OB CASE STUDY GRAND

PRESENTATION
 PATIENTS PROFILE:
Mrs. Rowena Salas

• Age: 30 years of age

• Address: Cala-cala, Macasandig
CDO
• Last Menstrual Period: December 22, 2008
• Height: 4’9’’ ft
• Weight: 53 kg.
• Civil Status: Married
• Educational Attainment: High School Level
• Religion: Roman Catholic
• Citizenship: Filipino
• Occupation: Housewife
• Expected Date of Confinement: September 29, 2009
• Name of Husband: Marcelo Salas Sr.
• Occupation: Laborer
• Number of Children: Three (3)
Fourth Pregnancy:
• LMP: December 22, 2008
• EDC: September 29, 2009
• Number of fetus: One (1)
• Presentation: Cephalic
• FHB: 128 beat per minute
• Prenatal Visits: Monthly at their clinic at Tibasak,
Macasandig CDO
• Medication: Ferrous Sulfate
• Date of Delivery: September 16, 2009
• Manner of Delivery: Normal Spontaneous Vaginal
Delivery
• Delivery History: G4P4T3P0A0L3
• Tetanus Toxoid 1, 2,& 3: During the previous pregnancies
• Tetanus Toxoid 4: 2009
• Tetanus Toxoid 5: September 16, 2010
ASSESSMENT:
First visit (July 24, 2009) Second visit (August 3, 2009)
• Age of Gestation: 33 weeks Age of Gestation: 36 weeks
• FHT: no chance to conduct yet FHT: 145bpm (LLQ)
• Respiration: 17cpm Respiration: 20 cpm
• Pulse Rate: 108 bpm Pulse Rate: 99 bpm
• Temperature: 36.4*c Temperature: 36.9*c
• Blood pressure: 100/60mmHg Blood Pressure: 90/60mmHg

Third Visit (September 7, 2009) Fourth visit (September 27,2009)

• Age of Gestation: 38 weeks Respiration: 18 cpm
• FHT: 130bpm (left lower quadrant) Pulse Rate: 90 bpm
• Respiration: 23 cpm Temperature: 36.8 C
• Pulse Rate: 95 bpm Blood Pressure: 100/70 mmHg
• Temperature: 36.6 C
• Blood Pressure: 100/80 mmHg
Baby Marcelo

• Respiration: 48 cpm
• Pulse Rate: 125 bpm
• Temperature: 36. 9 C
• Blood Pressure: N/A
Vaccine 1st Dose 2nd Dose 3rd Dose
BCG 9-16-09 --- ---
DPT --- --- ---
OPV --- --- ---
Hepatitis B --- --- ---
HEALTH HISTORY
Mrs. Rowena Salas had never gone any
surgery during her pregnancy. She hasn’t
experienced abortion or death of the infant during
delivery, and she hasn’t attempted to abort the
child.
She has not received any blood transfusion.
She experienced constipation during her second
pregnancy, her 4th months of pregnancy and she
haven’t take any medicines during that time, but
she has able to manage constipation by eating
fruits that would facilitate easy and normal bowel
movement. She is neither drinking alcohol nor
smoking. She eats any kind of foods, especially
nutritional foods, foods that is known to have rich
in iron such as “kalamunggay” which is very
readily accessible around the community.
 This is good and recommended for her knowing
that she has low blood pressure and red blood cell
count during her past pregnancies and also now.
She is also not allergic to any kinds of drug.
Our patient claims that they have no common
diseases within their family, or the so called the
heridofamilial disease. So we asked the most
common disease that the family has acquired. As
claimed, the most common disease in their family
was Tuberculosis.
During her first trimester of pregnancy she had
experienced nausea and vomiting.
PHYSIOLOGY OF LABOR
Mechanism of labor

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

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

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

• Internal Rotation – The head flexes as it touches the pelvic floor and the occiput
rotates until it is superior, or just below the symphisis pubis, bringing the head into
the best relationship to the outlet of the pelvis. This movement brings the
shoulders, coming next, into the optimal position to enter the inlet, putting the
widest diameter of the shoulders in line with the wide transverse diameter of the
inlet.
• Extension – As the occiput is born, the back of the neck
stops beneath the pubic arch and acts as a pivot for the rest
of the head. The head extends and the foremost parts of the
head, and the face and chin, are born.
• External Rotation – In external rotation, almost immediately
after the head of the infant is born, the head rotates back to
the diagonal back to the diagonal or transverse position of
the early part of labor. This brings the after coming
shoulders into an anteroposterior position, which is best for
entering the outlet. The anterior shoulder is born first,
assisted perhaps by downward flexion of the infant’s head.
• Expulsion – One of the shoulders are born, the rest of the
baby is born easily and smoothly because of its smaller size.
This is the end of the pelvic division of labor.
Theories of the stages of Labor
A. Hormonal factors

• Estrogen theory

• Progesterone withdrawal theory

• Prostaglandins theory

• Oxytocin theory

• Fetal cortisol theory

B. Mechanical factors

• Uterine distension theory

• Uterine Stretch Theory

• Theory of Aging Placenta

• STAGES OF LABOR

The First Stage:

» Latent Phase
» Active Phase
» Transition Phase
The Second Stage:
» Fetal Expulsion

The Third Stage:

» Placental separation

The Fourth stage:

» Recovery
SIGNS OF LABOR
PRELIMINARY SIGNS OF LABOR

»LIGHTENING
»Increase in Level of Activity
»Braxton Hicks Contractions
»Ripening of the Cervix
 SIGNS OF TRUE LABOR

UTERINE CONTRACTIONS
• The surest sign that labor has begun is productive uterine
contractions. Because contractions are involuntary and
come without warning, their intensity can be frightening in
early labor. Helping a woman appreciate that she can
predict her pattern and therefore can control the degree of
discomfort she feels by using breathing exercises offer her
a sense of control.
SHOW
• As the cervix softens and ripens, the mucus plug that filled
the cervical canal during pregnancy (operculum) is
expelled. The exposed cervical capillaries seep blood as a
result of pressure exerted by the fetus. The blood, mixed
with mucus, takes on a pink tinge and is referred to as
“show”. Women need to be aware of this event so that they
do not think they are bleeding abnormally.
RUPTURE OF THE MEMBRANES
• Labor may begin with rupture of the membranes,
experienced either as a sudden gush or as scanty,
slow seeping of clear fluid from the vagina. Some
women may worry if their labor begins with rupture
of the membranes, because they have heard that
labor will then be “dry” and that this will cause to
be difficult and long. Actually, amniotic fluid
continues to be produced until delivery of the
membranes after the birth of a fetus, so no labor is
very”dry”. Early rupture of the membranes c an be
advantageous if it causes a fetal head to settle
snugly into the pelvis; this can actually shorten
labor.
 DIFFERENTATION BETWEEN TRUE AND FALSE LABOR CONTRACTION

FALSE CONTRACTION TRUE CONTRACTION

Begin and remain irregular. Begin irregularly but become
regular and predictable.

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

Often disappear with ambulation Continue no matter what the

and sleep. woman’s level of activity.

Do not increase in duration, frequency Increase in duration, frequency,

or intensity. and intensity.
COMPONENTS OF LABOR
A. Passage
B. Power of Labor
a. Uterine Contraction

b.Cervical Changes
» Effacement
» Dilatation
c. Psyche
d. Passenger
» Structure of the fetal Skull
» Diameters of the fetal skull
FETAL PRESSENTATION AND POSITION
Two other factors play a part in whether a fetus is lined
up in the best position to be born; fetal presentation and
position.

»Attitude
»Engagement
»Fetal station
»Fetal lie
TYPES OF FETAL PRESENTATION
Fetal presentation denotes the body part
that will first contact the cervix or be born
first. This is determined by a combination of
fetal lie and the degree of fetal flexion.

Cephalic (head-first) presentation:

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

Shoulder presentation
TYPES OF FETAL POSITION
 Type of Fetal Presentation
Position is the relationship of the presenting part to a
specific quadrant of a woman’s pelvis. For convenience, the
maternal pelvis is divided into four quadrants according to
mother’s right and left: (1) right anterior, (2) left anterior, (3)
right posterior, and (4) left posterior. Four parts of a fetus
have been chosen as landmarks to describe the relationship
of the presenting part to one of the pelvic quadrants. In a
vertex presentation, the occiput is the chosen point; in a
face presentation, it is the chin (mentum), in a breech
presentation, it is the sacrum; in a shoulder presentation, it
is the scapula or the Acromion process. Position is indicated
by an abbreviation of three letters. The middle letter denotes
the fetal landmark (O for occiput, M for mentum, Sa for
sacrum, and A for Acromion process). The first letter defines
whether the landmark is pointing to the mother’s right (R) or
left (L). The last letter defines whether the landmark points
anteriorly (A), posteriorly (P), or transversely (T).
IDEAL NURSING INTERVENTION
A. Antepartum
1.)Fatigue
• Nursing Diagnosis: fatigue related to physiologic
demands of pregnancy and labor
• Note clients belief about what is causing the fatigue and
what relieves it to give a sense of respect.
• Advice client to increase amount of rest and sleep to
relieve fatigue
• Instruct methods to conserve like sitting instead of
standing to conserve energy.
• Advice client to sleep in side lying position to allow good
circulation in lower extremities.
• Provide environment conducive to relief of fatigue since
high temperature are known to affect exhaustion.
2.)Breast Tenderness
• Nursing Diagnosis: disturbed body image related to breast tenderness
secondary to pregnancy.
• Advice patient to dress warmly to avoid cold drafts.
• Encourage patient to wear a bra with a wide shoulder strap for
support.
• Sleeping Pattern
• Nursing Diagnosis: Altered sleep pattern disturbance due to change
body image related to pregnancy
• Create quite environment conducive to sleep; for example, close
curtains, adjust lighting, and close doors. These measures promote
rest and sleep.
• Ask patient to describe and specific terms each morning the quality of
sleep during the previous night. These help detect sleep related
behavioral symptoms.
• Educate patient in such relaxation techniques as guided imagery.
Purposeful relaxation effort usually help promotes sleep
• Administer medication that promotes normal sleep patterns as
ordered. Hypnotic agent induced sleep; tranquillizers reduces anxiety
• Allow patient to discuss any concern that maybe preventing sleep.
Active listening help you to determine causes of difficulty with sleep
B. Intrapartum
1.)Fear
• Nursing Diagnosis: Fear related to stressful situation secondary to labor
and delivery.
•
– Sense of abandonment can exacerbate fear.
– Encourage and assist client to develop exercise program.
– Explain procedures within level of clients ability
– Provide a healthy outlet for energy generated by feeling and promotes
relaxation.
– Stay with the client of make arrangements to have someone else be there.
2.)Powerlessness
• Nursing diagnosis: powerlessness related to change in labor pattern and
increase in contraction in pregnancy.
• Reassure as appropriate, the labor is proceeding without problems.
• Slowly and clearly explain the events and changes occurring with the
active stage of labor. Inform the couple of things that can and cannot be
controlled.
• Emphasize positive aspects of situation and what can be controlled.
• Assess couple for contributing factors related to feeling of control.
3.)Risk of Infection
• Nursing diagnosis: risk for infection related to
rupture of amniotic membrane.
• Maintain sterile technique for invasive
procedures.
• Monitor visitors/caregivers to prevent exposure
of client.
• Maintain adequate hydration.
• Stress proper hand washing techniques by all
caregivers between therapies/clients. It is a first
line of defense against nasocomial infections or
cross contamination.
• Stand or sit to void and catheterize if necessary
to avoid bladder distention.
C. Postpartum
1.)Sleep Pattern
• Nursing Diagnosis: Disturbed sleep pattern related to exhaustion from
and excitement of birth
• Ask patient what environmental factors make sleep difficult. Sleeping and
strange or new environment tends to influence both REM and non-REM
sleep
• Ask patient what changes would promote sleep. This allows patient to
take an active role in treatment.
• Make whatever immediate changes are possible to accommodate patient;
for example, reduce noise, change lighting, and close door. These
measure promote rest and sleep.
• Plan medication administration schedule to allow for maximum rest. If
patient requires diuretics in the evening, give far enough in advance. To
allow peak effect before bedtime.
• Instruct patient to eliminate caffeine from diet, limit alcohol intake, and
avoid foods that interfere with sleep (for example, spicy foods). Foods
and beverages containing caffeine consumed fewer than 4 hours before
bedtime may interfere with sleep.
D. Newborn Care
1. Ineffective thermoregulation
• Nursing Diagnosis: Risk for ineffective thermoregulation
related to newborn’s transition to extra uterine environment.
• Gently rub a newborn dry to allow little body heat lost by
evaporation.
• Swaddle the newborn loosely with a blanket to prevent
compromising respiration.
• encourage the patient to place the child on the parent’s arms
to conserve heat and encourages bonding
• perform extensive procedures, such as resuscitation, under
the radiant heat source to reduce heat loss
• encourage the mother to start breast-feeding immediately
after birth to reduce heat loss
2. Injury
• Nursing Diagnosis: Risk for injury related to
newly clamped umbilical cord.
• perform cord care properly to prevent infection
• put the permanent cord clamp to the infant cord
to prevent further complications such as
infection
• inspect the cord to be certain it is securely
clamped to prevent hemorrhage
• encourage the parents to continue providing
cord care to keep the cord dry until it falls off
after they return home
 2.)Fear
• Nursing Diagnosis: Fear related to uncertainty of pregnancy
outcome.
• Encourage patient to identify of fear. Patient’s perceptions
maybe erroneously based.
• Explain all treatments and procedures, answering any
questions patient might have. Present information at
patient’s level of understanding or acceptance to reduce
patient’s anxiety and enhance cooperation.
• Orient patients to surroundings. This enhances patient’s
ability to orient to time, place, person and events.
• Assign the same nurse to care for patient whenever
possible. Provide consistency of care, enhance trust, and
reduce threat commonly associated with multiple caregivers
• Spend time with patient each shift to allow time for
expression of feelings. Provide emotional outlet, and
promote feeling of acceptance.
Discomfort Solution
Ankle Edema Rest with your feet elevated, avoid
standing too long, avoid restricted
garments in the lower half of your
body.
Backache Apply local heat, avoid long period
of standing, Stoop to pick up
object.
Constipation Increase fiber in your diet. Drink
additional fluids, Have a regular
time for bowel movement.
Difficulty in Drink warm water, caffeine free
Sleeping drink before bed, practice
relaxation technique.
Fatigue Schedule rest daily, Have a regular bedtime
routine, have extra pillow for comfort.

Faintness Move slowly, avoid crowds, lie on your left side

when at rest.

Leg Cramps Avoid pointing your toes, straighten your legs

and dorsiflex your ankle.

Nausea Eat a piece of dry toast or some crackers before

getting to bed. Eat six small meals rather than 3

Shortness of Breath Use proper posture, use pillow behind head,

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

Varicose Veins Walk regularly, rest with feet

elevated, avoid long period of
standing, Avoid knee-high
stockings
Heart Burn Eat small frequent meals, avoid
over eating as well as spicy, fatty,
and fried food
 ACTUAL NURSING INTERVENTION
• Antepartum
• Reducing Anxiety and Providing Knowledge in
Preparation for Labor, Delivery, and Parenthood:
• Encourage the women and couple to discuss
their knowledge, perception, and expectations of
the labor and delivery process.
• Provide information on childbirth education
classes and encourage participation.
• Discuss coping and pain control techniques for
labor and birth
• Encourage the women and couple to discuss
their perception and expectations of parenthood
and their “ idealized child ”
• Discuss physical preparations for infant, such as
a sleeping space, clothing, feeding, changing and
bathing equipments.
• Encourage discussion of feelings and concerns
regarding the new role of mother and father
• Teaching the women and couple that there are
no contraindications to sexual activity provided
the woman’s membranes are intact, there is no
vaginal bleeding, and she has no current
problems or history of premature labor
• Promoting Exercise and Mobility:
• Explain that exercise during pregnancy should in keeping
with the woman’s pregnancy pattern and type of exercise.
• Identify activities or sports that have a risk of bodily harm.
• Explain the endurance of during exercise may be
decreased.
• Recommended exercise classes for pregnant woman that
concentrate and toning and stretching to enhance physical
condition, increase self-esteem, and provide socialization.
• Avoiding Constipation
• Instruct the woman to increase her fluid intake to at least 8
glasses of water a day; 1-2 liter of fluid per day is desirable.
• Teach in food high in fiber.
• Encourage regular patterns of elimination.
• Encourage daily exercise such as walking.
• Discourage the use of over -the-counter laxatives; bulk
forming agents that may prescribe if indicated.
• Minimizing Fatigue
• Advised 8 hours rest at night.
• Advised the woman that, in the later months of pregnancy,
sleeping on the side under the pillow may enhance comfort.
• Encourage frequent 15-30 min. rest period during the to

• avoid over fatigue.

• Suggest the woman work while sitting with legs elevated
whenever possible.
• Discourage standing prolonged periods, especially during
third trimester.
• To promote placental perfusion, discourage the woman from
lying on the back-the left lateral position provides the best
placental perfusion.
Intrapartum
– Strengthening Coping
• Providing comfort measure measures, which may include
back and leg rubs; a cool cloth to face, neck, abdomen, or
back; ice chips to moisten mouth; clean pads and linens as
needed; and quite environment; and repositioning- either
side preferable –with the pillow and blanket.
• Encourage the women to deal with one contraction at a time
and to alter her breathing techniques to maintain control.
Provide reassurance method encouragement during each
contraction.
• Encourage resting between contraction.
• Postpartum
-Reducing Fatigue
• Provide a quite and minimally disturbing environment.
• Organizing nursing care to keep interruption to a minimum.
• Encourage the women to minimize visitors and phone calls.
• Encourage the women to sleep while the baby is sleeping.
•
 Promoting Breast-feeding
• Have the mother wash her hands before feeding to help prevent
infection.
• Encourage the mother to assume a comfortable position, such as sitting
upright, tailor sitting, or lying on her sides.
• Have the women hold the baby so he or she is facing the mother “cradle
hold,” with the baby’s head and body are supported against mother’s
arm with buttocks resting in her hand; the “football hold” supports the
baby’s legs under the mother’s arm while his or head is at the breast
resting in her standing; lying on the side with the baby lying on his or her
side facing the mother.
• Have the women place her nipple against the baby’s mouth, and, when
the mouth opens, guide the nipple and the areola into mouth.
• Encourage the women to alternate the breast she begins feeding with at
each feeding to ensure emptying of both breast and stimulation for
maintaining milk supply.
• Teach the mother to provide for adequate rest and to avoid tension,
fatigue and a stressful environment, which can inhibit the letdown reflex
and make breast milk less available at feeding.
• Advise the women to avoid taking medications and drugs because
many substance pass into the breast milk and may affect milk
production or the infant
Promoting Health Maintenance
• Teach the woman to carry out perineal care.
• Teach the woman to apply perineal pads by touching the outside
only.
• Inform the woman that intercourse may be resumed when
perineal and uterine wounds have healed.
• Counsel the woman to provide quiet times for herself at home and
help her establish realistic goals for resuming her own interests
and activities.
• Teaching the Postpartum Exercise
• Instruct the woman in exercises for the immediate postpartum
period (can be performed in bed)
• Toe stretch (tightens calf muscles): while lying on back, keep legs
straight and point toes away from body, and then pull legs toward
body and point toes toward chest. Repeat 10 times.
• Pelvic floor exercise (tightens perineal muscles): contract
buttocks, press thighs together for a count of 7, and relax.
Contract buttocks, press thighs together, and draw in anus for a
count of 10 and relax.
• Bicycle (tightens thighs, stomach, and waist): lie on
back on the floor, arms at sides, palms down. Begin
rotating legs as if riding a bicycle, bringing the knees
all the way in toward the chest and stretching the
legs out as long and straight as possible. Breathe
deeply and evenly. Do the exercises at a moderate
speed and do not tire your self.
• Buttocks exercise (tightens buttocks): lie on
abdomen and keep legs straight. Raise left leg in the
air, and then repeat with right leg to feel the
contraction in buttocks. Keep hips on the floor.
Repeat 10 times.
• Twist (tightens waist): stand with legs wide apart.
Hold arms at sides, shoulder level, palms down.
Twist body from side to front and back again to feel
the twist in waist.
Newborn Care
Bathing the Neonate
• Make sure bath water is 98 degree to 100 degree Fahrenheit (37
degree to 38 degree Celsius), and use neutral soap or plain water
(if skin is dry).
• Use cotton balls or soft disposable wash cloths to wipe eyes (from
inside corner outward), face, and outer ears.
• Wash head using circular motions, tilt head back to expose skin
folds to cleanse neck.
• Bathe torso and extremities quickly to prevent unnecessary
exposure and chilling.
• Clean genital area of male. Retract foreskin gently to clean
underneath, and replace quickly to prevent edema.
• Clean genital area of female. Gently separate folds of the labia
and remove secretions. Wipe vaginal area with cotton balls, using
one stroke from front to back.
• Bathe buttocks using a gentle, patting motion. Keep anal area
clean and dry to prevent diaper rash. If rash does occur, apply
protective ointment, such as zinc oxide or A&D, or expose
buttocks to air or heat lamp.
Providing Umbilical Care
• Inspect the umbilical cord stump for bleeding
or foul odor, which may indicate infection.
• Apply a drying agent such as 70% alcohol or
merthiolate to cord stump where it exits
abdominal wall, using gauze or cotton
swabs, 3 to 4 x a day.
• Leave open to air; do not cover with diaper
or use a dressing.
• Teach care to family, and tell them to expect
stump to dry up and fall off within 7 to 10
days.
• First Visit
It was July 29, 2009, when we did our first
visit. First we did, we approach her regarding to
our intention of visiting her and get her approval.
After getting patient’s approval, we interviewed
about the patients profile and any discomfort she
had been experienced. Then we tackled about
the importance of nutrition related to pregnancy
such by explaining the benefit you could get by
following the food pyramid, we emphasized the
food which is high in iron because we have
observed that our patient has a low blood
pressure, in addition, we brought some fruits and
vegetables that are rich in vitamins and minerals
such as green leafy vegetables that are highly
acceptable to improve heath status.
• We also did help teaching about the importance of
immunization specifically the tetanus toxoid which may
help in avoiding complications during pregnancy. We did
ask some any complaint about her condition, and she
told us that she has constipated. She said that “galisud
kug kalibang ning niaging adlaw pa”. Second is she
complaining about her urination that she told us that
“sige kug ihi ihi”.. Prior to the patient complaint we did
some health teaching that this discomfort is normally to
occur during pregnancy. Then we ask for the frequency
of urination and voiding to confirm for there is any
abnormalities. After gaining the important cues, we did
some nursing intervention that would help the patient
regarding on her problem. We did intervention that
where based on the availability of source, competency,
and time factor. Because our group agreed that nursing
intervention will be more just likely effective if we meet
these factors.
• Second Visit
During the second visit, last August 3, 2009,
we were able to assess and observe about the
discomfort experienced by our patient. We did
some physical assessment and taking of vital
signs in order to determine patients subsequent
condition if she has abnormalities that she can
hardly to determine. Then we asked if our
nursing intervention is effective in improving on
her condition. We questioned her also that if she
had new discomfort that she can already
determine or recognized. She told us that she
had problem regarding on lower back pain, she
said that “sakit ang akoang likod “and we
observed also non-pitting edema is present.
Regarding on complains we did some health
teachings that could help patients discomfort
• Health teaching imparted was antepartal
exercise, major discomfort during
pregnancy. We also had performed the
Leopold’s maneuver, we found out that the
baby is in cephalic presentation, the fetal
heart rate heard at left lower quadrant with
estimated age of gestation of 36 weeks.
By that information that we obtain, we
securely said to the mother that her baby
is in good condition by means of this
factor.
• Third Visit
September 7, 2009 Monday, we had our third visit
on our clients’ house, we perform urinalysis. This is to
know if there are abnormalities on our patients’ urine. As
far as we’ve noticed the results are all negative, and we
are all glad for the result. Since we have the same
problems during our second and third visit, we monitored
the patients’ status and there is a continuity of care and
nursing interventions regarding the noted problems
specifically the non-pitting edema of the lower
extremities and back ache. After that we have imparted
health teachings to our client. These are the following;
encourage ambulation, this is to stretch properly the
clients muscle specifically the vaginal muscles and also
this is helpful to deliver the baby easily, encourage
patient to increase fluid intakes for about 8-10 glasses of
water/day to include milk, encourage patient for
breastfeeding to protect the baby from any diseases and
infection.
• Fourth Visit
September 27, 2009 Tuesday at around 10:00 in the morning,
our group decided to visit our postpartum client. We took the clients
vital signs first. Having these results; BP=100/70 mmHg,
pulse=90bpm, respiration=18cpm, temperature=36.8*C, we also
include baby Marcelo’s vital signs; Respiration=48cpm, pulse=125
bpm, temperature=36.9*C. After taking vital signs, we did the
physical assessment, the baby’s physical appearance is normal but
we have noticed that he has skin rashes. After the assessment, we
did the health teaching, we taught the client on how to perform the
postpartum exercise and the reason behind each exercise. Since
the client already has 4 offspring which has a short on gap, we
advised her to apply some of the family planning method; we
introduced IUD which has a long term effect, withdrawal, and
cervical mucus method. Since our client prioritize their family’s basic
needs rather than buying contraceptives we introduced to her the
methods that are non-expensive and have no cost.
• We also tackled about the importance and
benefit of breastfeeding for her as one of the
effective family planning methods, explaining to
her that if she plans to use this method, she
must exclusively breastfeed baby Marcelo and
her menstruation must be regular. For baby
Marcelo, breastfeeding is important because
almost all the nutrients are there that would
protect him for any diseases and infections. We
also emphasized to her breast care as one of
the important doings before she will breastfeed
the baby. After the health teaching, we ended
the discussion by giving some offerings that
would help to improve the clients’ health status,
and thanked them for their cooperation and
promised to go back after few weeks.
CUES NURSING Dx OBJECTIVES INTERVENTION RATIONALE EVALUATION

Subjective: Urinary retention At the end of 24 Independent: -to evaluate volume At the end of 24hrs,
related to urethral hours, the patient Monitor losses the patient was able
“Sigeg kog ihi blockage. will able to decrease frequency and to decrease stress
ihi, ika daghan stress incontinence. consistency of -TO increases incontinence.
sa isa ka adlaw” urine. bladder pressure
and this may
Perform Kegels stimulate relaxation
maneuver of sphincter to allow
voiding.
Objective: Increase fluid intake
-to avoid urine
distention.
Void as necessary
9 times to
urinate within a Caffeine can
Avoid Caffeine stimulate pain in
day
urination
CUES NURSING Dx OBJECTIVES INTERVENTION RATIONALE EVALUATION

Subjective: Ineffective tissue At the end of 24hrs, Rest with your feet Promotes arterial At the end of 4hrs,
perfusion related to the atient will be elevated blood circulation the patient was able
“ nanghupong electrolyte able to maintain to maintain tissue
lagi akong tiil” imbalance. tissue perfusion on Encourage the To reduce pressure perfusion on both
both ankle ankle.
patient the to turn in on bony
bed frequently or prominences and
Objective: ambulate. areas of edema.

Non-pitting Instruct the patient To avoid pain or

edema to correct body injury during
mechanics activities,
observed at
To maintain
both ankles.
Provides foods low electrolyte balance.
in sodium to
minimize edema
and provide foods
high in potassium
such as bananas
CUES NURSING Dx OBJECTIVES INTERVENTION RATIONALE EVALUATION

Subjective: Acute pain at the At the end of 3mins, Advised the client, Early intervention At the end of
lower back, related the patient will partner or significant may decrease the 30mins, of
“kasagara to the increasing verbalized adequate others to anticipate total amount of independent and
gasakit ako weight of the gravid relief of pain or the need for pain analgesic required. independent nursing
likod jud” uterus. ability to cope with relief The patient intervention the pt,
incompletely Provide rest periods experiences of pain has verbalized relief
relieved pain to facilitate comfort, may become of pain.
sleep and relaxation. exaggerated as the
Instruct the client to result of fatigue.
verbalized pain in To be able to
scale from 1-10 determine the type or
Objective: level of care to be
Provide comfort
measure such as given.
massage at the site ofTo relief or reduce
Relief or pain pain into tolerable
destruction Dependent: scale
behavior( like Give analgesic as
seeking other ordered, evaluating Pain medication are
peoples effectiveness and absorbed and
observing for any metabolized
attention) signs and symptoms differently by pt’s, so
Guarding for untoward effects. their effectiveness
must be evaluated
Behavior or from pt. to pt.
protecting body
part.
CUES NURSING Dx OBJECTIVES INTERVENTION RATIONALE EVALUATION

Subjective: Impaired skin At the end of Instruct the mother to To maintain After 15mins of our
integrity related to 15mins,the mother bath the baby with cleanliness without conversation with
“naay poor sanitation. would be able to lukewarm water and irritating the skin. the mother, she was
gamay na apply the health mild soap. able to know the
burot2x na pula teaching that we Encourage the
mother to avoid Help prevent skin nursing intervention
sa panit niya” taught to her, to that could minimize
minimized the skin vigorous rubbing and friction to sensitive the skin rashes of
rashes of the baby. scratching and to pat tissue her baby.
skin dry instead of
rubbing. Promotes circulation
Objective: Turn/ reposition and prevent undue
frequently pressure on
Inforn the parents skin/tissues.
Rashes that that all linens and
clothing used by the To prevent further
provide child should be complications of the
discomfort to washed with skin
the baby. detergent in hot water
separately from those To facilitate wound
of other household healing
members
Allow lesions to dry
by air exposure.
CUES NURSING Dx OBJECTIVES INTERVENTION RATIONALE EVALUATION

Subjective: Constipation related At the end of 24 Independent: -assist in identifying At the end of 24
to decreased dietary hours, the patient Determine stool causative or hours of nursing
“galisod ko intake. will able to defecate color, consistency, contributing factors intervention, the
ug kalibang ning normally as possible frequency and and appropriate patient defecated
niaging adlaw as once in a day. amount interventions normally.
pa”, as Auscultate bowel -bowel sounds
verbalized by sounds generally decreased
in constipation
the patient. Encourage fluid
intake of 2500-3000 -assist in improving
Objectives: ml/day within stool consistency
Abdominal pain, cardiac tolerance -decrease gastric
urgency and Recommended distress and
avoiding gas abdominal
cramping distention
forming foods
Altered bowel Encourage to eat At the end of 24
sounds high-fiber rich foods hours of nursing
intervention, the
patient defecated
normally.
-to enhance easy
defecation
Referral and Summary
Since our client settled in lowland area of Macasandig
us advice our patients to continue visit the Macasandig
Health Center for the continuation of immunization of her
child and for consultation, if there are manifestation of
sickness that they should be guided properly by person who
is working in any of the sector of health care. We advised the
parents to be guided properly with the family planning method
for greater good of their living. We give emphasis also on the
sanitation and proper hygiene to avoid risk for sickness and
diseases. We promote breast care and breast feeding in
nourishing the newborn. We give also the mother some
protective measures for the newborn since accident do
happen no matter what.
We thanks to this experience of interacting with our
patient that we learn a lot not just for our future job as a nurse
but also as a person for developing us as a better person that
is thankful for the gift of life and love.
 ORGANIZATION AND BIBLIOGRAHY
I was able to come up with this care study with
the help primarily of my awesome God. Next would
be the cooperation and accommodation of our
client. These are our source:
• Lippincott, Williams, and Wilkins. Manual of Nursing
Practice Hanbook...3rd edition page.981-1024
• Adele Piliteri, ed. Maternal and Child Health
Nursing.5th edition , C and E Publishing, Inc. San
Juan Metro Manila, Philippines
• Doenges, Moorhouse, Geissler-Murr.8th edition.
Nurse’s Pocket Guide …452-457
• www.wikipedia.com
• www.google.com