Institute of Nursing

Dr. Nicanor Reyes St., Sampaloc Manila

S.Y. 2010-2011

CASE PRESENTATION
The Post Partum Mother

Submitted to:
M. Esguerra

Submitted by:
Olimba, Rachelle Joyce
Pagtama, Altini
Pantaleon, Mark Kevin
Pentecostes, Mary Lopeline
Portento, Erick Anthony

BSN 127 – Group 107B

December, 2010
 Initial Data Base

I. BIOGRAPHIC DATA

The client, M.P., is a 25-year old female who lives at Valenzuela City. She is not yet
married to her partner BB. Her nationality is Filipino and she is a Roman Catholic. She is a
management graduate and work at BDO for 2 years as a teller.

II. NURSING HISTORY

Past Health History

The client has history of childhood illnesses such as Measles, Chicken Pox and
Mumps. When asked about the immunizations she received, she answered “Kumpleto
naman ako sa bakuna sabi ni mama”. The client stated that she does not have any allergy
in foods and medicine. She also said that she has never been hospitalized or was in any
kind of accident. She claimed that she has had no history of travel for at least 10 years.

A. History of present illness

The client has no present disease or illness. But she complained of a dull pain in her
abdomen. She stated, “Masakit pa tiyan ko. Siguro kasi ‘di pa nakakalabas lahat ng dugo.
Normal lang siguro yun.” Masakit din yung tahi ko kaya medyo hirap din ako kumilos. She
rate the pain as 6/10 as 10 being the highest and 10 being the lowest. When ask if she is
experiencing any dizziness or headache, the client stated “medyo nahihilo ako
pagtumatayo.”

B. Family History

The client stated that Hypertension were prevalent in her family in both mother and
father side. According to her, most of her relatives are hypertensive. Dengue is also
prevalent in their community and her siblings got also infected with dengue before.

C. Menstrual History
The patient have her menarche when she was 12 years old, stated that the client
have a normal cycle of menstruation. She stated “30 day cycle ako, madalas 7 days
ang itinatagal at malakas ako mag mens”. The client does not experience any
dysmenorrheal pain when menstruating but experienced headache and blurring of
vision.

D. Obstetric History

She is a G1P1, delivered via NSD cephalic, with a birth weight of ______delivered at
Valenzuela Emergency Hospital on Dec 11, 2010 at ____ and had no complications
 after the delivery. The client undergoes episiotomy and episiorraphy. She had her
first prenatal check up during her 6 th month pregnancy. She had 2 shots of Tetanus
Toxoid

E. Gynecological History
The patient have no previous surgery, does not undergo any cervical smears and
pap smears. After delivery blood discharge are prominent with a bright red in color.
No itchiness noted but the client complained pain on the suture site with a pain scale
of 6/10.
F. Contraceptive History
The client was asked if she and her partner use contraceptives of any kind, the client
stated “ gumamit ako dati ng pills, for half a year, kaso madalas pumapalya ako ng
pag inom dahil nalilimutan ko, liban dun wala na, kahit condom ayaw naming
gumamit”.
G. Sexual History
The client had her coitarche when she was 20 years old and only having 1 partner
ever since, who became the father of her son. The client is sexually active, the client
stated “siguro mga twice a week kami magtalik, pero nung nabuntis ako, tuloy pa din
kami hanggang sa 2nd month ng pregnancy ko, pero simula nung ikatlong buwan
tinigil na muna naming kasi baka makaapekto sa bata.” . When asked if the client is
satisfied in their sexual intercourse she verbalized “ oo naman, satisfied ako,
makakabuo ba kami kung hindi”. She also stated “madalas tumaas ang libido ko lalo
na pag malapit na ko magkaroon, at nasasatisfy naman ako after naming gawin
yun”. The pregnancy was unplanned since they are not yet married. The client has
no history of sexually transmitted diseases as well as her partner.

III. Patterns of Functioning

A. Health Perception/ Health Management

The client views herself as a healthy person, she rated her health as 8/10, since she
had just delivered a baby, but stated “healthy ako dahil naipanganak ko ang baby ko
na healthy din.” When asked if she have her regular check ups the client stated
“nung nabuntis lang ako napadalas ang check up, dati ay pag magpapamedical
lang, 6 months na nga ako buntis nung nagpaprenatal ako.” When asked what she
usually do when she is sick the client verbalized “ madalas ay self medication lang
ako, pero nung buntis ako hindi ako nagiinom ng gamot dahil baka makasama sa
baby ko.” The client felt dizziness when standing after delivery and has difficulty in
urinating because of pain at the suture site. When asked if she already have
knowledge on how she can take care of the newborn she verbalized “hindi pa
masyado, madami pa ko hindi alam gawin, wala din naman ako makakatulong sa
bahay masyado sa pag-aalaga sa anak ko, pero handa naman ako matuto ng pag
 aalaga”. “Masaya ako at excited ako sa pagiging mommy ko at fulfilled ang feeling
ko bilang babae, pero may takot pa din ako dahil hindi ko alam kung mabibigyan
naming sya ng magandang buhay at maalagaan ng maayos.”
B. Nutritional Metabolic Patterns
The client eats almost any kind of food and fond of eating eggs specially quail eggs.
She also loves to eat meat and vagetables but during her pregnancy she increased
in eating fruits and eggs. She drinks 2litres of water every day and take ferrous
sulfate and multivitamins everyday during her pregnancy as advised by her OB-
gynecologist. When asked if she planned to continue beast feeding her baby she
stated “oo naman, ibebreast feed ko sya hanngat may gatas pa ko, as much as
possible ay hindi ko sya ibobottle fed, medyo nagwoworry lang ako kasi parang wala
akong gatas at medyo masakit pag pinapadede ko sya, siguro sa simula lang naman
to.” The client shows desire to know information about newborn care and benefits of
breast feeding as manifested by asking questions about things on how to effectively
care for her baby.
C. Elimination Pattern
The client usually defecates 3 times a week with slight difficulty before her
pregnancy, she is usually constipated. During her pregnancy, she has difficulty in
her bowel movement because she is afraid to exert too much effort for the fear of
any miscarriages. Before pregnancy she urinates 3-5 times a day, during pregnancy
she urinates 15-20 times a day, even during her sleep, she have to wake up to
urinate, after her delivery, she have difficulty in urinating because of pain in her
episiorrhaphy.
D. Activity Exercise Pattern
The client has no definite exercise before pregnancy, other than walking. She
considers her work as her exercise, the client verbalized “sapat na ang pagod ko sa
trabaho, para na din ako nagexercice, pero nung buntis ako ay nagpepelvic rocking
ako, advice ni doc eh”.
E. Sleep-Rest Pattern and Coping Stress Tolerance Pattern
The client usually have 4 to 5 hours of sleep before pregnancy, and does not feel
refresh after sleeping, during pregnancy she still sleep 4-5 hours and with naps, her
sleep was frequently interrupted specially when she need to urinate in the wee hours
in the morning, she seldom feel refresh after sleeping. When she feels stress she
just lay down and watch TV. She takes a nap when she is tired or not feeling well.
She verbalized “effective naman pampawala ng stress”. The client verbalized “pag
may prob ako ay hinahanapan ko ng solusyon, pag hindi ko kaya humihingi ako ng
tulong s pamilya ko, sa asawa ko o kaya kaibigan, ayaw ko dibdibin o sarilinin,
mahirap na baka hipan ako ng hangin at magkasira ako sa utak”.
F. Cognitive-Perceptual Pattern
The client has no visual and hearing impairment, has no difficulty in speech and
expressing herself. The client is a college graduate, and work as a teller at BDO, she
 is a first time mother and does not have any experience in taking care of a new born,
and the client shows enthusiasm in gaining knowledge. “Gusto ko matutunan lahat
ng bagay sa pagiging ina, I want to be the best mom for my son.”
G. Self Perception Self Concept Pattern and Value Belief Pattern
The client rate her self esteem as 8/10 as 10 being the highest and 1 being the
lowest, she views her self as a good person, she describes herself as a happy and
industrious woman, she think positively in any problems that she encounters. The
client verbalized “pag may prob ako ay hinahanapan ko ng solusyon, pag hindi ko
kaya humihingi ako ng tulong s pamilya ko, sa asawa ko o kaya kaibigan, ayaw ko
dibdibin o sarilinin, mahirap na baka hipan ako ng hangin at magkasira ako sa utak”.
When asked if she feel any fear after her delivery she stated “oo naman, natatakot
ako para sa anak ko, kung mapapalaki ko ba sya ng maayos, maaalagaan, at
mabibigyan ng magandang buhay, pero syempre pipilitin ko mabigyan sya ng
magandang buhay at alam kong gagabayan kami ni God at hindi kami pababayaan.”
The client is a Catholic but not an active member but the client stated “wala naman
yun kung araw araw ka nagsisimba, ang mahala ay strong ang faith mo sakanya at
alam mo ang tama at mali.”
H. Sexualty Pattern and Role Relationship Pattern
The client had her coitarche when she was 20 years old and only having 1 partner
ever since, who became the father of her son. The client is sexually active, the client
stated “siguro mga twice a week kami magtalik, pero nung nabuntis ako, tuloy pa din
kami hanggang sa 2nd month ng pregnancy ko, pero simula nung ikatlong buwan
tinigil na muna naming kasi baka makaapekto sa bata.” . When asked if the client is
satisfied in their sexual intercourse she verbalized “oo naman, satisfied ako,
makakabuo ba kami kung hindi”. She also stated “madalas tumaas ang libido ko lalo
na pag malapit na ko magkaroon, at nasasatisfy naman ako after naming gawin
yun”. The pregnancy was unplanned since they are not yet married. The client has
no history of sexually transmitted diseases as well as her partner.