Submitted By: Bsn-Iv A Submitted To: Clinical Instructor: Cabatbat, Wyen C

Saint Louis University
Baguio City
School of Nursing
S.Y. 2019-2020
ERCP
Submitted By:
Cabatbat, Wyen C.
BSN-IV A4
Submitted To:
Jonas Borja
Clinical Instructor
Baguio City
School of Nursing
S.Y. 2019-2020
DEMOGRAPHIC DATA
Name: C.R.
Age: 28
Address: La Trinidad, Benguet
Religion: Roman Catholic
Birth place: La Trinidad, Benguet
Civil Status: Single
Nationality: Filipino
Occupation: Unemployed
1. CHIEF COMPLAINT: Labor Pain and Active Contractions.

2. HISTORY OF PRESENT ILLNESS: At 2 a.m. in the morning, client started to Labor pain & active contraction. With associated
dizziness. Prior to feelings of pain, patient has observed vaginal discharge milky white in color with a mild smelling.
3. PAST MEDICAL HISTORY: Patient had her first child and delivered through normal spontaneous vaginal delivery and revealed no
complications.
4. HEREDOFAMILIAL HISTORY: There is said to be no history of DM, cancer, pulmonary tuberculosis, and hypertension.
Baguio City
School of Nursing
S.Y. 2019-2020
Discussion of the Case Nursing Care Plan Extensive Learning Insight

A. Demographic Data A. Assessment/Cues Some patient will adhere to the health teachings
The patient, Female, Filipino, Single but S> “ang sakit pero nakakaya ko pa naman at given if they are not distracted by the discomfort
with partner, born on August 22, 1991, nakakalakad pa naman ako”. Patient exhibits that they are experiencing. In my case, I have given
Roman Catholic, currently residing in arching back when contraction episodes appropriate health teachings and I have also
Baguio City). She has 1 child born on July occur. Patient also grimaces when facilitated the discomfort the patient is feeling. It is
21, 2013 in the same institution she has contractions are occurring. Claims to have impossible for the patient to adhere if she is
consulted in. The patient is a housewife 8/10 pain scale. experiencing discomfort. Furthermore, the care
while her partner is a construction worker. O> with stabbing pains, radiating from the rendered must also be optimal and health teachings
abdominal area to the lumbo-sacral area, must be instructed to facilitate the whole delivery
during contractions. However, still able to process.
communicate properly and smile in between
contractions. Facilitating factors that helped in the
implementation of health teaching and optimal care
B. History B. Nursing Diagnosis
Present Illness: Patient was brought into ER Acute pain related to contractions and include the staff who helped out, the patient herself,
with her sister with complaints of dilatation of tissues evidenced by verbal and my prior knowledge. These 3 helped in the
unbearable labor pains and active reports “ang sakit sakit na” and narrowed process of rendering optimal care since it was just a
contractions. With an OB score of G2P1 focus during contractions simple recall of what I needed to ay to the patient,
(1001) the patient is in the latent phase of the staff aided and added critical points and the
labor with. No other threatening symptoms C. Explanation of the problem patient was very conducive and adherent to the
assessed such as elevated blood pressure and Stretching of the peritoneum managements presented.
seizures, verbalized having dizziness. overlying the uterus
Past Illness: the patient claims that her first
child was delivered through normal Stretching of cervix during dilatation
spontaneous vaginal delivery.
Stretching of the ligaments
Baguio City
School of Nursing
S.Y. 2019-2020
Family History of Illnesses: no family Compression of nerve ganglia in the

history of abortions, hypertension, arthritis, cervix
& CVD.
There is hypoxia of contracted

myometrium
Labor pains
D. Objective
In 30 minutes of nursing interventions, the
patient will be able to:
a. Exhibit proper breathing techniques
b. Restate proper bearing down techniques
c. Report discomfort is minimized
d. Appear relaxed/resting between
contractions
E. Implementation/interventions
 Taught proper breathing techniques such
as pursed lip breathing and breathing in
through the nose and breathing out
through the mouth.
 Instructed bearing down techniques such
as exerting pressure on the pelvic floor
rather than exerting pressure on her
head.
Baguio City
School of Nursing
S.Y. 2019-2020
 Instructed with comfort measures such

as sacral pressure, repositioning
 Engaged patient in conversation to
assess sensorium
 Encouraged patient to void when feeling
the need.
F. Brief evaluation
 Fully met if patient is able to achieve 4-
5/5 objectives
 Partially met if patient is able to achieve
3/5 objectives
 Not met if patient is able to achieve 2 or
less than 2 objectives
Patient was able to achieve 5/5 objectives
given. A simple test of recall was done to
assess if the information given to the patient
was retained. She was able to recall all the
information she needed to be used in the
delivery room while enduring labor pains.
References
Doenges, M.E., Moorhouse, M.F., & Murr, A.C. (2008). Nurse's Pocket Guide Diagnoses, Prioritized interventions and Rationales edition 11. Philadelphia: Davis Company.
Doenges, M.E., Moorhouse, M.F., & Murr, A.C. (2010). Nursing Care Plans. Phladelphia, PA: F.A. Davis Company.
Pillitteri, A. (2010). Maternal & Child Health Nursing: Care of the Childbearing & Childbearing Family (Edition 6). Philadelphia, PA 19106: LIppincott Williams & Wilkins.
Priscilla Lemone, Karen Burke. (2014). Medical- Surgical Nursing: Critical Thinking in Patient Care 5th Edition. Pearson.

Submitted By: Bsn-Iv A Submitted To: Clinical Instructor: Cabatbat, Wyen C

Uploaded by

Copyright:

Available Formats

Submitted By: Bsn-Iv A Submitted To: Clinical Instructor: Cabatbat, Wyen C

Uploaded by

Document Information

Original Description:

Original Title

Copyright

Available Formats

Share this document

Share or Embed Document

Sharing Options

Did you find this document useful?

Is this content inappropriate?

Copyright:

Available Formats

Submitted By: Bsn-Iv A Submitted To: Clinical Instructor: Cabatbat, Wyen C

Uploaded by

Copyright:

Available Formats

Saint Louis University

1. CHIEF COMPLAINT: Labor Pain and Active Contractions.

Discussion of the Case Nursing Care Plan Extensive Learning Insight

Family History of Illnesses: no family Compression of nerve ganglia in the

There is hypoxia of contracted

 Instructed with comfort measures such

You might also like