GENERAL DATA

Hospital: Cebu Puericulture Center & Maternity

House, Inc.

Name of Patient: K.R.A

Age: 23y.o

Address: Sitio Kalamansi Mabolo Cebu City

Citizenship: Filipino

Sex: Female

Civil status: Single

Religion: Roman Catholic

Occupation: Cashier

Height: 5’3 ft

Weight: 66 kls

Date of admission: January 26, 2020

Time of admission: 1:00 am

How the patient was admitted: Received patient in emergency room

accompanied by mother and husband

conscious and coherent; afebrile and

had labor pain as verbalized by the

patient.

Attending Physician: Dr. Buot

HEALTH ASSESSMENT

A. HEALTH HISTORY

A.1. Current Health Status

Upon receiving patient K . A. A., was sitting on bed coherent,

conscious and body parts are symmetrical without IVF attached. No edema

noted.

A. 2. Reason for seeking Consultation

Labor pain

A. 3. Past Health History

Patient K.A.A., had no previous childhood illnesses no operations

and surgeries, never been admitted since childhood. Started her menarche at

13 years old. Menstrual cycle duration of 3-4 days consuming 3 pads/day.

A. 4. Family Health History

Patient family history had genetic deaseases which includes

hypertension and tuberculosis both on the mother’s side.

 GENOGRAM

J. A. R. I
M. Y E.
B.

M. T.
K.R.
A.

Z. T.

A. Physical Examination\

 ______________________
  Lifestyle:

 Religious Beliefs:

 Home Situation:

 Substance Abuse:

 Sexual History:

Anatomy and Physiology of the System Involve

Conceptual framework of the Physiology of Pregnancy

A. Medical Management

CLINICAL LABORATORY
 COMPLETE BLOOD COUNT RESULT FLAG REFERENCE UNIT

White Blood Cell 13.1 ↑ 4.4-11.0 10 ̂ 9/L

Red Blood Cell 3.68 ↓ 4.5-6.1 10 ̂ 12/L

Hemoglobin 12.4 12.0-16.0 g/dL
Hematocrit 35.3 ↓ 37.0-47.0 %
MCV 96.0 76-96 Fl

MCH 33.6 ↑ 27-32 pg

MCHC 35.0 32-36 g/dL

Platelet Count 206 150-450 10 ̂ 9/L

Neutrophils 64 45.0-75.0 %

Lymphocyctes 23 20-40 %

Monocyctes 10 2.0-10.0 %

Eosinophils 2 0.0-5.0 %

Basophils 1 0.0-2.0 %

RDW-CV 12.1 10.9-15.7 %

MPV 7.62 4.5-100 .

 Diagnostic Examinations:

 Treatment and Procedures:

 Medications and Diet

 B. Nursing Management

 Nursing Care Plan

INTRODUCTION

Postpartum care presents a special challenge, as it concerns two; the mother

and her baby, people with very distinct needs. However it is believed that

contribution to good quality care ensure to balance the challenge. The major

maternal and neonatal health challenges include nutrition and breastfeeding,

birth spacing, immunization and HIV/AIDS, therefore Post partum care is pre-
eminently about the provision of a supportive environment in which a woman,

her baby and the wider family can begin their new life together. This includes

the complications of the mother that she may experience after delivery which

includes postpartum -depression; it is a kind of depression that some women

experience after childbirth (Miller, 2002). Carrying a pregnancy for nine months

is not a simple task, given the changes and complications that the individual is

likely to face. Giving birth is one of the things that stress pregnant women.

However, the main challenge is providing becoming a mother. Many women are

confused or even depressed about the idea of being a mother (Field, 2010).

Others feel that they are not ready to be moms at all. Postpartum depression is a

severe condition that few months after childbirth. The same condition can also

occur after the pregnant mother has experienced stillbirth or a miscarriage

(Miller, 2002). Women experiencing postpartum depression have feelings of

sadness, hopelessness, and worthlessness. They always have a problem caring

or even bonding with their babies (Cohn et al., 2009). It is believed to develop

as a result of changes in the level of hormones that occur during a period of

pregnancy. If a woman receives inadequate support from family, her partner, or

friends, she has a high chance of developing postpartum depression (Field,

2010).In addition, some women may experience restless, loss of enjoyment in

doing the things they previously enjoyed doing, and some can hardly

concentrate on anything (Miller, 2002). Therefore, we can all agree that

postpartum depression has significant impacts not only to the child’s

development but especially with the mothers.

 Therefore this guideline aims to identify the essential core (routine) care that

every woman and her baby should receive in the first 6-8 weeks after birth,

based on the best evidence available.

This guideline has been written within a conceptual framework which places the

woman and her baby at the centre of care, appreciating that all post partum care

should be delivered in partnership with the woman and should be individualized

to meet the needs of each mother-infant dyad. Thus this clinical guideline of

post partum is to offer information to support midwives to increase the

knowledge and skills that enable them to handle mothers and their neonates and

management of postpartum complication, and referral.

1.4. Appendices

APPENDIX A

January 28, 2020

Piluchi Victorina M. Villegas

Level 1&2 chairman/
Nursing Education Coordinator
University of Cebu-Banilad Campus
College of Nursing

Dear Ms. Villegas,

Good Day!

In partial fulfillment of the requirement of the subject NCM 109 Maternal and
Child Health Nursing, I would like to ask permission from your good office to
allow me to take the case of Kimberly Rose Abne, for my care study.

Hoping for your kind approval. Thank you very much.

Respectfully Yours.

POTOT, JELLAN T.
BSN II-E

Noted By:

MARIA THERESA M. SANCHEZ, MAN, RN

Approved By:

Piluchi Victorina M. Villegas, MN, RN

Level 1&2 chairman
Nursing Education Coordinator

1.6. Curriculum Vitae

POTOT, JELLAN T.
Tipolo, Mandaue, Cebu, City
Smalljellan28@gmail.com
09481463815
OBJECTIVES:
To obtain a position where I can utilize my skills and gain further experience
while enhancing the company's productivity and reputation.
EDUCATIONAL BACKGROUND
Tertiary:
University of Cebu-Banilad
Bachelor of Science in Nursing
2018-2019
Secondary:
Doña Liling Neis Negapatan National High School
Piyo, Tabogon, Cebu
2017-2018
Primary:
Salag Elementary School
Salag, Tabogon, Cebu
2011-2012

PERSONAL INFORMATION
Birthdate: July 28, 2000
Birth Place: San Isidro, Tabogon, Cebu
Age: 19
Civil status: Single
Nationality: Filipino
Religion: Roman Catholic
Height: 5'4
Weight: 45
Contact Information:
Email address: smalljellan28@gmail.com
Home address: Tipolo, Mandaue Cebu City
Moblie number: 09481463815

1.2. Conclusion and Recommendations

According to the data above, The main purpose of providing optimal postnatal

care is to avert both maternal and neonatal death, as well as long-term

complications. ... Knowing what mothers and newborns are dying from

is important in order to identify the high impact interventions that address all

the major causes of death during the postnatal period.

The postpartum period involves your moving through many changes, both

emotionally and physically. You are also learning how to deal with all the

changes needed with becoming a new mother. The postpartum period also

involves you and your partner learning how to care for your newborn and

learning how to function as a changed family unit.

You need to take good care of yourself to rebuild your strength. You will need

plenty of rest, good nutrition, and help during the first few weeks.-