CASE STUDY Acute Pain Related To Laceration 1

OUR LADY OF FATIMA UNIVERSITY
College of Nursing
Valenzuela Campus
120 MacArthur Highway, Marulas, Valenzuela City
CASE STUDY: ACUTE PAIN RELATED TO LACERATION
In partial fulfilment of the requirements for Normal Obstetrics

– Related Learning Experience
CALOOCAN CITY MEDICAL CENTER
DELIVERY ROOM
Submitted by:
Danofra, Eula Paulline C.
Deliola, Angelique C.
Delos Reyes, Lindsay Clarenz I.
Dumdum, Ma. Jessica D.
Egnal, Deah Demma
Submitted to:
Mrs. Marivic E. Ilarde, MAN, RN
CLINICAL INSTRUCTOR
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I. Introduction
Sensation of discomfort and subjective symptom expressed by a human is a pain. It is a

basic protective mechanism that alerts a person with a threatening feeling in the body. Pain is
automatically decreased by the production of endorphins and encephalins, naturally occurring
opiates that limit transmission of pain. In addition, acute pain serves a protective purpose,
warning the body of impending danger by activating the “fight or flight” response of the
sympathetic nervous system, which often produces pallor, diaphoresis, increased pulse rate,
elevated blood pressure, dilated pupils, tenseness of skeletal muscles, and rapid or shallow
respiration. Patients in acute pain may also exhibit such behavioral signs as crying, moaning, or
guarding painful body areas. Physiologic and behavioral signs, however, are not always evident
in acute pain and, if present, may last for only a brief period. Acute pain tends to be easier to
assess and treat than chronic pain. Patients can often localize acute pain, describe its quality and
character and indicate temporal patterns, when it originated and how it has changed over time.
Typically, acute pain is related to a diagnostic procedure such as the normal spontaneous
delivery and is generally defined as lasting no longer than three months or during the period of
postpartum. This could be due to caesarean delivery, breast engorgement, uterine contractions
and perineal laceration or episiotomy. Postpartum is the period after the delivery of a baby and
have physiological changes in mother’s body. The period that women most often suffer from
perineal skin trauma that lead to an acute pain caused by surgical incision such as episiotomy and
laceration considered as the most common types of postpartum morbidities. Episiotomy is a
procedure performed in modern day obstetrics. Some authors estimate that as many as 50 to 60%
of patients who deliver vaginally in the will have an episiotomy. Perineal laceration is classified
as first degree when reaching the skin and mucosa, second degree when extending to perineal
muscles, and third and fourth degree when reaching the anal sphincter muscle.
When the sensory impulses are coming from the perineum, there is a way to block the
occurring pain by administering anesthetic pain relievers. However, the study is about the post
partum pain and the doctors will order parenteral analgesics includes acetaminophen and
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non-steroidal anti-inflammatory drugs (NSAIDs) that will help to reduce the pain. Furthermore,
proper hygiene, daily perineal care and warm and clean bath may help speed the healing that will
gradually lessen the pain. Inadequate management of acute postoperative pain can have
numerous undesirable consequences, including poor patient outcomes, increased likelihood of
readmission, increased health care costs, and patient dissatisfaction.
II. Anatomy and Physiology
THE REPRODUCTIVE SYSTEM
EXTERNAL GENITALIA
Our overview of the reproductive system begins at the external genital area or vulva―
(wrapper or covering) external genitalia of female consist of vestibule and its surrounding
structure. The mons pubis is a prominence formed by a pad of elevating tissue over the pubic
symphysis that covered with coarse hair. The mons pubis contains oil-secreting (sebaceous)
glands that release substances that are involved in sexual attraction (pheromones).
The labia majora (literally, large lips) lateral to labia minora are two prominent, rounded
folds of skin are relatively large, fleshy folds of tissue that enclose and protect the other external
genital organs. They are comparable to the scrotum in males. The labia majora contain sweat and
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sebaceous glands, which produce lubricating secretions. During puberty, hair appears on the
labia majora. The labia minora (literally, small lips) bordered by pair of thin, longitudinal skin
folds. can be very small or up to 2 inches wide. The labia minora lie just inside the labia majora
and surround the openings to the vagina and urethra. A rich supply of blood vessels gives the
labia minora a pink color. During sexual stimulation, these blood vessels become engorged with
blood, causing the labia minora to swell and become more sensitive to stimulation. The region
between the vagina and anus, below the labia majora, is called the perineum. It varies in length
from almost 1 to more than 2 inches (2 to 5 centimeters). The skin and muscle of this region can
tear during child birth. The opening to the vagina is called the introitus. The vaginal opening is
the entryway for the penis during sexual intercourse and the exit for blood during menstruation
and for the baby during birth. When stimulated, Bartholin glands (located beside the vaginal
opening) secrete a thick fluid that supplies lubrication for intercourse. The clitoris, small and
erectile structure located in the anterior margin of vestibule between the labia minora at their
upper end, is a small protrusion that corresponds to the penis in the male. The clitoris, like the
penis, is very sensitive to sexual stimulation and can become erect. Stimulating the clitoris can
result in an orgasm.
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The vagina is a genital canal in the female. a muscular canal (approximately 10 cm long)
that serves as the entrance to the reproductive tract. It also serves as the exit from the uterus
during menses and childbirth. The outer walls of the anterior and posterior vagina are formed
into longitudinal columns, or ridges, and the superior portion of the vagina—called the fornix—
meets the protruding uterine cervix. The walls of the vagina are lined with an outer, fibrous
adventitia; a middle layer of smooth muscle; and an inner mucous membrane with transverse
folds called rugae. Together, the middle and inner layers allow the expansion of the vagina to
accommodate intercourse and childbirth. The vagina is home to a normal population of
microorganisms that help to protect against infection by pathogenic bacteria, yeast, or other
organisms that can enter the vagina. The ovaries are the female gonads located in the pelvic
cavity; produce oocyte, estrogen and progesterone. Paired ovals, they are each about 2 to 3 cm in
length, about the size of an almond. The ovaries are located within the pelvic cavity, and are
supported by the mesovarium, an extension of the peritoneum that connects the ovaries to the
broad ligament. The ovaries produce eggs and hormones. The uterus is a hollow, pear-shaped
organ in which fertilized oocyte developing fetus. The uterus is divided into two parts: the
cervix, which is the lower part that opens into the vagina, and the main body of the uterus, called
the corpus. The corpus can easily expand to hold a developing baby. A channel through the
cervix allows sperm to enter and menstrual blood to exit. Fallopian tubes (oviducts), are narrow
tubes that are attached to the upper part of the uterus and serve as tunnels for the ova (egg cells)
to travel from the ovaries to the uterus. Conception, the fertilization of an egg by a sperm,
normally occurs in the fallopian tubes. The lower part of the uterus extends to the vagina. The
fertilized egg then moves to the uterus, where it implants into the lining of the uterine wall. 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 tube where, if a sperm encounters an
ovum (egg), conception occurs. The cervix is lined with mucus, the quality and quantity of which
governed by monthly fluctuations in the levels of the two principle sex hormones, estrogen and
progesterone.
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III. Pathophysiology
Peripheral sensitization is an increase in sensitivity to an afferent nerve stimuli or sensory

nerve cells and commonly known as peripheral nociceptors. Specialized peripheral sensory
neurons alerts to potentially damaging stimuli. Noxious stimulus detected by the sensory neurons
or the afferent nerve, also it is a tissue damaging event. In clinical situation, noxious stimuli will
result in tissue damage. This process leads to a release of inflammatory mediators such as the
K+1, serotonin, bradykinin substance P, histamine, etc. The aforementioned mediators act to
sensitize high threshold nociceptors that would normally perceived as painful, hence, patient
experienced acute pain. In pain management and acute rehabilitation, reducing and preventing
the release of inflammatory mediators could decrease peripheral sensitization. Use of non-
steroidal anti-inflammatory drugs or NSAIDS will aid the acute pain. Thus, sensible
modification of the injury became a strategy in management and rehabilitation of pain.
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IV. Nursing Health History
Nursing health history is athorough systematic collection of subjective data which stated
by the client, and objective data which observed by the nurse. It will allows the nurse, to obtain
descriptions about the patient’s symptoms, how the symptoms developed, and a process to
discover any associated physical findings that will aid in the development of differential
diagnoses.
PATIENT’S PROFILE
Name: Age: Birthday: Sex:

Patient C.L 16 y/o January 16, 2003 Female
Address: Nationality: Civil status: Religion:
Maypajo, Caloocan city Filipino Single Roman Catholic
Admitting Diagnosis: Admission Date: Ward: Time:
G1P0 Pregnancy August 10, 2019 OB-Gyne ward 4:29 pm
Final Diagnosis: Vital signs upon Admission:
G1P0 Pregnancy Temperature: 36.5° c
Uterine:38 4/7 AOG Heart rate: 80 bpm
Cephalic Respiratory rate: 20cpm
Chief complaint: BP: 110/80mmHg
(+) Labor pain
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HISTORY OF PRESENT ILLNESS

Patient C stated that prior to admission, She experience morning sickness symptoms
of vomiting and since she was late for her period, there was concern that she might be pregnant.
Otherwise: (-) trauma, (-) fever, (-) headache, (-) dyspnea, (-) vaginal bleeding or discharge.
PAST HEALTH HISTORY
Childhood Illness: Childhood immunization:

The patient had some instances of fever, The patient C claimed that she has a
cough and common colds during her childhood complete vaccine and immunization but she
days. She had chicken pox at the age of 9 y/o. can’t remember what she had received.
PAST MEDICAL HISTORY: ALLERGIES:
No known history of previous hospitalization. No known allergies to food and drugs.
FAMILY HISTORY:
(+) HPN Paternal side
OBSTETRIC HISTORY:
The patient C claimed that her first menarche occurred when she was 12 years old. Her
menstruation takes 1 week regularly and she consume 2 pads per day. She claimed that she never
experienced dysmenorrheal during menstruation. She admitted that she had her first sexual
intercourse at the age of 13 years old.
SOCIAL HISTORY:
According to patient C, She is a victim of physical abuse from her boyfriend, when she was not yet
pregnant but denies sexual abuse, receiving judgments and having depression or any suicidal
ideations due to early pregnancy. The child states that sometimes she feel disappointed to herself but
do nothing but to accept and be happy.
.
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V. Physical Assessment
Physical examination follows a methodical head to toe format in the Cephalocaudal

assessment. This is a process of evaluating objective anatomic findings through the use of
observation, palpation, percussion, and auscultation with the use of materials and investments
such as penlight, thermometer, sphygmomanometer, tape measure and stethoscope and also
senses. The information obtained must be thoughtfully integrated with the patient's history and
pathophysiology. During the procedure the student nurses made every effort to recognize and
respect the patient’s feelings as well as to provide comfort measures and follow appropriate
safety precautions.
A. General Physical Assessment
Patient is a 16 years old female, stands 5’4, with pulse rate of 80 beats per minute,
Respiratory rate of 20 breathes per minute and a temperature of 36.1°C. She is conscious
and coherent upon interaction but answer only the questions she is comfortable with.
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. Dandruff and
lice were absent.
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.
D. Assessment of the Ears
Ears are clean, no ear wax noted and approximately of the same size and shape.
Patient can hear normally when spoken softly. No pain is noted.
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E. Assessment of the Nose
With slightly flat nose, 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 missing 3 teeth and 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
and dry upon observation.
J. Assessment of the Neck
Neck has strength that allows movement back and forth, left and right. Patient is
able to freely move her neck without pain.
H. Assessment of the Lungs and Thoracic Region
No reports of pain during inhalation and exhalation. Absence of adventitious

sound upon auscultation. Respiratory rate 20 breathes per minute from the normal range of 15-
20 breathes per minute.
I. Assessment of the Heart
Patient has an audible heart sound. PM1 is heard between 4th-5th intercoasta space.
Heart is pumping well with a pulse rate of 80 beats per minute from the normal range of
60-100 beats per minute.
J. Assessment of the Abdomen
Abdominal movement as with respiration, presence of peristalsis during

auscultation. Presence of scars and hyperpigmentation upon observation.
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K. Assessment of the Upper Extremities
 Skin: Fair in color, presence of marks/scars of wounds in arms and legs. Skin
is slightly rough and dry 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 the arms in front or
push them out to the side.
L. Assessment to the Lower Extremities
Size of the feet is unidentified with linens on the sole, presence of scars and
lesions. Ten fingers are present. Nails are clean and short. Patient is bedrest.
M. Assessment of the Genitalia
A presence of two Genital Warts on the lower left side of the vagina and a post
hemorrhage on the area of the 2° episiorrhaphy. No foul odor is noted.
N. Neurological Assessment
 Behavior- Patient is silent but conscious and coherent upon interaction.

 Motor Functioning- able to move extremities through active ROM. Able
To extend arms and resist active as pushed down/up
on her hands.
 Reflexes- Reflexes were present such as blinking reflex and deep tendon
reflex.
 Sensory Functioning- Patient’s sensory system is intact, she was able to
distinguish touch, pain, hot and cold.
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VI. Laboratory and Diagnostic Exam Results
JULY 24, 2019
CBC &Urinalysis
Complete Blood Count Urinalysis
Test Result Normal Macroscopic Microscopic
Value
Hematocrit 0.33 F=0.38-0.47 Color Yellow W.B.C 3-5/hpf
Hemoglobin 110 F=120-160g/L Transparency Sl. Hazy R.B.C 0-3/h pf
R.B.C Count 3.6 F=4.5-5.5x10 Sp. Gravity 1.015 E.Cell Few
W.B.C Count 6.0 6.0 4.5-11x10 9L Albumin Negative Yeast
Glucose Negative Bacteria Rare
Platelet Count Adequate 150-450x10 Crystals & Cast
9L
A. Urates Rare Hyaline
Differential Count A. Phosphate A. RBC Cast
Neutrophils 0.77 0.50-0.70 Ca.Oxalate
Lymphocytes 0.23 0.20-0.40 Others:
Monocytes 0.02-0.07 Pregnancy:
Eosinophils 0.00-0.03 ABO TYPE: RH TYPE:
Basophils 0.00-0.01
Based on the patient’s CBC & Urinalysis result, The result of CBC; the hematocrit of the patient
is lower than normal, hemoglobin is lower than normal and red blood cells is lower than normal
which indicates that the patient has Anemia. The result of Urinalysis is all Normal.
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75 Oral Glucose Tolerance Test

SI CONVENTIONAL UNIT
Result Normal Value Result Normal Value
EXAMINATION
Fasting Blood Sugar (FBS) 5.08 3.89-6.40 mmol/L 91.52 70.08-115.29 mg/dL
1st Hour 9.58 <10 mmol/L 172.58 <180.15 mg/dL
2nd Hour 9.14 <8.60 mmol/L 164.66 <154.93 mg/dL
Based on the patient’s 75 Gram Oral Glucose Test, The first result was the FBS of the patient
which resulted to be Normal. The second one which is the 1st hour of taking the test is also
Normal. On the 3rd hour, however is lower than normal but it indicates no signs of underlying
conditions.
July 25, 2019
HEMATOLOGY
ABO TYPE RH TYPE
“B” (+) POSITIVE
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Based on the patient’s Hematology, the ABO type of the patient resulted to “B” and the RH type
resulted to (+) positive.
July 24, 2019
The patient undergoes Hepatitis B Screening which results to non-

reactive which means the patient is negative, the patient RPR screening is
also non-reactive which means the patient is negative.
SPECIAL TEST
TEST RESULT RECOMMENDATION
HBs Ag Screening NON REACTIVE REPORT
Rapid Plasma Rea gin (RPR) NON REACTIVE REPORT
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July 25, 2019
SPECIAL TEST
TEST RESULT
HIV SCREENING NON REACTIVE
The patient is HIV Negative.
May 22, 2019
URINALYSIS
MACROSCOPIC RESULT MICROSCOPIC RESULT
COLOR YELLOW Pus Cells (h pf) TNTC
CHARACTER CLOUDY RBC (h pf) 0-1
pH 6.0 Epithelial Cells Occasional
Specific Gravity 1.020 Amorphous Urates Occasional
Albumin Trace Mucus Threads Few
Sugar Negative Bacteria Many
Crystal (l pf)
Casts (l pf)
Pregnancy Test: Others:
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The patient’s Urinalysis result; the urine of the patient under microscopic is positive of having
pus cells which indicates that the patient has Pyuria which makes the patient’s urine to appear
cloudy, the patient’s urine has also albumin traced which is a sign of kidney disease.
May 22, 2019
HEMATOLOGY
Examination Result Reference Value Differential Count Result Reference Value
(M) 140-180 (F) 120-160

Hemoglobin 119.0 (C) 100-140 (P) 100-150 Neutrophil 0.74 0.50-0.75
gm/L
(M) 0.40-0.54 (F) 0.37-0.47
Hematocrit 0.36 (C) 0.30-0.40 (P) 0.30-0.44 Lymphocyte 0.19 0.25-0.49
(Adult) 5.0-10.0 x 10^9/L

WBC Count 0.83 (C) 8.0-15.0 x 10^9/L Monocyte 0.06 0.02-0.06
RBC Count (M) 4.5-6.5 x 10^12/L

3.92 (F) 4.0-4.0 x 10^12/L Eosinophil 0.01 0.01-0.04
Platelet Count ADEQUATE 150-450 x 10^9/L Stab Cell 0.02-0.05
Bleeding Time 1-4 mins. Basophil 0.00-0.01
Clotting Time 2-5 mins. Blood Type “B” POSITIVE

Rh
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Based on the patient’s Hematology, the examination result turns out to be; the hemoglobin,
hematocrit and RBC count is slightly lower than normal but doesn’t indicate underlying
conditions. The lymphocyte of the patient resulted to be lower which indicates lymphocytopenia
which is resulted from a cold or another infection, severe stress, or malnutrition.
BLOOD CHEMISTRY
SYSTEM INTERNATIONAL CONVENTIONAL
TEST RESULT REFERENCE RESULT REFERENCE
FBS
3.94 3.92-5.88 mm o 70.4 70.0-105.0 mg/dL
l/L
Blood Chemistry of the patient is Normal.
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VII. Drug Study
DRUG DRUG ACTION INDICATIONS CONTRAINDICATI ADVERSE EFFECT NURSING

ON CONSIDERATION
GENERIC  Inhibit  Respiratory  Contraindi  CNS: headache, ASSESMENT:
NAME: cell tract infection cated with dizziness,  History:
Cephalexin wall cause by allergy to lethargy, penicillin
(sef a lex’ in) synthe streptococcus, cephalospr paresthesia. or
sis, pneumonia, A ins or cephalos-
BRAND NAME: promot beta-hemolytic penicillins.  GI: nausea, porin
 Apo- ing streptococci.  Use vomiting, allergy,
Ceph osmoti  Skin and Skin cautiously diarrhea, pregnancy,
ale c Structure with renal anorexia, lactation.
 Bloce instabil infection caused failure, abdominal pain,  Physical:
f ity; by lactation flatulence, Renal
 Kefle usually staphylococcus, pregnancy. pseudo function
x bacteri Streptococcus.  Drug may membranous tests,
 Novol cidal.  Otits media increase colitis, resspirator
exi  Bacteri caused by S. risk of hepatotoxicity. y status,
 Nu- cidal: pneumoniae, seizures. skin
Ceph Inhibit haemophilus, Cautiously  GU: status;
alex synthe Influenza, in patient Nephrotoxicity. culture
sis of Streptococcus, with and
DOSAGES: bacteri staphylococcus, history of  HEMATOLOGIC: sensitivity
 500m al cell Moraxella seizures. Bone marrow tests, of
g wall catarrhalis.  Severe depression. infected
causing hypertensi area.
 Bone infections
ROUTE: cell vity  HYPERTENSIVIT
caused by
 Oral death. reactions Y: INTERVENTIONS:
staphylococcus
and proteus can  Ranging from Arrange for culture
FREQUENCY: mirabilis. occurs. rash to fever to and sensitivity test.
 q6x7  GU infections anaphylaxis;  Give drug
days caused by serum sickness with meals
Escheriza coli, P. reaction. if
mirabilis, GIcomplica
-tions
Klebsiella.  OTHER:
occurs.
Superinfections
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DRUG DRUG ACTION INDICATIONS CONTRAINDICATIO ADVERSE EFFECT NURSING

N CONSIDERATION
GENERIC NAME:  An essential  Prevention  Hemochrom  CNS: ASESSMENT:
mineral and a- tosis, seizures,  Monitor
Multivitamins + found in treatment of hemosi- dizziness, blood
feSO4 hemoglobin, iron derosis and headaches, studies of
myoglobin, vitamins and other syncope. patient.
BRAND NAME:
and many dietary evidence of  Observe
 Multiviro enzymes. deficiency iron  CV: proper
n  Enter the anemias. overload; hypotensive, dosage of
bloodstream  Used in anemias not Hypertensio medication.
, and is anemias due due to iron n,  Note other
DOSAGES: transported to blood loss deficiency. tachycardia. drugs
to the organ during patient is
 1 tab of menstruatio Precautions: taking to
 GI: nausea,
reticuloendo n,  Use constipation avoid
ROUTE: thelial Infections, cautiously in possible
, dark stools,
system surgery, peptic ulcer, interaction.
 Oral diarrhea,
(liver, delivery, severe During:
womiting.
spleen, bone intoxications hepatic  Administer 1
FREQUENCY: marrow), impairment, to 2 hours
,  DERMATOGI
 Once a where it is renal before meal.
Parasitosis, C:
day separated impairemen  Do not crush
and other Flushing,
out and t, pregnancy enteric
anemias urticaria.
becomes or lactation. coated
part of iron during
tablets.
pregnancy.  RESPIRATIO
stores. Interaction:  Avoid
 MV+ feSO4  Drug-drug:
N: cough,
coffee, tea,
is prescribe dyspnea
antacids dairy
for that products.
postpartum contains  MS: After:
to prevent calcium, arthralgia,  Monitor
the proton myalgia. adverse
occurency of pump effect
anemias and inhibitor.  Asess bowel
keep 
 Drug-food: LOCAL: pain function.
nutritionally at IM site
iron
balance. absorption
is decreased  OTHERS:stai
33-50% ning teeth,
anaphylaxis,
sweating.
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DRUG DRUG ACTION INDICATIONS CONTRAINDICATIONS ADVERSE EFFECT

GENERIC NAME:  Anthranilic  Short term  Hypersensitivity  CNS: drowsiness,
acid relief of to drugs; GI insomnia, dizziness,
Mefenamic Acid nervousness, confusion,
derivative. mild to inflammation,
headache.
BRAND NAME:  Like moderate ulceration.
ibruprofen pain  Patient who
 Ponstan  GI: severe diarrhea,
inhibits including have
ulceration, bleeding,
prostaglandi primary experienced nausea, vomiting,
DOSAGES: n synthesis dysmenorr asthma, abdominal cramp, flatus,
and affects hea. uricaria, or constipation, hepatic
 500mg cap platelet  Safety in allergic type toxicity.
function. children <1 reaction after
ROUTE:  No evidence year old, taking aspirin or  HEMATOLOGIC:
that is during other NSAIDs. prolonged prothrombin
 Oral
superior to pregnancy time, severe
aspirin. or lactating autoimmune hemolytic
FREQUENCY:
not anemia, leukopenia,
 1 cup q6 PRN
eosinophilia,
established
agranulocytosis, bone
. marrow hypoplasia.
 UROGENITAL:neproxicit
y, dysuria, albuminuria,
hematuria, elevation of
BUN.
 DERMATOGIC:
Flushing,urticaria,
rashes.
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DRUG DRUG ACTION INDICATIONS CONTRAINDIC ADVERSE EFFECT NURSING

ATION CONSIDERATION
GENERIC NAME:  Replaces  Symptomat  Digitali  Syncope,  Have patient
calcium in ic relief of s cardiac chew antacid
Calcium
deficiency upset toxicit arrest, tablets
Carbonate
states, stomach y, dysrhyth thoroughly
BRAND NAME: controls associated Hyper mia, before
hyper- with calce bradycard swallowing;
 Caltrate phosphaturia. hyperacidit ia, following
mia.
 Calcium is y, gastritis,  Renal asystole, with a glass
DOSAGES: essential for peptic calculi metallic of water or
function, esophagitis  Ventri taste, milk.
 1 tab integrity of , gastric tissue  Give calcium
cular
nervous, hyperacidit fibrilla necrosis. carbonate
ROUTE: muscular, y, hiatal  Nausea, antacid 1
tion
 Oral skeletal hernia. during Hypercalc and 3 hours
system.  Prophylaxis cardia emia, after meals.
FREQUENCY:  Important of GI c rebound  Report loss
 Once a role in bleeding, resusci hyperacid of appetite,
day normal stress tation. ity and nausea and
cardiac, renal ulcers and  Hypert milk vomiting,
function, aspiration ensive alkaline abdominal
respiration, of to syndrome pain,
blood pneumonia drugs. , constipation,
coagulation, possibility. alkalosis, dry mouth,
and cell  Dietary renal thirst,
membrane supplemen damages. increasing
and t when  Constipati voiding.
capillaries. calcium on,
 Assist in intake is flatulence
regulating adequate. ,
release/stora diarrhea,
ge of renal
neurotransmi disfunctio
tter n.
hormones.
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VIII. Nursing Care Plan
ASSESSMENT NURSING BACKGROUND GOALS OF INTERVENTI RATIONALE EVALUATION

DIAGNOSIS KNOWLEDGE CARE ON
SUBJECTIVE: Acute pain EPISIORRAPH SHORT 1. Assess vital 1. Elevated SHORT TERM:
“Sobrang sakit related to Y TERM: signs especially blood pressure After 2 hour of
po” effects of labor ↓ done by Within 2 her blood is usually nursing
“hindi ko po and delivery hours of shift pressure level. observed. intervention the
maintindihan process as SUTURE of nursing 2. Obtain client 2. Observations client’s pain is
yung sakit” evidence by ↓ causes interventions assessment of may or may not relieved and
“Hindi po ako facial grimace , the client’s pain including be congruent controlled. The
makatulog ng and a pain WOUND pain is location, with verbal pain scale
maayos” scale score of ↓ leads to relieved and characteristic, reports or may decrease 8/10 to
8 out of 10. controlled. onset, be only 2/10
OBJECTIVE: ACUTE PAIN frequency, indicators
 Facial LONG quality, present when LONG TERM:
grimace TERM: intensity and client is unable After 3 days the
 Expressiv Within 3 precipitating to verbalized. pain and
e days the pain factors. 3. Before discomfort is no
behavior will decrease Observed non- sitting squeeze longer felt. The
(Uncomf or no pain verbal ques. buttocks sleeping pattern
ortable and 3. Promotes together and sit is improved. The
and discomfort perineal within that pain scale is
irritable) that may exercise and position to 0/10.
 Restlessn improve comfortable reduce
ess sleeping sitting position. discomfort.
 Pain patterns. 4 .Promotes 4. The patient
scale: positive may fix her
8/10 reinforcement mind frame
 Vital and about the pain,
Signs: encouragement this in return
BP= to patient. will lessen the
130/80 5. Promotes perception of
teaching pain and
between uterine anxiety.
contraction and 5. To promote
breathing non
technique. pharmacologic
pain
management.
22
College of Nursing
Valenzuela Campus
Assessment NURSING BACKGR GOALS INTERVEN RATIONALE EVALUA

DIAGNOSIS OUND OF CARE TION TION
KNOWL
EDGE
S: Knowledge Teenage SHORT 1. Evaluate 1. Individual SHORT
“Ma’am ano po ba deficit related Pregnancy TERM: desire/readine may not be TERM:
ginawa sakin? to care of ↓ Within 1 ss of patient physically, After 1
Matagal po ba itong episiotomy as hour of to learn. emotionally, or hour of
gumaling?” as evidence by Primigrav nursing mental capable nursing
verbalized by the patient’s first ida intervention at this time. interventio
patient. experience s the client 2. Explain 2. Provides ns the
O: with the ↓leads to will be able episiotomy knowledge base client was
 Presence of procedure. to express process at from which able to
perineal Knowledg understandi client’s level client can make expressed
wounds due e Deficit ng about the of informed understan
to 2nd degree process and understanding choice. ding about
episiotomy treatment of . 3. Will allow the
 V/S taken as the family and process
follows: episiotomy. 3. Teach patient to be and
-BP: 120/80 patient and proactive in treatment
-T: 36°C family about patients care and of the
-RR: 20 breaths per signs and health. episiotom
minute symptoms to 4. To provide y.
-PR: 80 bpm look out for. information to
the client
4.Discuss the regarding the
possible activities that
restriction in she needs to
activity avoid.
because of
her condition
23
College of Nursing
Valenzuela Campus
Assessment NURSING BACKG GOALS INTERVENTI RATIONALE EVALUATION

DIAGNOS ROUND OF ON
IS KNOWL CARE
EDGE
S: Risk for Wound SHORT 1. Change 1. To prevent SHORT TERM:
“Meron po infection ↓invasion TERM: perineal pads vaginal After 1 hour of
akongtahisaari related to a of Within 1 frequently. contamination or nursing interventions
ko, pano po site for hour of infection. the client was able to
baiwasannamag organism Pathogeni nursing 2. Assess general 2. To determine any verbalize different
karoon ng invasion as c intervent condition deviations from ways on how to
impeksyon?” as evidence Organism ions the normal. prevent infection.
verbalized by by 2nd s client 3. Assess skin 3. The skin is the
the patient. degree ↓leads to will be for severity of body’s first line of LONG TERM:
O: Median able to skin integrity defense against After two days of
 Presenc Episiotomy Bacterial verbaliz compromise. infection. Disruption nursing intervention
e of . Growth e of the integrity of the client was free
perineal ↓ different skin increases the from infection.
wounds ways on 4. Perfrom patient’s risk of
due to Colonizat how to perineal care. developing an
2nd ion prevent infection or of
degree ↓causes infection scarring.
episioto . 5. Encourage 4. To promote
my INFECTI intake of protein- cleanliness to the
 Good ON LONG rich and calorie- perineal area.
skin TERM: rich foods. 5. Helps support the
turgor Within immune system
 WBC two days 4. Maintain or responsiveness.
Count: of teach asepsis for 4. Aseptic technique
6.5 nursing dressing changes decreases the
 V/S intervent and wound care. changes of
taken as ion the transmitting or
follows: client spreading pathogens
-BP: 120/80 will be to the patient.
-T: 36°C able to Interrupting the
-RR: 20 breaths be free transmission of
per minute from infection along the
-PR: 80 bpm infection chain of infection is
. an effective way to
prevent infection.
24
College of Nursing
Valenzuela Campus
IX. Discharge Planning
Name:Lubo, Cristina Sex: Female
Age: 16 y/o Civil Status: Single
Date Admitted: 08/20/19
Chief Complaint:Labor pain
Admitting Impression: G1P1, Cephalic delivery simultaneously to all body

parts.
Course in The Ward: u/n
Medications: Multivitamins, Cefalexin, Mefenamic Acid, Ferrous Sulfate
Special Instructions/Andillary Procedure:Breastfreeding, Perinial Care
Follow Up: After 1 week.
Medications:Multivitamins, Cefalexin, Mefenamic Acid, Ferrous Sulfate
Exercise: 150 minutes/week of moderate-intensity aerobic activity
Treatment:Perenial care everyday
Health Teaching: Educate yourself, sleep and eat properly, exercise and
avoid making major life changes after childbirth
Diet: Drink plenty of fluids, eat foods that have protein such as milk, cheese,
yogurt, meat, fish and beans, eat your fruits and vegetables and limit junk
foods.
25
College of Nursing
Valenzuela Campus
X. References
Anaesth, I. J. (2006). Acute Post Operative Pain. 50(5), p340-344.
Claudette. (2012). Nursing Health Assessments. Retrieved from
https://www.slideserve.com/claudette/nursing-health-assessments
Episiotomy. Johns Hopkins Medicine. Rerieved from
https://www.hopkinsmedicine.org/health/treatment-tests-and-therapies/episiotomy
Flagg, S. J., & Pillitteri, A. (2018). Maternal and Child Health Nursing: Physiology of Pain.
Philippines: Absolute Services Inc.
Introduction and scope (2013). Retrieved from
https://www.ncbi.nlm.nih.gov/books/NBK190083/
Jungquist, C. R., Vallerand, A. H., Sicoutris, C., Kwon, K. N., & Polomano, R. C.
(2017). Assessing and Managing Acute Pain. AJN, American Journal of
Nursing, 117. doi:10.1097/01.naj.0000513526.33816.0e
Kizza, I. B. & Nabirye, R. C. (2016). Nurses’ knowledge of the principles of acute
pain assessment in critically ill adult patients who are able to self-report.
International Journal of Africa Nursing Science,4,p.20-27. Retrieved from
https://www.sciencedirect.com/science/article/pii/S2214139116300026
Regan, J. L., Russo, A. F., & VanPutte, C. (2019). Seeley’s Essential of Anatomy
and Physiology. New York: McGraw Hill Education
26
College of Nursing
Valenzuela Campus
Team, T. H. (2019). Labor & Delivery: Episiotomy. Retrieved from
https://www.healthline.com/health/pregnancy/intrapartum-cepisiotomy
The American College of Obstetricians and Gynecologists: Womens Health Care
Physicians (2018). Postpartum Complications [PDF File]. Retrieved from
https://www.acog.org/-/media/Departments/Toolkits-for-Health-Care-
Providers/Postpartum-Toolkit/ppt-
complications.pdf?dmc=1&ts=20190815T1458467928
XI. Profile of Group Members
Danofra, Eula Paulline C. Deliola, Angelique C.

0956-720-4756 0995-654-0956
#33 Orange Rd. Potrero, Malabon City #132 Damzon St. Dampalit, Malabon City
eulapaullinedanofra@gmail.com angeldeliola26@gmail.com
Delos Reyes, Lindsay Clarez I. Dumdum, Maria Jessica D.

0915-922-6085 0998-854-8922
#516 Dimasalang St.Maypajo, Caloocan City #62 Interior Santiago St. San Antonio, Quezon City
Lindsayclrnz09@gmail.com i.jessica.dumdum@gmail.com
27
College of Nursing
Valenzuela Campus
Egnal, DeahDemma
0921-945-4073
Blk 16 Phase 2 Area 3 Dagatdagatan, Longos, Malabon city
deahquiatchon@gmail.com
XII. Inputs/Contributions of Group Members
Danofra, Eula Paulline C.
 Pathophysiology
 Introduction
 References
 Compilation
Deliola, Angelique C.
 NCP
 Profile of the members
 Drug Study
Delos Reyes, Lindsay Clarenz I.
 Nursing Health History

 Powerpoint for the case study presentation
28
College of Nursing
Valenzuela Campus
Dumdum, Ma. Jessica D.
 Introduction
 Anatomy and Physiology
 NCP
 Physical Assessment
Egnal, Deah Demma
 Discharge Planning
 Laboratory and diagnostic exams result
29

CASE STUDY Acute Pain Related To Laceration 1

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CASE STUDY Acute Pain Related To Laceration 1

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OUR LADY OF FATIMA UNIVERSITY

CASE STUDY: ACUTE PAIN RELATED TO LACERATION

In partial fulfilment of the requirements for Normal Obstetrics

CALOOCAN CITY MEDICAL CENTER

Delos Reyes, Lindsay Clarenz I.

Dumdum, Ma. Jessica D.

Egnal, Deah Demma

Mrs. Marivic E. Ilarde, MAN, RN

Sensation of discomfort and subjective symptom expressed by a human is a pain. It is a

II. Anatomy and Physiology

THE REPRODUCTIVE SYSTEM

Peripheral sensitization is an increase in sensitivity to an afferent nerve stimuli or sensory

IV. Nursing Health History

Name: Age: Birthday: Sex:

HISTORY OF PRESENT ILLNESS

PAST HEALTH HISTORY

Childhood Illness: Childhood immunization:

Physical examination follows a methodical head to toe format in the Cephalocaudal

A. General Physical Assessment

B. Assessment of the Head

C. Assessment of the Eyes

D. Assessment of the Ears

E. Assessment of the Nose

F. Assessment of the Mouth

J. Assessment of the Neck

H. Assessment of the Lungs and Thoracic Region

No reports of pain during inhalation and exhalation. Absence of adventitious

I. Assessment of the Heart

J. Assessment of the Abdomen

Abdominal movement as with respiration, presence of peristalsis during

K. Assessment of the Upper Extremities

M. Assessment of the Genitalia

 Behavior- Patient is silent but conscious and coherent upon interaction.

VI. Laboratory and Diagnostic Exam Results

JULY 24, 2019

75 Oral Glucose Tolerance Test

July 25, 2019

ABO TYPE RH TYPE

“B” (+) POSITIVE

July 24, 2019

The patient undergoes Hepatitis B Screening which results to non-

TEST RESULT RECOMMENDATION

HBs Ag Screening NON REACTIVE REPORT

Rapid Plasma Rea gin (RPR) NON REACTIVE REPORT

July 25, 2019

HIV SCREENING NON REACTIVE

The patient is HIV Negative.

May 22, 2019

May 22, 2019

Examination Result Reference Value Differential Count Result Reference Value

(M) 140-180 (F) 120-160

(Adult) 5.0-10.0 x 10^9/L

RBC Count (M) 4.5-6.5 x 10^12/L

Platelet Count ADEQUATE 150-450 x 10^9/L Stab Cell 0.02-0.05

Bleeding Time 1-4 mins. Basophil 0.00-0.01

Clotting Time 2-5 mins. Blood Type “B” POSITIVE

which is resulted from a cold or another infection, severe stress, or malnutrition.

SYSTEM INTERNATIONAL CONVENTIONAL

TEST RESULT REFERENCE RESULT REFERENCE