CASE STUDY

LABOR PAIN
GROUP 15
BSN II- TURQUOISE

OCLARIT, GESSEL S.
PELIGRO, MALVIN
PINDANG, ANN CRISTIL
RAMIREZ, ZEDRIX
RANES, SYGRED
SALUDES, KEZYA
TOREEON, REYNA FATIMA
ZABALA, KENNETH
I. Patient’s Profile
Name :
Age :
Address :
Sex :
Religion :
Date of Admission :
Attending Physician :
Ward :
Diagnosis :

II. Past Health History

III. History of Present Illness

IV. Review of Systems (Significant Findings)

A. Nervous System
B. Musculoskeletal System
C. Integumentary System
D. Endocrine System
E. Lymphatic System
F. Cardiovascular System
G. Respiratory System
H. Digestive System
I. Urinary System
J. Reproductive System
K. Special Senses

V. Laboratory Results

VI. Anatomy and Physiology of Organ Involved (Drawing with Labeling)

Description and Physiology
 VII. Pathophysio-Tree
Disease

Description of the
Etiology Predisposing Factor/s
Disease

Pathophysiologic

Process

Clinical Manifestation
(Signs and Symptoms)

Medical Management Surgical Management Nursing Management

Complications

VIII. Nursing Care Plan / OPST

 OUTCOME PRESENT STATE TEST
Name: Pinar, Hazel G. Date Admitted: September 23, 2021, 8:00 AM
Age: 33 y.o Chief Complaints: Onset of labor pains.
Sex: Female Admitting Diagnosis: G2P0 Intrauterine Pregnancy 39
weeks 4/7 days AOG, Cephalic in Active Phase of Labor
Civil Status: Married Attending Physician: Dr. Jean C. Navarro
Address: Calceta Street, Tagbilaran City, Bohol Ward/Area: OB-ER

CLIENT IN CONTEXT ASSESSMENT INTERVENTIONS RATIONALE EVALUATION

Patient Subjective Cues: Independent After the

History/Reason for “Sakit naman akong > Perform Leopold’s > To determine the intervention, the
Consultation: bat-ang maam inig manuever position of a fetus labor pain will
A 33-year-old lutong sa akong inside the uterus by decrease and the
pregnant female tiyan. Mura kog touching the patient will deliver
from Tagbilaran City kalibangon. Dugay abdomen by hands. her baby in good
came in due to labor pa ba ko manganak condition.
pains. maam? Hinaot ok ra >Establish rapport > To gain cooperation
ni oi kay nakuhaan ra and trust from the
History of Present ba akong unang client
Illness: bata.” as verbalized
She has been by the patient. > Admit to Labor > Provide the needs
experiencing painful Room of the patient and
uterine contractions Objective Cues: assess the progress of
for the past 4 hours. Grimace face upon labor.
The contractions are contractions are
occurring at 10-15 noted, the patient > Secure consent > To ensure that the
minutes intervals appears anxious and patient is fully aware
with approximately restless. and accepting of a
50-60 seconds particular treatment.
duration. She Vital signs:
continues to feel fetal T = 36.8 C, > Start IV line of D5LR >To prevent
movement between BP = 130/80 mmHg, 1 liter regulate at 30 dehydration which
the contractions. She P = 88 bpm, gtts/min can cause increased
denies rupture of R = 19 br/min interventions and
membranes. complications.

1 hour prior to Nursing Diagnosis: > Liquid diet >To help maintain
consultation, she Impaired comfort adequate hydration.
experienced gradual related to uterine
progress of labor contractions as
pains and bloody evidenced by > Get baseline CTG >To help identify
show, thus prompting restlessness. signs of suspected
her consultation. fetal compromise in
Minimal bilateral order to initiate
edema related to the management that
pressure from the may reduce or
History of Past Illness: growing uterus. prevent fetal
Non-asthmatic morbidity.

Non-diabetic > Continuous > To continuously

electronic fetal record the heartbeat
Non-hypertensive monitoring of the fetus and the
contractions of the
No known food/drug woman's uterus
allergies during labor.

Gyne: History of > Monitor progress of > To recognize

Cervicitis 1x labor incipient problems,
 so that her
Past Surg Hx: progression to
appendectomy at age serious problems
12yo. may be prevented.

Past Hospitalization: > Anticipate normal > To provide

June 2018 for Dilation spontaneous vaginal continuous support
and Curettage delivery during labor and
(Abortion) delivery.

Socio-economic
Status: Dependent
She is a college >Ask for a doctor’s > To lessen the labor
graduate with referral for Analgesics pain.
ongoing master’s related to labor pain.
degree studies. She is
a public-school > Administer > To treat symptoms
teacher and her medicine as and to help manage
husband is a car shop prescribed by the or overcome certain
mechanic. physician order. health conditions.

Organ Involved:

Cervix

IX. Drug Study

X. Health Teaching Plan