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Case Study NSVD
Case Study NSVD
Butuan City
Nursing Program
A CASE STUDY
ON
NORMAL SPONTANEOUS VAGINAL
DELIVERY
In partial fulfillment
Of the requirements for the
Subject NCM 101
Submitted by:
Florence Phil H. Amoroso
BSN III
Submitted to:
Mr. Paul Ritchie Pelos, RN
Clinical Instructor
INTRODUCTION
STAGE II: This stage lasts for three or more hours. However,
the length of this stage depends upon the mothers position (e.g.; upright
position yields faster delivery). Once the cervix has completely dilated,
the second stage had begun. This stage ends with the expulsion of the
fetus.
Patient P was born on December 19, 1992. She was born to parents
from Surigao Del Norte, but she didnt actually live with them. She was
technically abandoned to the relatives, but those people could not
essentially foster her. She stayed at the Department of Welfare and Social
Development or DSWD and spent her 15 years of existence. Her
TPR q 4
NPO
Labor watch
Head Circ:
Chest Circ: 30 cm
Abd Circ:
32 cm
20 cm
After her delivery, she was admitted to the Ob ward with repaired
episiotomy. Post partum doctors orders were as follows which was carried
out:
Perineal care
May room in
On the following day, June 30, 2008, doctors order was to secure
HBsAg result. Patient Ps baby was admitted to NICU because of frequent
vomiting and fever. 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 = 37.3c
82 bpm
21 cpm
120/70 mmHg
Continue meds
Repeat hemoglobin
By 1:25 pm:
Defer MGH
BT (blood transfusion)
PHYSICAL ASSESSMENT
assessment.
This
is
done
systematically
using the
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 seen.
Ears are clean, no ear wax was noted and approximately of the
same size and shape. Patient can hear normally when spoken softly.
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.
Lymph nodes noted. Neck has strength that allows movement back
and forth, left and right. Patient is able to freely move her neck.
Arms:
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.
With episiotomy dry and intact, urinates 2-4 times a day and has
not defecated yet since her delivery.
O. Neurological Assessment
Motor Functioning -
EXTERNAL GENITALIA
The 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 .
The 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.
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
DRUG LIST
Date Ordered
Ordering Physician
Dr. Bombeo
Dr. Bombeo
Dose
Cephalexin 500mg 1
cap TID
DRUG STUDY
(ORAL MEDS)
GENERIC NAME:
CEPHALEXIN
CLASSIFICATION: Anti-Infective
ACTION: Inhibits DNA synthesis by inhibiting DNA gyrase in susceptible
gram negative and gram positive organisms
INDICATIONS:
Infectious
diarrhea,
respiratory
tract infection,
Hypersensitivity
to
drug
or
other
fluoroquinolones
ADVERSE REACTIONS:
CNS: Headache
OTHER: Taste
GENERIC NAME:
MEFENAMIC ACID
Hypersensitivity
with
drugs,
acute
CNS: dizziness
CV: Vasodilation
SKIN: pruritus
NURSING CONSIDERATIONS:
Tell patient that drug works best when taken before pain
becomes severe
Recommend
abstinence
from
alcohol
when
medication
Caution patient that drug can cause dependence
taking
PROBLEM LIST
Nursing
Date
Date
Diagnosis
Identified
Evaluated
July 1, 2008
July 1, 2008
July 1, 2008
July 1, 2008
Not Evaluated
Problem #
traumatized skin
tissue 2 to
episiotomy
Interrupted breast
feeding r/t infant
illness
Situational Low
Self-Esteem r/t
perceived failure at
life events 2 to
rape trauma
LEARNING OUTCOMES
Three days of multi-tasking and time management, the OBNURSERY ward exposure has taught me how to appropriately handle
pregnant and post partum women. The idea of caring for mothers and
newborns which is not in my lineage is hard. Hard, because some of the
patients are uncooperative and non compliant. It isnt that smooth to
establish an interacting relationship specially that most of the patients
admitted in the institution has a low educational attainment. Therefore, I
cannot expect them to fully comprehend the instructions I have imparted.
However, it was a marvelous experience since I was exposed to various
kinds of maternal paragons and procedures which werent return
demonstrated yet. Fortunately, there is our clinical instructor who
persistently supervised us and assisted us to make it through with just
minimal errors.
also
focused
to
building
and
developing
intrapersonal
and
The next time that Ill render care and perform procedures, I
will try to do my best to attain satisfaction and accomplishment.
ACKNOWLEDGEMENT
the
overwhelming
support,
help
and
camaraderie,
for
being