis A & W Alive and well

A.6 Review of Systems General: Patient is awake, responsive, coherent, febrile, and weak, shows facial grimaced with a guarding movement on her abdomen. She sweats a lot because of the environment in the hospital. She is infused with D5LR 1L @ 30 gtts/ minute. Skin: Skin is light brown in color & it is thoroughly distributed with minimal coarses of hair. Head: Head is normocephalic & symmetrical, smooth & firm. Client experiences mild headache. Eyes: The patients eyelids appear symmetrical with no drooping, infections, or tumors of the lids. There were also no enlargement, swelling, or any tenderness, and no redness that is visible. Ears: The ears match the flesh color of the rest of the patients skin and is positioned centrally and in proportion to the blood. The top of the ear crossed an imaginary line drawn from outer canthus of the eye to the occiput. Nose: The shape of the external nose is located symmetrically in the midline of the face and is without swelling, bleeding, lesions and masses. Nasal flaring is not noted & nares are patent. Throat: The ventral surface of the tongue has prominent blood vessels. Has dry lips, doesnt have any swelling of gums. Can swallow her own saliva with ease. Respiratory: Breath is normal with an average of 35 cpm due to pain; its regular but rapid respiratory pattern. Gastrointestinal: Patient complains pian due to Episiorraphy by operation Normal Spontaneous Vaginal Delivery Genitourinary: Patient has FBC-Uro Bag to monitor her urine output. She has 30 cc/ hour urine output.. Endocrine: No changes in hair distribution, no intolerance of heat and cold, fatigue noted. Musculoskeletal: Movement is limited due to pain on her fresh incision, with muscle weakness and with ease in moving her neck. Psychiatric: No mood swings, anxiety and suicidal thoughts or attempts.

GORDONS LEVEL OF FUNCTIONING Health Perception and Health Management Patient started having regular prenatal check-ups during her first pregnancy. Walking a few meters away from their yard serves as her daily exercise. In addition, she does her household chores everyday and does the general cleaning once a month. As a teacher, she wakes up early to cook for her family & prepare for school. If she feels ill, she takes medicines in order to give remedy for her and her family. She had an allergy to crabs and crustaceans. She does not smoke & drink alcoholic beverages. Her family has history of hypertension, diabetes mellitus and tuberculosis. Nutrition and Metabolism Patient eats whatever she likes but avoided consumption of crabs & crustaceans for she had food allergies with it. However, she avoids fatty foods which she knows are risk factors for heart diseases. She loves to eat fruits but less on vegetables. She does not drinks alcoholic beverages & denies use of prohibited drugs. Elimination Patient defecates once a day without experiencing discomforts, usually morning before she heads to her duty. Stool is brown in color and is well-formed. Patient voids usually 3-4 times a day. Urine is yellow in color. There is no pain when voiding. She easily releases sweat while doing household chores. Activity and Exercise Everyday, patient usually walks a few meters in their yard which serves as her daily exercise. Her job in the school is mostly standing & less amount of time in sitting. She loves to teach preschoolers & taught them with good manners, narrating stories & etc. At home, she loves to watch primetime shows on TV. Cognition and Perception

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Patient is assertive, answers the questions appropriately. Patient is optimistic, she always sees the brighter side of life though problems bumped her many times. Sleep and Rest Patient sleeps from 10pm and wakes up 6-7a.m. On her admission patient merely sleep and take rest due to an uncomfortable environment. Self-Perception and Self-Concept Patient has many friends due to her extrovert personality. It is easy for her to get along with others since she knows how to handle people. She considers herself as a holistic human being as long as she is healthy and her family is always there for her. She wants to maintain a good health and live his life to the fullest. Roles and Relationships Patient verbalized that it is her 1st born baby. She is excited to have a new born baby. She also does the budgeting on her husbands income as a Janitor. Patient belongs to an extended family, she has a good relationship to both her parents and husband. Sexuality and Reproduction Patient had her menarche at the age of 13. Patient is sexually active, she hasone partner, she had her first sexual contact at the age of 28. Patient hasnt used yet a Family Planning Method for the reason it is their 1st born baby. Patient states that she had an regular menstruation lasting for 5 or 6 days and consumes 2 to 3 pads a day without dysmenorrhea. Coping and Stress Tolerance Patient compensates with stress through sleeping, watching TV and talk with her friends.

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Values and Belief Patient is a Roman Catholic, usually attending Sunday masses with her partner. She has a strong faith in God that she asks faithfully healing of any perceived illnesses. Patient inculcated honesty and integrity in their relationship and outlook in life. There is no hindrances of seeking care & her outlook of illnesses. A.7 Psychosocial Profile Patient wakes up at 6AM and makes breakfast with her partner. Walking a few meters away in their yard serves as her daily exercise. She goes to work from 8AM to 6PM. Patient is living with her partner and is well-supported by her immediate family. Patient finished her High school Education and Elementary Education at Naga School. She is just in their house and doing household chores. Patient is a Roman Catholic, usually attending Sunday masses with her partner. Hence, there is no hindrances in seeking care & her outlook of illnesses. Patient is residing in their own house made of concrete materials at Uling City of Naga Cebu with sufficient electrical & water supply from their district provider. They are supplied with mineral water for drinking purposes. Has good-closed drainage & their garbage is collected every other day. Patient is not an alcoholic drinker, not a tobacco user as stated & denies use of prohibited drugs. She denies abuse and binging. Patient is heterosexual and is sexually active with her husband as her sole partner for almost 3-4 years already. She doesnt use yet a Family Planning Method.

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PHYSICAL ASSESSMENT

Physical examination follows a methodical head to toe format in the Cephalocaudal assessment. This is done systematically using the techniques of inspection, palpation, percussion and auscultation with the use of materials and investments such as the penlight, thermometer, sphygmomanometer, tape measure and stethoscope and also the senses. During the procedure, I made every effort to recognize and respect the patients feelings as well as to provide comfort measures and follow appropriate safety precautions.

A. General Physical Assessment Patient is a 31 year old female, stands 54, with pulse rate of 70 beats per minute, respiratory rate of 20 breathe per minute and a temperature of 37.5 C. She is conscious and coherent upon interaction but answers only the questions she is comfortable with. Most of the time, she is pacing inside the ward and appears withdrawn.

B. Assessment of the Head Head is round in shape. Hair is long, thick and coarse, straight and evenly distributed. Scalp is smooth and white in color, minimal lesions were noted. No dandruff and lice noted.

C. Assessment of the Eyes Her eyes are symmetrical, black in color, almond shape. Pupils constricts when diverted to light and dilates when she gazes afar, conjunctivas are pink. Eyelashes are equally distributed and skin around the eyes is intact. The eyes involuntarily blink.

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D. Assessment of the Ears Ears are clean, no ear wax was noted and approximately of the same size and shape. Patient can hear normally when spoken softly.

E. Assessment of the Nose With narrow nose bridge, there were discharges noted upon inspection. No swelling of the mucous membrane and presence of nasal hairs were seen.

F. Assessment of the Mouth She has a complete set of teeth with minimal dental caries noted. Oral mucosa and gingival are pink in color, moist and there were no lesions nor inflammation noted. Tongue is pinkish and is free of swelling and lesions. Lips are symmetrical, appears pale without bits noted upon observation.

J. Assessment of the Neck Lymph nodes noted. Neck has strength that allows movement back and forth, left and right. Patient is able to freely move her neck.

H. Assessment of the Lungs and Thoracic Region No reports of pain during the inhalation and exhalation. Absence of adventitious sounds upon auscultation. Respiratory rate 21 breathes per minute from the normal range of 16-20 breaths per minute. I. Assessment of the Heart

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Patient has an audible heart sound. PMI is heard between 4th - 5th intercostals space. Heart is pumping well with a pulse rate of 82 bpm from the normal rate of 60-100 beats per minute.

J. Assessment of the Abdomen Abdominal movement as with respiration, presence of peristalsis during auscultation. Presence of rashes and lesions.

K. Assessment of the Upper Extremities Skin: White in color; presence of marks/scars of wounds in the arms, neck and legs. Skin is smooth, moist and soft to touch. Hands: Medium in size with 5 fingernails in each side. Nails are short, small dusty particles are present. Arms: Able to move through active ROM. Able to extend arms in front or push them out to the side.

L. Assessment to the Lower Extremities Size of the feet is undefined with lines on the sole, presence of scars and lesions. Ten fingers are present. Nails are clean and short. Patient is ambulatory.

M. Assessment of the Genitourinary With episiotomy dry and intact, urinates 2-4 times a day and has not defecated yet since her delivery.

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N. Assessment of the Perineum With episiotomy intact, absence of lesions and swelling.

O. Neurological Assessment Behavior Patient is silent but is conscious and coherent upon interaction. She sits and walks if she wants to. Motor Functioning - Able to move extremities through active ROM. Able to extend arms front and resist active as pushed down/up on his hands. Reflexes -reflexes were present such as the blinking reflex and deep tendon reflex. Sensory Functioning Patients sensory system is intact, she was able to distinguish touch, pain, hot and cold.

ANATOMY AND PHYSIOLOGY OF THE REPRODUCTIVE SYSTEM

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EXTERNAL GENITALIA Our overview of the reproductive system begins at the external genital area or vulva which runs from the pubic area downward to the rectum. Two folds of fatty, fleshy tissue surround the entrance to the vagina and the urinary opening: the labia majora, or outer folds, and the labia minora, or inner folds, located under the labia majora. The clitoris, is a relatively short organ (less than one inch long), shielded by a hood of flesh. When stimulated sexually, the clitoris can become erect like a man's penis. The hymen, a thin membrane protecting the entrance of the vagina, stretches when you insert a tampon or have intercourse. INTERNAL REPRODUCTIVE STRUCTURE

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 vagina functions as a two-way street, accepting the penis and sperm during intercourse and roughly nine months later, serving as the avenue of birth through which the new baby enters the world.

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Cervix The vagina ends at the cervix, the lower portion or neck of the uterus. Like the vagina, the cervix has dual reproductive functions. After intercourse, sperm ejaculated in the vagina pass through the cervix, then proceed through the uterus to the fallopian tubes where, if a sperm encounters an ovum (egg), conception occurs. The cervix is lined with mucus, the quality and quantity of which is governed by monthly fluctuations in the levels of the two principle sex hormones, estrogen and progesterone. When estrogen levels are low, the mucus tends to be thick and sparse, which makes it difficult for sperm to reach the fallopian tubes. But when an egg is ready for fertilization and estrogen levels are high the mucus then becomes thin and slippery, offering a much more friendly environment to sperm as they struggle towards their goal. (This phenomenon is employed by birth control pills, shots and implants. One of the ways they prevent conception is to render the cervical mucus thick, sparse, and hostile to sperm.) Uterus The uterus or womb is the major female reproductive organ of humans. One end, the cervix, opens into the vagina; the other is connected on both sides to the fallopian tubes. The uterus mostly consists of muscle, known as myometrium. Its major function is to accept a fertilized ovum which becomes implanted into the endometrium, and derives nourishment from blood vessels which develop exclusively for this purpose. The fertilized ovum becomes an embryo, develops into a fetus and gestates until childbirth. Oviducts The Fallopian tubes or oviducts are two very fine tubes leading from the ovaries of female mammals into the uterus.

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On maturity of an ovum, the follicle and the ovary's wall rupture, 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. 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 ovum is captured by the oviduct, where it travelled down the oviduct to the uterus, occasionally being fertilised on its way by an incoming sperm, leading to pregnancy and the eventual birth of a new human being. The Fallopian tubes are often called the oviducts and they have small hairs (cilia) to help the egg cell travel.

MAMMARY GLANDS Although the mammary glands are structurally related to the skin, they are functionally related to the reproductive system. This is because they produce milk for the nourishment of offspring. The mammary glands are enclosed within the breasts and are Anterior to the pectoralis major muscles, adipose tissue surrounds the glandular tissue. The alveolar glands produce milk after pregnancy. The milk enters the lactiferous ducts which converge at the nipple. The area of pigmented skin around the nipple is called the areola. Milk formation is controlled by hormones. High levels of estrogen and progesterone prepare the mammary glands for milk production during pregnancy. After pregnancy, the hormone prolactin, secreted from the anterior 19

pituitary gland, causes milk synthesis. When an infant sucks on the nipple, the hypothalamus is stimulated. It sends nerve impulses to the posterior pituitary gland, which subsequently secretes oxytocin to cause the milk to be, released (Scanlon, 1991). Lactation Lactation is the secretion and ejection of milk by the mammary glands. Prolactin, a hormone produced by the anterior pituitary gland is principally involved in the process. Its release is stimulated by prolactin releasing hormone (PRH) secreted by the hypothalamus. Prolactin levels increase throughout pregnancy but milk secretion is inhibited by the presence of progesterone. Suckling initiates a nerve response to the hypothalamus resulting in the release of PRH and thus prolactin, and a decrease in the release of prolactin inhibiting hormone (PIH). At the same time oxytocin is released by the posterior pituitary gland that causes contraction of muscles surrounding the alveoli thus ejecting milk. The oxytocin also contracts the uterine muscles: speeding recovery of the uterus to normal size. During the first few days of feeding a fluid called colostrum is secreted. It is not as nutritious as true milk which begins on the fourth day. Milk secretion normally declines within seven to nine months but can be maintained indefinitely through sustained nursing. Breast-feeding carries the following benefits for mother and child: B- best for baby R- reduces incidence of allergy E- economical A- antibodies S- stool in offensive T- temperature is always ideal

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F- fresh milk E- emotionally bonding E- easy once established D- digested easily within 2-3 hrs. I- immediately available N- nutritionally optimal G- gastroenteritis is greatly reduced

V. CONCEPTUAL FRAMEWORK OF THE PATHOPHYSIOLOGY OF PREGNANCY Release of FSH by the anterior Pituitary Gland

Development of the graafian follicle

Production of estrogen
(thickening of the endometrium)

Release of the Luteinizing Hormone Ovulation

(release of mature ovum from the graafian follicle)

Ovum travels into the graafa tube

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Fertilization
(union of the ovum and sperm in the ampulla)

Zygote travels from the fallopian tube to the uterus

Implantation

Development of the fetus/ embryo and placental structure until full term

Preliminary signs of labor

Lightening cervix
(descent of the fetal wherein and head into the pelvis softer like earlobe) labor)

Braxton Hicks Contraction

Ripening of the

(or false labour or practice

(the softened, effaced

contractions)

dilated condition of the cervix just prior to

True labor

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Uterine contractions membranes

(at regular intervals that begin onset before the fetus is mature, usually before the due date of delivery)

Show

Rupture of the

(After the discharge of the mucous

(rupture of the amniotic sac at the

plug that has filled the cervical canal during pregnancy, the pressure of the descending presenting part of the fetus causes the minute capillaries in the cervix to rupture. )

of, or during, labor.)

Non-Recessing Fetal Heart Tone

(when the baby exhibits persistent variable deceleration in which there is cord compression in relation to uterine contractions)

Caesarean Section
(The baby is taken out through the mother's abdomen and uterus.)

VI. THEORETICAL FRAMEWORK OF THE PHYSIOLOGY OF PREGNANCY or PATHOPHYSIOLOGY OF PREGNANCY

Variable decelerations are characterized by slowing of the FHR with an abrupt onset and return. They are frequently followed by small accelerations of the FHR. They vary in depth, duration, and shape. Variable decelerations coincide with cord compression, and they usually coincide with the timing of the uterine contractions. Variable decelerations are the most common decelerations seen in labor, and they are caused by umbilical cord compression. They are generally associated with a favorable outcome. Persistent, deep, and long lasting variable decelerations are nonreassuring.

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Persistent variable decelerations to less than 70 bpm, lasting more than 60 seconds are concerning. Variable decelerations with persistently slow return to baseline are considered nonreassuring, as these reflect persistent hypoxia. Nonreassuring variable decelerations are associated with tachycardia, absence of accelerations, and loss of variability. Variable decelerations are transitory decreases in fetal heart rate caused by umbilical cord compression.

A variable deceleration is unrelated to contractions. They mean umbilical cord compression. They may appear V-shaped or U-shaped. If a woman could be monitored throughout the 9 months of her pregnancy, it would be apparent that variable decelerations occur transiently as the baby grabs the umbilical cord or the cord gets compressed between the baby and the uterine wall during fetal movement. As many as fifty percent of all monitored babies experience variable decelerations during labor. If the baseline fetal heart rate remains stable and the variability remains good, variable decelerations are not associated with poor fetal outcome. They indicate possible compromise if they become prolonged or are persistent.

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VII. CLINICAL MANAGEMENT A. MEDICAL MANAGEMENT A.1 Laboratory and Diagnostic Examinations Hematology Diagnostic Test Hematocrit (Hct) Normal Values 37.0 47.0 vol % Patients Result Significance 0.32 Decreased in various anemias, pregnancy, severe or prolonged hemorrhage and with excessive fluid intake. Decreased in various anemias, pregnancy, severe or prolonged hemorrhage and with excessive fluid intake. Above Normal Below Normal Below Normal Below Normal Normal Normal Normal

Hemoglobin (Hgb)

12 16 g/dL

106

White Blood cells Eosinophills Lymphocytes Monocystes Platelet count MCH MCV

5-10 10`9/L 14% 20 40 % 2 8 % 150,000 450,000/ cumm 27 33 uu gm 82 928 fL

18.20 4.20 6.40 4.20 307.00 28.20 84.00

A.2 Treatment and Procedures After her delivery, she was admitted to the Ob ward with repaired episiotomy. Post partum doctors orders were as follows which was carried out: 3 MEDICATIONS (See Appendix B) - ferrous sulfate(A.FEOSOL) , PO , TID - cephalexin (Airex), PO, TID - mefenamic acid (Revalan), PO, TID

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Patient Ps temperature was monitored until stable. The staff continued to monitor her vital signs and administered prescribed medications. As a student nurse, I also did my assessment towards my patients condition. Upon assessing, I was able to take and record her vital signs: T = 37.5c 70 bpm 20 cpm 90/70 mmHg

Patient I was able to take a bath because of her beliefs. Since she was observing proper hygiene, she looked very neat. She was attentive to all my questions. As I assessed her on her feeling of being admitted in the hospital, she stated that her baby died after she gave birth. I made my independent nursing interventions. I encouraged verbalization of her feeling; I showed willingness while listening to her anxiety and provided her a friendly atmosphere. On the same day, I did my Physical assessment to Patient I and a brief history about her case. A.3 Medications See Appendix B A.4 Diet . Diet and nutrition play a vital role in the health of a postpartum mother. Getting adequate rest, healthy food, and keeping the immune system strong are important. It is important to eat a healthy, well-balanced diet which includes all four food groups. Particularly important to normal delivery are fresh fruits and vegetables, dairy foods and protein, vitamins from food and supplements, especially vitamins E and C as these promote health and healing and help the body resist infection.

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Postoperatively, the patient started with clear soft diet for hours until flatus experienced. Soft diet. This diet is often used during the transition from liquid diets to regular or general diets. Whole foods low in fiber and only lightly seasoned are used. Food supplements or between-meal snacks may be used to add calories. Regular or general diet. Patient has this diet since she had no dietary restrictions and modifications. This is to provide her more protein for wound healing, and more calories in preparation for lactation. Diet as tolerated. It is common for this diet to be ordered postoperatively especially peristalsis has returned. This permits patients preference of food and helps alleviate prolonged use of clear liquid and full liquid diets. Furthermore, this diet order provides an excellent opportunity for collaboration by the nurse, dietician, and patient to plan and provide food that is eaten, tolerated and nourishing. B. NURSING MANAGEMENT A. ACTUAL CARE GIVEN 1. Monitored and charted vital signs every 4 hours 2. Monitored and recorded Input and Output 3. Regulated and time-taped IV fluid at desired rate 4. Encourage patient to rest and sleep 5. Assisted in proper positioning especially when rising in bed 6. Advised significant other to care patient 7. Assisted patient in walking 8. Encouraged patient to sit in bed 9. Provided hair grooming

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10. Did health teaching regarding administration of medication 11. Encouraged conversation and used humor in conversing to patient 12. Provided a positive reinforcement for every effort exerted by the patient in promoting faster recovery. 13. Encouraged use of relaxation techniques such as deep breathing exercises. 14. Provided health teaching on post-partum exercises 15. Taught the importance of breastfeeding and adequate nutrition for lactating mothers. 16. Encourage patient to increase fiber and liquid intake 17. Gave health teaching on proper breastfeeding techniques and the importance of breastfeeding to her and to the baby.

B. PROBLEMS ENCOUNTERED Shes just not comfortable due to Episiorraphy. It is her 1st time to have a baby. But she just manage the pain that she got. C. RESORATIVE MEASURES USED Due

Encourage patient to ambulate early to facilitated circulation of blood flow which can facilitated wound healing.

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D. EVALUATION After 24 hours of nursing care plan, patient was able to demonstrate improvements in her condition. She was able to increase her urine output and was able to verbalize ways in prompting health in her condition. On the other hand, pt. was not able to defecate. Was able to express her feelings openly. Therefore, goal partially met. E. PATIENT TEACHING Patient and significant others were taught to: *Follow the medication regimen as prescribed, encouraged in routine physical activity *Increased fluid, fiber and carbohydrate intake as to facilitate in bowel movement and wound healing. *Report immediately any signs and symptoms of complication to the attending physician for early management. *Do post-partum exercises to promote good circulation of blood

B.1 Nursing Care Plan See Appendix C B.2 Discharge Plan See Appendix D

VIII. CONCLUSION AND RECOMMENDATION Conclusion The main purpose of the study was successfully met., Because of being a preterm., this result to the dying of the baby and as a nursing student who iss assigned, ill

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make sure that she would easily recover from the depress she was undergoing, by let her express her feeling of anxiety. Recommendation

As a nursing student, it is my big responsibility to give the patient the proper recommendation so that she would know what to do if ever there is problem that will arise. Monitored Vital signs and how she will going to position her body. IX. IMPLICATIONS OF THE STUDY TO A.Nursing Education This study helps in learning the concepts of the postpartum period and the care we must rendered to all mothers, the procedures to be performed and how to interact to pregnant. This will also encourage the patient on how they should take care of herself as well as the baby inside of their uterus. B. Nursing Practice The nurse skills must be guided with the rules and regulations in performing care to the patient. the nurse should take note all responsibilities to avoid accident and any other form of malpractice. This will make the practice more effective. C. Nursing Research This study greatly helps in the profession of nursing in dealing with the postpartum cases. This care study will help my fellow nursing students in giving some information and data about normal spontaneous vaginal delivery.

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BIBLIOGRAPHY

Books

Pillitteri, Adele. (2007). Maternal & Child Health Nursing: Care of the Childbearing & Childrearing Family. 5th edition. Lippincott Williams & Wilkins Doenges, Marilynn E. et. al.(2002). Nursing Care Plans. 6th edition. Philadelphia. F. A> Davis Company Altman, Gaylene B. (2005). Delmars Fundamental & Advanced Nursing Skilla. 2nd edition. Thomson/Delmar Learning Potter, Patricia A. et. al. (2005) Fundamentals of Nursing. 6th edition. Elsevier/Mosby Estes, Mary Ellen Z. (2006). Health Assessment & Physical Examination. 3rd edition. Thomson/Delmar Learning. Smeltzer, Suzanne C. et. al.(2008). Textbook of Medical-Surgical Nursing. 11th edition. Lippincott Williams & Wilkins Klossner, N. Jayne et. al. (2006). Introductory Maternity & Pediatric Nursing. Lippincott Williams & Wilkins Karch, Amy M. (2003). Focus on Nursing Pharmacology. 2nd edition. Lippincott Williams & Wilkins Gulanick, Meg. et.al. (2007). Nursing Care Plans. 6th edition. Elsevier/Mosby Clayton, Bruce D. et. al. (2007). Basic Pharmacology for Nurses. 14th edition. Elsevier/Mosby.

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